Chronic Pancreatitis Patients Who Leave Against Medical Advice: Prevalence, Trend, and Predictors.

BACKGROUND AND AIMS: Leaving against medical advice (LAMA) is an unfortunate occurrence in 1-2% of all hospitalized patients and is associated with worse outcomes. While this has been investigated across multiple clinical conditions, studies on patients with chronic pancreatitis (CP) are lacking. We aimed to determine the prevalence and determinants of this event among patients with CP. METHODS: The Healthcare Cost and Utilization Project-Nationwide Inpatient Sample (NIS), 2007-2014, was used in the study. Patients with LAMA were identified, and the temporal trend of LAMA was estimated and compared among patients with and without CP. We then extracted patients with a discharge diagnosis of CP from the recent years of HCUP-NIS (2012-2014) and described the characteristics of LAMA in these patients. Multivariate logistic regression models were used to evaluate predictors of LAMA. RESULTS: 3.39% of patients with CP discharged against medical advice. LAMA rate in CP patients was higher and increased more steeply at quadruple the rate of those without. More likely to self-discharge were patients who were young, males, non-privately insured, or engaged in alcohol and substance abuse, likewise were those with psychosis and those admitted on a weekend or non-electively. The northeast and for-profit hospitals also had higher odds of LAMA. However, patients transferred from other healthcare facilities have reduced LAMA odds. Among all patients with CP, those with LAMA had shorter length of stay (2.74 [2.62-2.85] days vs. 5.78 [5.71-5.83] days) and lower hospitalization cost $23,271 [$22,171-$24,370] versus $45,472 [$44,381-$46,562] compared to the no-LAMA group. CONCLUSION: LAMA occurs in approximately 1 in 29 patients with CP and is increasing at almost quadruple the rate of those without. Clinicians need to pay closer attention to the identified at-risk groups for ameliorative targeted interventions.

Vedolizumab Dose Escalation Improves Therapeutic Response in a Subset of Patients with Ulcerative Colitis.

BACKGROUND: The Gemini trial failed to detect a significant difference in response rate for patients with ulcerative colitis (UC) randomized to standard (every 8 week) vedolizumab dosing vs escalated (every 4 week) dosing. Subsequent real-world data imply the Gemini trial design may have obscured a benefit of escalated dosing. AIMS: We investigated outcomes after vedolizumab dose escalation for patients with UC. We also explored potential clinical predictors of dose escalation requirement. METHODS: In this retrospective study, we included patients with UC who received vedolizumab between 1/2017-1/2019. We compared rates of clinical response (decrease in partial Mayo score by ≥ 2) and remission (partial Mayo < 2) for standard vs escalated dosing. RESULTS: Among the 90 patients reviewed, 52 achieved and maintained remission on standard dosing. The average time to remission with standard dosing was 33.3 ± 6.6 weeks. After an average of 56.3 ± 7.4 weeks standard dosing, 24 patients (22 "partial responders" and 2 "non-responders") were dose-escalated. Of the 22 "partial responders" dose-escalated, 10 (45%) achieved remission, 10 (45%) achieved further improvement. Neither "non-responder" demonstrated further clinical benefit. Prior anti-tumor necrosis factor (anti-TNF) biologic exposure predicted dose escalation requirement (p = 0.008). Patients requiring dose escalation had more severe disease at baseline as measured by both full Mayo (p = 0.009) and partial Mayo scores (p = 0.01). CONCLUSIONS: We show dose escalation benefited patients with UC who exhibit a "partial response" to standard dosing. Early vedolizumab dose escalation should be considered in both patients with severe disease and those with prior anti-TNF experience.

Reduced Risk of Alcohol-Induced Pancreatitis With Cannabis Use.

BACKGROUND: Pancreatitis is an increasingly common clinical condition that causes significant morbidity and mortality. Cannabis use causes conflicting effects on pancreatitis development. We conducted a larger and more detailed assessment of the impact of cannabis use on pancreatitis. METHODS: We analyzed data from 2012 to 2014 of the Healthcare Cost and Utilization Project-Nationwide Inpatient Sample discharge records of patients 18 years and older. We used the International Classification of Disease, Ninth Edition codes, to identify 3 populations: those with gallstones (379,125); abusive alcohol drinkers (762,356); and non-alcohol-non-gallstones users (15,255,464). Each study population was matched for cannabis use record by age, race, and gender, to records without cannabis use. The estimation of the adjusted odds ratio (aOR) of having acute and chronic pancreatitis (AP and CP) made use of conditional logistic models. RESULTS: Concomitant cannabis and abusive alcohol use were associated with reduced incidence of AP and CP (aOR: 0.50 [0.48 to 0.53] and 0.77 [0.71 to 0.84]). Strikingly, for individuals with gallstones, additional cannabis use did not impact the incidence of AP or CP. Among non-alcohol-non-gallstones users, cannabis use was associated with increased incidence of CP, but not AP (1.28 [1.14 to 1.44] and 0.93 [0.86 to 1.01]). CONCLUSIONS: Our findings suggest a reduced incidence of only alcohol-associated pancreatitis with cannabis use.

Reduced Prevalence of Alcoholic Gastritis in Hospitalized Individuals Who Consume Cannabis.

BACKGROUND: Alcoholic gastritis, a superficial erosive disease of the stomach, is a common manifestation of risky alcohol use. In contrast, cannabis which is frequently co-used with alcohol suppresses gastric acidity and might counteract the deleterious effect of alcohol on the gastric mucosa. However, no clinical study has examined the impact of cannabis use on the development of alcoholic gastritis among risky alcohol users. METHODS: We analyzed hospital discharge records of adults (age ≥ 18 years), from 2014 of the Nationwide Inpatient Sample, with a diagnosis of risky alcohol use (n = 316,916). We used a propensity-based matching algorithm to match cannabis users to nonusers on 1:1 ratio (30,713: 30,713). We then measured the adjusted relative risk (aRR) for having alcoholic gastritis using conditional Poisson regression models with generalized estimating equations. RESULTS: Our study revealed that among risky alcohol users, cannabis co-users have a lower prevalence of alcoholic gastritis compared to noncannabis users (1,289 [1,169 to 1,421] vs. 1,723 [1,583 to 1,875] per 100,000 hospitalizations for risky alcohol use), resulting in a 25% decreased probability of alcoholic gastritis (aRR: 0.75 [0.66 to 0.85]; p-value <0.0001). Furthermore, dependent cannabis usage resulted in a lower prevalence of alcoholic gastritis when compared to both nondependent cannabis users (0.72 [0.52 to 0.99]) and to noncannabis users (0.56 [0.41 to 0.76]). CONCLUSIONS: We reveal that risky alcohol drinking combined with cannabis use is associated with reduced prevalence of alcohol-associated gastritis in patients. Given increased cannabis legislation globally, understanding whether and how the specific ingredients in cannabis plant extract can be used in the treatment of alcoholic gastritis is paramount. In this regard, further molecular mechanistic studies are needed to delineate the mechanisms of our novel findings not only for alcoholic gastritis but also for gastritis from other causes.

Use and abuse of fecal occult blood tests: a community hospital experience.

BACKGROUND: The Fecal Occult Blood Test (FOBT) is one of the diagnostic modalities indicated for screening patients for Colorectal Cancer (CRC). Despite being approved only for screening for CRC, numerous studies in the past have illustrated misuse of the FOBT. We examined utilization of the FOBT for patients admitted to a community teaching hospital. METHODS: The study was conducted at Saint Joseph Hospital, Chicago USA. A retrospective review of Electronic Medical Records (EMRs) of patients admitted from January 2016 to December 2017 was performed. RESULTS: We reviewed the EMRs of 729 patients who received the stool testing for occult blood (FOBT). All tests (100%) were carried out for purposes other than CRC screening. Anemia (38%) was the most common reason documented for carrying out the FOBT. Further, 88% of the tests were ordered on patients who either did not fulfill CRC screening criteria or had other contraindications for testing. Usage of contraindicated medication was the most important factor (58% of patients) that made the candidates ineligible for testing. A total 73 Colonoscopies were ordered for patients who received the test inappropriately with a resulting low yield (0.47%) of CRC diagnosis. CONCLUSION: The stool occult blood test continues to be utilized for reasons other than CRC screening. Majority of patients who underwent the test were not suitable candidates due to the presence of contraindications for testing. Unsuitable FOBT testing led to further unnecessary investigations.

Early Endoscopy Is Associated with Better Clinical Outcomes in Patients Hospitalized with Ischemic Bowel Disease.

BACKGROUND AND AIMS: Providing diagnostic and therapeutic interventions, lower gastrointestinal endoscopy is a salient investigative modality for ischemic bowel disease (IB). As studies on the role of endoscopic timing on the outcomes of IB are lacking, we sought to clarify this association. METHODS: After identifying 18-to-90-year-old patients with a primary diagnosis of IB from the 2012-2014 Healthcare Cost and Utilization Project-Nationwide Inpatient Sample, we grouped them based on timing of endoscopy into three: early (n = 9268), late (n = 3515), and no endoscopy (n = 18,452). We explored the determinants of receiving early endoscopy, the impact of endoscopic timing on outcomes (mortality and 13 others), and the impact of the type of endoscopy (colonoscopy vs. sigmoidoscopy) on these outcomes among the early group (SAS 9.4). RESULTS: Less likely to receive early endoscopy were Blacks compared to Whites (adjusted odds ratio [aOR] 0.81 95% CI [0.70-0.94]), and individuals on Medicaid, Medicare, and uninsured compared to the privately insured group (aOR 0.80 [0.71-0.91], 0.70 [0.58-0.84], and 0.68 [0.56-0.83]). Compared to the late and no endoscopy groups, patients with early endoscopy had less mortality (aOR 0.53 [0.35-0.80] and 0.09 [0.07-0.12]), shorter length of stay (LOS, 4.64 [4.43-4.87] days vs. 8.87 [8.40-9.37] and 6.62 [6.52-7.13] days), lower total hospital cost (THC, $41,055 [$37,995-$44,361] vs. $72,598 [$66,768-$78,937] and $68,737 [$64,028-$73,793]), and better outcomes. Similarly, among those who received early endoscopy, colonoscopy had better outcomes than sigmoidoscopy for mortality, THC, LOS, and adverse events. CONCLUSION: Early endoscopy, especially colonoscopy, is associated with better clinical outcomes and decreased healthcare utilization in IB. Unfortunately, there are disparities against Blacks, and non-privately insured individuals in receiving early endoscopy.

Predictors, rates, and trends of opioid use disorder among patients hospitalized with chronic pancreatitis.

BACKGROUND: Patients with chronic pancreatitis (CP) suffer from pain and receive increased opioid prescriptions with a high risk of opioid use disorder (OUD). We studied the predictors, trends and outcomes of OUD among patients hospitalized with CP. METHODS: Records with CP (with/without OUD) were extracted from the Nationwide Inpatient Sample (NIS) 2012-2014, and the association of OUD with the burden of CP was calculated. We then charted the trends of OUD and its interaction with concomitant CP from NIS 2007-2014 (SAS 9.4). RESULTS: In the period 2012-2014, 4349 (4.99%) of the 87,068 CP patients had concomitant OUD, with higher risk among patients who were young, females, white vs. Hispanics, and individuals with chronic back pain, arthritis, non-opioid substance use, mental health disorders, and those hospitalized in urban centers. OUD was associated with a longer hospital stay (6.9 vs. 6.5 days, P=0.0015) but no significant difference in charges ($47,151 vs. $49,017, P=0.0598) or mortality (1.64% vs. 0.74%, P=0.0506). From 2007-2014, the average yearly rate of OUD was 174 cases per 10,000 hospitalizations (174/10,000), almost 3 times higher among CP vs. non-CP (479/10,000 vs. 173/10,000, P<0.001), and it increased from 2007 to 2014 (135/10,000 to 216/10,000, P<0.001). The yearly increase was 2.7 times higher among patients with CP vs. non-CP (29.9/10,000 vs. 11.3/10,000 hospitalizations/year, P<0.001). CONCLUSIONS: CP is associated with higher rates and trends of OUD. Patients with CP at high risk of OUD may benefit from alternate analgesic regimens or surveillance for OUD when they are prescribed opioids.

Asians Have Higher Risk of Developing Pancreatic Necrosis in Inflammatory Bowel Disease Patient Population: A National Inpatient Sample Database Study.

Background  The aim of this study is to evaluate race-associated risk factors of acute pancreatitis (AP) in inflammatory bowel disease (IBD) patients. Methods  A retrospective analysis using 2016 and 2017 National Inpatient Sample database was performed. Inclusion criteria were principal diagnosis of AP and a secondary diagnosis of IBD. Patients below 18 years of age were excluded. The primary outcome was in-hospital mortality rate and secondary outcomes included pancreatic necrosis, surgical necrosectomy, total hospitalization charges, total parenteral nutrition use, and length of stay. For the primary and secondary outcomes, adjusted odds ratios (aORs) and mean difference calculation using multivariate regression were calculated. Results A total of 7,060 patients with AP in IBD were identified; of which 53.5% were female. The use of Medicaid was significantly higher in blacks (39.5%), Hispanics (32.6%), and Asian/Pacific Islanders (40%) compared to whites (19.9%). Approximately 63.2% of AP patients in IBD received care at an urban teaching hospital. Pancreatic necrosis was noted to be highest in Asians or Pacific Islanders compared to whites (aOR 12.62, 95% CI 1.00-159.3, p = 0.05). Conclusion Our study shows that racial disparities exist among AP in IBD patients with pancreatic necrosis being more common in Asians and Pacific Islanders compared to whites. Identification of potential causes of these disparities is of paramount importance to expand access to healthcare.

Inferior Outcomes of Patients With Acute Myocardial Infarction and Comorbid Protein-Energy Malnutrition.

BACKGROUND: Protein-energy malnutrition (PEM) diminishes amino acid and energy availability, impairing the body's healing capability after injury, such as in myocardial damage following acute myocardial infarction (AMI). AIMS: We sought to investigate the influence of PEM on clinical outcomes of AMI. METHODS: We identified records with a primary discharge diagnosis of AMI from the Nationwide Inpatient Sample (2012-2014), stratified by concomitant PEM. We matched PEM to no-PEM (1:1) using a greedy algorithm-based propensity methodology and estimated the impact of PEM on health outcomes (SAS 9.4). RESULTS: Of the 332,644 hospitalizations for AMI, 11,675 had concomitant PEM accounting for roughly $US 1.5 billion and over 119,792 hospital days. PEM was associated with older age (74.43- vs. 66.90-years; P < 0.0001), female sex (49.19% vs. 38.44%; P < 0.0001), black race (12.78% vs. 10.46%; P < 0.0001), and higher comorbidity burden (Deyo > 3: 32.77% vs. 16.69%; P < 0.0001). After propensity matching, PEM was associated with higher mortality (Adjusted odds ratio [AOR]: 1.59 [1.46-1.73]), cardiogenic shock (AOR: 2.26 [2.08-2.44]), discharge to secondary facilities (AOR: 2.21 [2.10-2.33]), charges ($135,500 [$131,956-139,139] vs. $81,084 [$79,241-82,970]), cardiac artery bypass surgery (AOR:1.81 [1.66-1.97]), intra-aortic balloon pump placement (AOR: 1.83 [1.65-2.04]) and longer length of stay (10.15- vs. 5.52-days). CONCLUSIONS: PEM is a predisposing factor for devastating clinical outcomes among AMI hospitalizations. Higher prevention, identification and management of PEM among high-risk individuals (older age, female sex, and black race) residing in the community are needed.

Predictors, burden and impact of cardiac arrhythmias among patients hospitalized with end-stage liver disease.

BACKGROUND: Cirrhotic cardiomyopathy, hyperammonemia, and hepatorenal syndrome predispose to cardiac arrhythmias in End-stage liver disease (ESLD). OBJECTIVES: Among ESLD hospitalizations, we evaluate the distribution and predictors of arrhythmias and their impact on hospitalization outcomes. METHODS: We selected ESLD records from the Nationwide Inpatient Sample (2007-2014), identified concomitant arrhythmias (tachyarrhythmias and bradyarrhythmias), and their demographic and comorbid characteristics, and estimated the effect of arrhythmia on outcomes (SAS 9.4). RESULTS: Of 57,119 ESLD hospitalizations, 6,615 had arrhythmias with higher odds with increasing age, males, jaundice, hepatorenal syndrome, alcohol use, and cardiopulmonary disorders. The most common arrhythmias were atrial fibrillation, cardiac arrest/asystole, and ventricular tachycardia. After propensity-matching (arrhythmia: no-arrhythmia, 6,609:6,609), arrhythmias were associated with 200% higher mortality, 1.7-days longer stay, $32,880 higher cost, and higher rates of shock, respiratory and kidney failures. CONCLUSIONS: Due to worse outcomes with arrhythmias, there is a need for better screening and follow-up of ESLD patients for dysrhythmias.

Ustekinumab dose escalation improves clinical responses in refractory Crohn's disease.

BACKGROUND: Clinicians often utilize off-label dose escalation of ustekinumab (UST) in Crohn's disease (CD) patients with disease refractory to standard dosing. Previous studies report mixed results with dose escalation of UST. METHODS: A retrospective observational study of 143 adult patients with CD receiving UST over a 33-month time period was conducted. Patients receiving UST at standard dosage for a minimum of 16 weeks were included in the analysis. Primary outcomes collected were clinical response [Physician Global Assessment Score (PGA) by >1] and remission (PGA = 0). Changes in clinical parameters were calculated for dose-escalated patients beginning with the time of dose switch (~42 weeks) and compared with a group of patients who were classified as "failing" standard dosing at 42 weeks who were not dose escalated. RESULTS: Dose escalation improved PGA by 0.47 ± 0.19 compared with patients remaining on every 8 weeks dosing (Q8 week), who worsened by 0.23 ± 0.23 (p < 0.05). Dose escalation decreased CRP 0.33 ± 0.19 mg/L and increased serum albumin 0.23 ± 0.06 g/dL (p < 0.05). Surprisingly, disease duration and prior CD surgeries inversely correlated with the need for dose escalation. CONCLUSION: Our results support UST Q4 week dose escalation for selected CD patients who fail to achieve remission on standard Q8 week dosing. Dose escalation improves clinical outcomes, prevents worsening disease severity, and positively impacts CRP and albumin levels. Together these data indicate that clinicians should attempt Q4 week UST dosing in refractory CD patients before switching to an alternative class of biologic therapy.

Among inpatients, ischemic bowel disease predisposes to Clostridium difficile infection with concomitant higher mortality and worse outcomes.

BACKGROUND AND AIMS: Clinical conditions resulting in hypoxia, hypoperfusion, anaerobic milieu within the gut, and intestinal epithelial breakdown, such as seen in heart failure, precipitates Clostridium difficile infection (CDI). Given that ischemic bowel disease (IB) typically results in similar changes within the gut, we investigated the relationship between CDI and IB, and the impact of CDI on the clinical outcomes of IB. PATIENTS AND METHODS: We initially performed a cross-sectional analysis on the 2014 Healthcare Cost and Utilization Project - Nationwide Inpatient Sample (NIS) patient's discharge records of ages 18 years and older, by estimating the crude and adjusted odds ratio (aOR) of CDI and IB as the outcome and predictor respectively. We then pooled data from the 2012-2014 NIS, identified, and compared mortality (and 15 other outcomes) between three groups: IB+CDI, IB-alone, and CDI-alone (Statistical Analysis System 9.4). RESULTS: In the 2014 NIS, records with IB (n=27 609), had higher rate and odds of CDI [3.95 vs. 1.17%, aOR: 1.89 (1.77-2.02)] than records without IB (n=5 879 943). The 2012-2014 NIS contained 1105 IB+CDI, 30 960 IB-alone, and 60 758 CDI-alone groups. IB+CDI had higher mortality [aOR: 1.44 (1.11-1.86)], length of stay [9.59 (9.03-10.20) vs. 6.12 (5.99-6.26) days], cost [$93 257 (82 892-104 919) vs. $63 257 (61 029-65 567)], unfavorable discharge disposition [aOR: 2.24 (1.91-2.64)] and poorer results across most of the other outcomes than IB-alone. Comparable results were found for IB+CDI versus CDI-alone. CONCLUSION: IB is a risk factor for CDI in hospitals. CDI is associated with higher mortality, longer length of stay, higher cost, unfavorable discharge, and many other poorer health outcomes in patients with IB.

Protein Energy Malnutrition Is Associated with Worse Outcomes in Sepsis-A Nationwide Analysis.

BACKGROUND: Protein-energy malnutrition (PEM), resulting from depleted energy and nutrient stores, compromises the body's defense systems and may exacerbate sepsis and its impact. However, population-based studies examining the association of PEM on the prevalence and health-care burden of sepsis are lacking. OBJECTIVE: To investigate the relationship between PEM and sepsis, influence of PEM on clinical outcomes of sepsis, and impact of PEM on trends in sepsis mortality. DESIGN: The primary study is a retrospective cohort analysis of the 2012-2014 National Inpatient Sample (NIS) patient discharge records. Secondary analyses are cross-sectional study on the 2014 NIS and trend analysis on 2007-2014 NIS. PARTICIPANTS/SETTING: The primary study included adult inpatient hospitalizations for sepsis in the United States. MAIN OUTCOME MEASURES: Mortality, complicated sepsis, and 10 other metrics of clinical outcomes and health care utilization. STATISTICAL ANALYSIS: First, patients with sepsis (2014 NIS) were stratified into two groups: uncomplicated (without shock) and complicated (with shock). The adjusted odds ratio of having sepsis (total, uncomplicated, and complicated) was estimated with PEM as predictor using logistic regressions (binomial and multinomial). Second, among patients with sepsis (2012-2014 NIS), PEM cases were matched to cases without PEM (no-PEM) using a greedy-algorithm based propensity-matching methodology (1:1), and the outcomes were measured with conditional regression models. Finally, the trend in mortality from sepsis was calculated, stratified by PEM status, as an effect modifier, using Poisson models (2007-2014 NIS). All models accounted for the complex sampling methodology (SAS 9.4). RESULTS: In 2014, PEM was associated with higher odds for sepsis (3.97 [3.89 to 4.05], P<0.0001) and complicated vs uncomplicated sepsis (1.74 [1.67 to 1.81], P<0.0001). From 2012-2014, about 18% (167,133 of 908,552) of hospitalizations for sepsis had coexisting PEM. After propensity matching, PEM was associated with higher mortality (adjusted odds ratio: 1.35 [1.32 to 1.37], P<0.0001), cost ($160,724 [159,517 to 161,940] vs $86,650 [85,931 to 87,375], P<0.0001), length of stay (14.8 [14.9 to 14.8] vs 8.5 [8.5 to 8.6] days, P<0.0001), adverse events, and resource utilization. Although mortality in sepsis has been trending down from 2007-2014 (-1.19% per year, P trend<0.0001), the decrease was less pronounced among those with PEM vs no-PEM (-0.86% per year vs -1.29% per year, P<0.0001). CONCLUSIONS: PEM is a risk factor for sepsis and associated with poorer outcomes among patients with sepsis. A concerted effort involving all health care workers in the prevention, identification, and treatment of PEM in community-dwelling people before hospitalization might mitigate against these devastating outcomes.

Voriconazole-induced Myositis in a Double Lung Transplant Recipient.

Voriconazole is a triazole antifungal agent commercially approved in 2002. It is commonly used in immunocompromised patients as a therapeutic and prophylactic agent. We present the case of a 26-year-old Caucasian female who is a double lung transplant recipient who presented with complaints of generalized left lower extremity swelling and extreme tenderness of her left thigh. Although her muscle enzymes were not significantly elevated, inflammatory changes were noticed on T2-weighted fat-suppressed short-TI inversion recovery (STIR) sequence magnetic resonance imaging (MRI). These findings were later confirmed with tissue biopsy. We hereby present the case of drug-induced myositis as a rare complication of voriconazole used as chemoprophylaxis in a double lung transplant recipient patient.

Ectopic Liver Tissue Mistakenly Diagnosed as a Right Atrial Myxoma.

Myxomas, metastatic tumors, thrombi, and vegetations top the differential diagnosis list of cardiac masses. We present a case of ectopic liver tissue, a far less common etiology of a right atrial mass, discovered incidentally on transthoracic echocardiography (TTE) of a 37-year-old female with multiple comorbidities who was referred to our facility for further management of left popliteal artery occlusion and right lower extremity cellulitis. We discuss further the categories, proposed pathogenesis, diagnostic approach, and potential complications of ectopic liver tissue.

A Rare Case of Herpes Simplex Virus-2 Hepatitis with Negative Serology.

Herpes simplex virus-2 (HSV2) hepatitis represents a rare but serious complication of HSV2 infection that can progress to acute liver failure (ALF). We describe a case of a pregnant teenager who presented with four days of fever, headache, malaise, nausea, and vomiting. She was initially misdiagnosed with sepsis of unclear source and treated with broad-spectrum antibiotics. Empiric acyclovir was started one week into her hospitalization despite negative serologies while awaiting HSV2 PCR leading to complete resolution of symptoms. Given its high mortality and nonspecific presentation, clinicians should consider HSV hepatitis in all patients with acute hepatitis especially in high-risk population.

Association between long-term NSAID use and opioid abuse among patients with breast cancer.

BACKGROUND: Improving survival rates among patients with breast cancer has been associated with an increase in the prevalence of co-morbidities like cancer-related pain. Opioids are an important component in the management of pain among these patients. However, the progression from judicious use to abuse defeats the aim of pain control. Non-steroidal anti-inflammatory drugs (NSAIDs) are recommended as the first step in cancer-related pain management. Due to their anti-inflammatory, anti-neoplastic and neuroprotective properties, NSAIDs have been shown to reduce the risk of progression of certain cancers including breast cancers. In this study, we assessed whether an association exists between long-term NSAID use and opioid abuse among breast cancer survivors. We also explored the relationship between long-term NSAID use and inpatient mortality and length of stay (LOS). METHODS: Using ICD-9-CM codes, we identified and selected women aged 18 years and older with breast cancer from the National Inpatient Sample. Our primary predictor was a history of long-term NSAID use. Multivariable regression models were employed in assessing the association between long-term NSAID use and opioid abuse, inpatient mortality and LOS. RESULTS: Among 170,644 women with breast cancer, 7,838 (4.6%) reported a history of long-term NSAID use. Patients with a history of long-term NSAID use had lower odds of opioid abuse (adjusted odds ratio (aOR) 0.53; 95% CI [0.32-0.88]), lower in-hospital mortality (aOR 0.52; 95% CI [0.45-0.60]) and shorter LOS (7.12 vs. 8.11 days). DISCUSSION: Further studies are needed to understand the underlying mechanism of the association between long-term NSAID use and opioid abuse.

Protein-Energy Malnutrition and Outcomes of Hospitalizations for Heart Failure in the USA.

Chronically elevated cytokines from un-abating low-grade inflammation in heart failure (HF) results in Protein-Energy Malnutrition (PEM). However, the impact of PEM on clinical outcomes of admissions for HF exacerbations has not been evaluated in a national data. From the 2012 to 2014 Nationwide Inpatient Sample (NIS) patient's discharge records for primary HF admissions, we identified patients with concomitant PEM, and their demographic and comorbid factors. We propensity-matched PEM cohorts (32,771) to no-PEM controls (1:1) using a greedy algorithm-based methodology and estimated the effect of different clinical outcomes (SAS 9.4). There were 32,771 (∼163,885) cases of PEM among the 541,679 (∼2,708,395) primary admissions for HF between 2012 and 2014 in the US. PEM cases were older (PEM:76 vs no-PEM:72 years), Whites (70.75% vs 67.30%), and had higher comorbid burden, with Deyo-comorbidity index >3 (31.61% vs 26.30%). However, PEM cases had lower rates of obesity, hyperlipidemia and diabetes. After propensity-matching, PEM was associated with higher mortality (AOR:2.48 [2.31 to 2.66]), cardiogenic shock (3.11[2.79 to 3.46]), cardiac arrest (2.30[1.96 to 2.70]), acute kidney failure (1.49[1.44 to 1.54]), acute respiratory failure (1.57[1.51 to 1.64]), mechanical ventilation (2.72[2.50 to 2.97]). PEM also resulted in higher non-routine discharges (2.24[2.17 to 2.31]), hospital cost ($80,534[78,496 to 82,625] vs $43,226[42,376 to 44,093]) and longer duration of admission (8.6[8.5 to 8.7] vs 5.3[5.2 to 5.3] days). In conclusion, PEM is a prevailing comorbidity among hospitalized HF subjects, and results in devastating health outcomes. Early identification and prevention of PEM in HF subjects during clinic visits and prompt treatment of PEM both in the clinic and during hospitalization are essential to decrease the excess burden of PEM.

Prevalence, trends, outcomes, and disparities in hospitalizations for nonalcoholic fatty liver disease in the United States.

BACKGROUND: As the frequency of nonalcoholic fatty liver disease (NAFLD) continues to rise in the United States (US) community, more patients are hospitalized with NAFLD. However, data on the prevalence and outcomes of hospitalizations with NAFLD are lacking. We investigated the prevalence, trends and outcomes of NAFLD hospitalizations in the US. METHODS: Hospitalizations with NAFLD were identified in the National Inpatient Sample (2007-2014) by their ICD-9-CM codes, and the prevalence and trends over an 8-year period were calculated among different demographic groups. After excluding other causes of liver disease among the NAFLD cohorts (n=210,660), the impact of sex, race and region on outcomes (mortality, discharge disposition, length of stay [LOS], and cost) were computed using generalized estimating equations (SAS 9.4). RESULTS: Admissions with NAFLD tripled from 2007-2014 at an average rate of 79/100,000 hospitalizations/year (P<0.0001), with a larger rate of increase among males vs. females (83/100,000 vs. 75/100,000), Hispanics vs. Whites vs. Blacks (107/100,000 vs. 80/100,000 vs. 48/100,000), and government-insured or uninsured patients vs. privately-insured (94/100,000 vs. 74/100,000). Males had higher mortality, LOS, and cost than females. Blacks had longer LOS and poorer discharge destination than Whites; while Hispanics and Asians incurred higher cost than Whites. Uninsured patients had higher mortality, longer LOS, and poorer discharge disposition than the privately-insured. CONCLUSIONS: Hospitalizations with NAFLD are rapidly increasing in the US, with a disproportionately higher burden among certain demographic groups. Measures are required to arrest this ominous trend and to eliminate the disparities in outcome among patients hospitalized with NAFLD.

Acute Severe Hyponatremia as a Serious Health Implication of Herbal Detox Regimens.

Hyponatremia is a serious health problem and can cause substantial morbidity and mortality as a result of osmotically induced cerebral edema if left untreated. Also, inappropriate rapid correction of chronic cases of hyponatremia can lead to osmotic demyelination with neurological impairment and death as consequences. It is defined as a serum sodium concentration less than 135 mmol/L. Herbal detox regimens are gaining popularity with their easy access over the counter and not well studied adverse effects. We hereby present a case of a 67-year-old man who developed severe hyponatremia after starting a five-day kidney detox regime. This regime consisted of drinking over a gallon (128 oz) of fluid daily, herbal tea with Uva Ursi leaves, juniper berries and several other ingredients. On the last day of this detox regime, he presented to the emergency department with a critical serum sodium level of 111 mmol/L associated with neurological symptoms. The purpose of this case report is to highlight the potential serious adverse effects associated with what is considered benign herbal medicine.