Comparison of the Safety of Transjugular and Percutaneous Liver Biopsies.

PURPOSE: To compare adverse events (AEs) between the transjugular liver biopsy (TJLB) and percutaneous liver biopsy (PLB) approaches. MATERIALS AND METHODS: A total of 1,300 patients who underwent liver biopsy between July 1, 2014 and January 31, 2018, were examined, and bivariate and multivariate analyses were used to determine predictors of the biopsy method used and AEs. To reduce bias in the comparison of the AE rates between patients who had TJLB or PLB, propensity score matching was used to control for baseline disease severity. RESULTS: PLB and TJLB were performed in 601 and 699 patients, respectively. The mean Charlson Comorbidity Index score was 3 (±2), and antiplatelet or anticoagulation therapy at the time of biopsy was used in <10% of patients. Patients with suspected cirrhosis or portal hypertension (odds ratio [OR], 9.9), an international normalized ratio of >1.5 (OR, 5.9), or a platelet count of <100 × 103/mL (OR, 3.9) were more likely to undergo TJLB. After propensity matching, which identified a population of patients with a mean international normalized ratio of <1.5 and platelet count of >150 × 103/mL, the only difference in the AE rate was for pain, which was present in 8% and 10% of patients after TJLB and PLB, respectively (P < .001). Bleeding requiring transfusion occurred in 2 patients who underwent TJLB and 1 patient who underwent PLB. There was 1 case of death occurring after TJLB. CONCLUSIONS: Severe/life-threatening AEs occurring after liver biopsy were uncommon, and the 2 liver biopsy approaches appeared to have similar safety profiles for low-risk patients. After matching for underlying disease severity, pain was the AE that was more likely to occur in patients who underwent PLB.

Role of Liver Biopsy in Assessment of Radiologically Identified Liver Masses.

BACKGROUND: Despite improvements in imaging techniques that have enhanced the ability to diagnose hepatocellular carcinoma (HCC), histopathological evaluation of many other types of liver masses is critical. AIMS: To evaluate the utility of liver biopsy in patients with radiologically undiagnosed liver masses. METHODS: We retrospectively analyzed 293 consecutive patients who had a liver biopsy for evaluation of an undiagnosed liver mass between January 2014 and January 2018. RESULTS: Out of 293 biopsies, 246 patients were found to have malignancy (84%), including 210 (72%) patients with metastatic malignancy and 36 with primary hepatic malignancies (20 HCC and 16 others). In the 47 patients without malignancy, 17 patients had necrotic abscess/granuloma, 16 patients had normal histology, eight patients had hepatic fibrosis/cirrhosis without malignant foci, and six patients had benign tumors. The most common primary lesion in patients with liver metastasis was breast carcinoma (32/293, 11%), followed by colon and pancreas (31 (each)/293, 11%), and lung (9%) adenocarcinomas. Histopathological analysis confirmed the presence of metastasis in 165/200 (83%) patients with a history of oncological malignancy and in 45/93 (48%) patients who had no malignancy history. CONCLUSIONS: In patients with a radiologically identified liver mass of unclear etiology, liver biopsy/histology made a diagnosis in 95% (277/293) of patients, including 84% (246/293) found to have an oncological malignancy. Liver biopsy/histology also identified malignancy in a high proportion of patients without known underlying cancer. We conclude that liver biopsy is valuable for evaluation of radiologically identified liver masses of unclear etiology.

Variability and Lability of Ammonia Levels in Healthy Volunteers and Patients With Cirrhosis: Implications for Trial Design and Clinical Practice.

INTRODUCTION: Ammonia levels are used to assess hepatic encephalopathy, but their levels are highly variable in clinical practice. METHODS: We studied factors associated with variation in ammonia values in cirrhotic patients without previous hepatic encephalopathy and healthy volunteers (HVs). RESULTS: Ammonia increased by 12% and 18% at 1 and 2 hour, respectively, after a protein meal in 64 cirrhotic patients (P < 0.001). In 237 HVs, ammonia levels varied significantly between sites (P < 0.0001). New site-specific ammonia upper limits based on HV levels using a strict analysis protocol differed from routinely used values. Correlation between paired fresh samples was high (r = 0.83) but modest between fresh and frozen samples (r = 0.62). DISCUSSION: Sample handling, processing, and protein intake impact ammonia levels across sites.

Cirrhotic Patients on Mechanical Ventilation Have a Low Rate of Successful Extubation and Survival.

BACKGROUND AND AIMS: We hypothesized that mechanically ventilated cirrhotic patients not only have poor outcomes, but also that certain clinical variables are likely to be associated with mortality. We aimed to describe the predictors of mortality in these patients. METHODS: This observational study examined 113 mechanically ventilated cirrhotic patients cared for at our institution between July 1, 2014, and February 28, 2018. We performed bivariate and multivariate analyses to identify risk factors for mortality on mechanical ventilation and created an equation to calculate probability of mortality based on these variables. RESULTS: Seventy percent of patients had a history of a decompensating event. Altered mental status was the most frequently encountered indication for intubation (46%). 53% patients died on mechanical ventilation. After controlling for variables associated with increased mortality, multivariate analysis revealed that vasopressor use was the strongest predictor of mortality on mechanical ventilation (OR = 9.3) followed by sepsis (OR = 4.1). A formula with an area under the curve of 0.85 was obtained in order to predict the probability of mortality for cirrhotic patients on mechanical ventilation (available at https://medweb.musc.edu/mvcp/ ). This model (AUC = 0.85) outperformed the CLIF-SOFA score (AUC = 0.68) in predicting mortality in this cohort. CONCLUSION: Cirrhotic patients requiring mechanical ventilation have an extremely poor prognosis, and in patients requiring vasopressors, having a history of decompensation, sepsis or low albumin, mortality is higher. Our data points to the clinical variables should be considered in the medical management of these patients and provide physicians with a formula to predict the probability of mortality.

Controversies in anticoagulation therapy in patients with cirrhosis.

PURPOSE OF REVIEW: This article aims to review the latest literature on prophylactic and therapeutic anticoagulation and the safety profile of anticoagulants in patients with cirrhosis. RECENT FINDINGS: The understanding of hematological hemostasis is cirrhotic patients has changed drastically in recent years. Although in the past, cirrhotic patients were often considered to be 'auto-anticoagulated' and at higher risk of bleeding, recent studies have demonstrated that there may be a rebalance in procoagulation and anticoagulation factors in patients with cirrhosis. This, and clinical experience, suggest that cirrhotic patients are at risk of development of venous thrombosis, pulmonary embolism and ischemic strokes and as such, the best management approaches in these patients remains controversial. The bulk of the data suggest that patients with cirrhosis who are at risk for thrombotic or embolic complications should be anticoagulated. However, it is imperative that they be closely monitored. SUMMARY: The medical literature on anticoagulation in patients with liver cirrhosis is conflicting and limited to small sample observational studies. However, most studies suggest that in patients with early stages of liver cirrhosis and no history of varices, anticoagulation appears to be well tolerated.

Emergency Medical Services Utilization and Outcomes of Patients with ST-Elevation Myocardial Infarction in Lebanon.

BACKGROUND: Arrival of patients with ST-elevation myocardial infarction (STEMI) by Emergency Medical Services (EMS) results in shorter reperfusion times and lower mortality in developed countries. OBJECTIVES: This study examines EMS use by STEMI patients in Lebanon and associated clinical outcomes. METHODS: A retrospective observational study with chart review was carried out for STEMI patients arriving to the Emergency Department of a tertiary care center in Lebanon between January 1, 2013 and August 31, 2016. A descriptive analysis was done and followed by a bivariate analysis comparing two groups of patients (EMS vs. Non-EMS). RESULTS: A total of 280 patients were included in the study. They were mostly male (71.8%). Mean age was 65.1 years (95% confidence interval [CI] 63.4-66.9). Only 12.5% (95% CI 8.6-16.4) presented by EMS. Chest pain (81.1%) was the most common presenting symptom. Anterior myocardial infarction was the most common electrocardiogram (ECG) diagnosis (51.4%). Most patients were admitted (98.2%), and 72.0% of these patients were treated with primary percutaneous coronary intervention. Cardiogenic shock was the most frequent in-hospital complication (6.2%). The mortality rate was 7.1%. Mean door-to-ECG and door-to-balloon times were 10.8 (95% CI 7.1-14.4) min and 106.2 (95% CI 95.9-116.6) min, respectively. Patients' characteristics, presenting symptoms, outcomes, and performance metrics were similar between the two groups. CONCLUSION: EMS is underutilized by STEMI patients in Lebanon and is not associated with improvement in clinical outcomes. Medical oversight and quality initiatives focusing on outcomes of patients with timely sensitive emergencies are needed to advance the prehospital care system in Lebanon.

Safety of Nonselective Beta-Blockers in Decompensated Liver Cirrhosis and Their Role in Inducing Hepatorenal Syndrome.

Background Nonselective beta-blockers (NSBBs) have been used in the management of portal hypertension and the prevention of initial and recurrent variceal bleeding in patients with liver cirrhosis. However, there is controversy regarding the use of NSBBs in patients with decompensated cirrhosis (DC) due to concerns over potential adverse effects, such as worsening of hepatic function and risk of hepatorenal syndrome (HRS). HRS is a serious complication of DC characterized by acute kidney injury (AKI) and progressive renal failure, and its development can lead to significant morbidity and mortality in this setting. Therefore, using NSBBs in patients with DC remains an area of ongoing research and debate. Our study aims to investigate the potential effect of NSBBs on HRS development. Methodology A retrospective chart review of 404 patients with cirrhosis was performed across all Northwell Health institutions between January 01, 2019, and December 31, 2020. An analysis was done on 516 patient encounters. Inclusion criteria included patients with an established International Classification of Diseases 10th Revision code of cirrhosis and AKI. After adjusting for clinical predictors, the Student's t-test or Mann-Whitney U-test was used to compare variables between the two outcome groups (HRS vs. no HRS) for the continuous variables. Pearson's chi-square test or Fisher's exact test was used for the categorical variables to test if an association existed between the use of NSBBs at home and HRS. A two-sided p-value <0.05 was considered statistically significant. SAS 9.4 (SAS Institute Inc., Cary, NC, USA) was used for statistical analysis. Results The primary outcome was the development of HRS during the hospital stay. With a total of 109 visits with HRS, we had 21 (23.60%) reported HRS in the 89 visits where NSBBs were used at home before the hospitalization, while 88 (20.61%) HRS were observed in the 427 visits with no NSBB use at home. The use of NSBBs at home was not significantly associated with the development of HRS (odds ratio = 1.1, 95% confidence interval = 0.6-1.9, p = 0.7321). We also found that higher serum albumin on admission is associated with lower odds of HRS. In contrast, increased serum creatinine, bilirubin, presence of ascites, and use of pressors were associated with a higher risk of HRS. Conclusions Our study highlights the relevant safety of NSBB use in end-stage liver disease. Their use did not appear to increase the risk of developing HRS during hospitalization with DC. Further randomized controlled trials are warranted to shed more light on the efficacy, dose tolerance limits, and safety of NSBBs in decompensated end-stage liver disease.

The Evolution of Iron-Related Comorbidities and Hospitalization in Patients with Hemochromatosis: An Analysis of the Nationwide Inpatient Sample.

Hemochromatosis, either hereditary hemochromatosis (HH) or secondary hemochromatosis, consists of the accumulation of iron in the liver, heart, and other organs. It leads to end-organ damage in a proportion of affected subjects. Although liver-related morbidity (cirrhosis and hepatocellular carcinoma [HCC]) and mortality are well established, the frequency of these complications remains controversial. The aim of this study is to examine the rate of hospitalization and the incidence of iron overload-related comorbidities in patients with hemochromatosis between the years of 2002 and 2010. We queried the Nationwide Inpatient Sample (NIS) database from the year 2002 to 2010. We included adults (age ≥18 years) and used the ICD-CM 9 code 275.0x to identify hospitalized patients with a diagnosis of hemochromatosis. Data analysis for this study was generated using SAS software version 9.4. A total of 168,614 hospitalized patients between 2002 and 2010 had a diagnosis of hemochromatosis. The majority were males (57%) with a median age of 54 years (37-68), with a predominance of white patients (63.3%) followed by black (26.8%). The rate of hospitalization among patients with hemochromatosis increased by 79% between the years 2002 and 2010 (34.5/100,000 in 2002 vs 61.4/100,000 in 2010). The main associated diagnoses were diabetes mellitus (20.2%), cardiac disease, including arrhythmias (14%) and cardiomyopathy (dilated 3.8%; peri-, endo-, myocarditis 1.3%), liver cirrhosis (8.6%), HCC (1.6%), and acute liver failure (0.81%). Of note, HCC was associated with cirrhosis in 1188 patients (43% of HCC patients) and male sex (87%). Diagnostic biopsies were performed in 6023 (3.6%) of those patients and liver transplant was performed in 881 (0.5%). In-hospital mortality occurred in 3638 (2.16%) patients. In this large database study, we found a rising trend in hospitalization for hemochromatosis, possibly due to the increased recognition of this entity and billing for the condition. The incidence of cirrhosis in hemochromatosis was found to be similar to other studies (8.6% vs 9%). However, the rate of HCC was lower than previous reports (1.6% vs 2.2%-14.9%), and only 43% of HCC was associated with cirrhosis. This raises important pathophysiologic questions regarding the impact of iron overload in HCC. There has been an increase in the rate of hospitalization for patients with a diagnosis of hemochromatosis. This may be related to an increased recognition of hemochromatosis as the underlying etiology for conditions such as diabetes, cardiomyopathy, cirrhosis, and HCC. Further prospective studies are needed to clarify the burden of liver disease in HH and secondary iron overload.

Infection in Hospitalized Cirrhosis Patients: Changing Epidemiology and Clinical Features.

BACKGROUND: Patients with cirrhosis are uniquely predisposed to infections, which can lead to acute decompensation and an increase in mortality rates. We hypothesized that not only are cirrhotic patients more likely to develop certain infections, but that specific infections are associated with poorer outcomes. Therefore, we aimed to examine the epidemiology, bacteriology, and outcomes of infections in cirrhotic patients admitted to the hospital. METHODS: In this single center observational retrospective cohort study, we identified admissions in which patients had an infection from a group of all admissions of cirrhotics from 2011-2016. Infections were categorized by the primary source of infection, and rigorous clinical and bacteriologic definitions were used. RESULTS: We identified 1,208 admissions in 877 unique patients during the study period. The most common infections identified were as follows: urinary tract infections (33%), pneumonia (23%), spontaneous bacterial peritonitis (14%), and bacteremia (11%). Gram-positive organisms were most commonly isolated in patients with spontaneous bacterial peritonitis and bacteremia, whereas gram-negative bacteria were most prevalent in urinary tract infections and pneumonia. Candida infections were common and identified in the following proportions: spontaneous bacterial peritonitis (16%), pneumonia (14%), bacteremia (13%), and urinary tract infections (9%). Pneumonia, spontaneous bacterial peritonitis, and meningitis were associated with increased mortality rates (29%, 32%, and 67%, respectively), compared to the overall mortality rate of 20% (p-value < 0.05). CONCLUSIONS: In summary, infections were common in patients with cirrhosis and were associated with poor outcomes, particularly in the presence of evidence of sepsis. Spontaneous bacterial peritonitis and bacteremia are now most commonly due to gram-positive organisms and fungal infections appear to be rising in prevalence.

Non-selective beta-blocker use in cirrhotic patients is associated with a reduced likelihood of hospitalisation for infection.

BACKGROUND: Non-selective beta-blockers (NSBBs) reduce enteric bacterial translocation rates and the frequency of spontaneous bacterial peritonitis (SBP) in animal models. AIM: To evaluate the effect of NSBBs on infection-related admissions. METHODS: We performed a case-control study of cirrhotic patients' first in-patient admission between 1 January 2011 and 31 December 2016. We examined NSBB use and the development of infection. We performed a propensity score-matched analysis in those with NSBB use vs no use and calculated odds ratios on this matched cohort to determine the odds of outcomes based on NSBB use. RESULTS: We identified 2165 cirrhotic patients who met our inclusion criteria. Most patients were Caucasian (69%), male (62%). Admission Model for End stage Liver Disease (MELD) score, Charlson comorbidity index and Child-Pugh score were 12 ± 1, 4 ± 2, and 8 ± 2, respectively. Ascites was the most common complication of portal hypertension (44%); 23% of patients used NSBBs at home. Infections occurred in 33% of admissions. In the propensity score-matched cohort, the use of NSBBs at home was associated with lower overall, and specific, infections. The effect was similar in patients taking NSBBs for either primary or secondary oesophageal variceal prophylaxis and for those on NSBBs for other indications. Patients not on NSBBs had higher odds of infection (OR = 2.5), SBP (OR = 4.0), and bacteraemia (OR = 6.0). CONCLUSION: Home use of NSBBs by patients with cirrhosis was associated with fewer infection-related admissions. The data suggest that NSBBs in this group of patients reduce the risk of infection.

Predictors of Development of Hepatorenal Syndrome in Hospitalized Cirrhotic Patients with Acute Kidney Injury.

Hepatorenal syndrome (HRS) is a type of acute kidney injury (AKI), occurring in patients with decompensated liver cirrhosis and is associated with high mortality. We aim to describe the predictors associated with the development of HRS in cirrhotic patients with AKI. We retrospectively analyzed 529 cirrhotic patient encounters with AKI across all Northwell Health institutions between 1 January 2015 and 31 December 2018. We performed multivariate analyses to determine independent predictors of development of HRS. Alcoholic cirrhosis was the most common identified etiology of cirrhosis. The mean Model for End-Stage Liver Disease Scorewas18 (±7). Ascites was the most commonly identified clinical feature of portal hypertension. Infection was identified in 38.4% of patients with urinary tract infection/pyelonephritis being the most common. Spontaneous bacterial peritonitis occurred in 5.9% of patients. The most common cause of AKI was pre-renal. Hepatorenal syndrome was identified in 9.8% of patient encounters. Predictors of HRS were history of ascites, serum creatinine >2.5 mg/dL, albumin <3 g/dL, bilirubin >2 mg/dL and spontaneous bacterial peritonitis. We demonstrate strong predictors for the development of HRS which can aid clinicians to attain an early diagnosis of HRS, leading to prompt and targeted management and improving outcomes.

Hemoglobin Monitoring in Acute Gastrointestinal Bleeding: Are We Monitoring Blood Counts Too Frequently?

BACKGROUND: Gastrointestinal hemorrhage is a common cause of hospital admission. However, there are little data to inform practice around blood count monitoring-a cornerstone of management. We hypothesized that more frequent testing leads to increased resource utilization without improvement in patient outcomes. METHODS: This retrospective observational cohort study examined all patients admitted to a large academic medical institution primarily for gastrointestinal bleeding between July 10, 2014, and January 1, 2018. We identified 1150 patients admitted for gastrointestinal hemorrhage. Patients under 18, who developed bleeding while hospitalized, or who were transferred were excluded. The primary outcome was the number of complete blood counts collected in the first 48 hours of admission. Propensity matched analysis was performed to assess blood transfusion, units of blood transfused, time-to-endoscopy, mortality, and 30-day readmission rate. RESULTS: On average, 5.6 complete blood counts were collected in the first 48 hours; 67% of the cohort was transfused (average of 2.6 units of packed red blood cells). When matched for comorbidity, anticoagulant use, location (ward vs. intensive care unit), vital signs, hemoglobin level, and international normalized ratio, patients having more frequent monitoring had similar hospital length of stay and mortality rates, but were more likely to receive a blood transfusion (0.93 vs 0.76, P < .05), and if transfused, receive more blood (4 vs 2 units, P < .05). CONCLUSIONS: Blood count monitoring occurs more frequently than is likely necessary, is associated with a higher likelihood of blood transfusion, and does not affect patient outcomes, suggesting patient care may be improved by less frequent monitoring.

The Utility of Liver Biopsy in the Evaluation of Liver Disease and Abnormal Liver Function Tests.

OBJECTIVES: We aimed to assess the value of liver biopsy in the evaluation of abnormal liver tests. METHODS: We analyzed consecutive liver biopsy specimens performed for evaluation of unexplained abnormal liver tests from 2014 to 2018. Diagnoses were categorized histologically and clinically. We determined whether histologic examination led to a specific diagnosis and whether prebiopsy laboratory variables predicted the underlying etiology. RESULTS: Among the 383 liver biopsy specimens included, chronic hepatitis was the most common histologic (25%) and clinical (17%) diagnosis. Liver biopsy led to a clinical diagnosis in 87% of patients. The most likely clinical diagnoses were autoimmune hepatitis, nonalcoholic fatty liver disease, and drug-induced liver injury (38, 33, and 32 patients, respectively). Using sensitivity, specificity, and positive and negative predictive values, we found that liver tests were not predictive of a specific diagnosis. In patients with no history of liver disease or clinical features of portal hypertension, biopsy specimens revealed histologic cirrhosis in 5% of patients. CONCLUSIONS: Histopathologic diagnoses were made in 85% of patients undergoing liver biopsy for investigation of unexplained liver tests, leading to a clinical diagnosis in 87% of patients. However, neither liver tests themselves nor their patterns were useful in predicting histologic or clinical diagnoses.

Anticoagulation Therapy in Patients with Liver Cirrhosis is Associated With an Increased Risk of Variceal Hemorrhage.

OBJECTIVE: The belief that cirrhotic patients are "auto-anticoagulated" often results in anticoagulation therapy being withheld in these patients. We aimed to understand patterns of use of anticoagulation and to determine the risk of bleeding complications in cirrhotic patients. METHODS: We retrospectively analyzed 320 cirrhotic patients treated with anticoagulation therapy from July 15, 2014 to January 30, 2018. We performed bivariate and multivariate analyses to identify risk factors for clinically relevant bleeding. We conducted a separate analysis using propensity score matching to compare bleeding rates of a noncirrhotic cohort group on anticoagulation to anticoagulated patients with cirrhosis. RESULTS: Nonalcoholic steatohepatitis (47%) was the most common cause of cirrhosis, and 49% were classified as Child-Pugh class B, a mean model for end-stage liver disease score of 14 and Charlson comorbidity index of 7. Anticoagulation was initiated for atrial fibrillation/atrial flutter in 56% of patients; warfarin was used in 57% of patients and concomitant use of antiplatelet therapy in 25%. Bleeding occurred in 18%, with upper gastrointestinal bleeding (53%) being the most common source. In the propensity-matched cohort, bleeding rates were higher in cirrhotics than in control patients who were matched for baseline characteristics. In multivariate analysis of the cirrhotic patients, the presence of esophageal varices was associated with higher odds of clinically relevant bleeding. CONCLUSION: Anticoagulated cirrhotic patients who have esophageal varices are at an increased risk of bleeding. We recommend that patients with cirrhosis and esophageal varices who require anticoagulation have their varices managed carefully prior to initiation of anticoagulation.

Riots in Beirut: Description of the Impact of a New Type of Mass Casualty Event on the Emergency System in Lebanon.

INTRODUCTION: In the summer of 2015, Beirut experienced a garbage crisis that led to rioting. Riot control measures resulted in multiple casualties. This study examines injury patterns of riot victims presenting to the emergency department of a tertiary care center in a developing country. METHODS: A retrospective study was conducted in the emergency department of the American University of Beirut Medical Center between August 22 and August 30, 2015. Patients seen in the emergency department with riot injuries were included. Patient characteristics, injuries, and resources utilized in the emergency department were analyzed. RESULTS: Ninety-five patients were identified. Most patients presented to the emergency department within a short time period. The mean age of the patients was 28.0 ± 8.7 years. Most (90.5%) of the patients were males and 92.6% were protestors. Emergency medical services were utilized by 41.0% of patients. Laceration was the most common presenting complaint (28.5%), and blunt trauma was the most common type of injury (50.5%). The head/face/neck was the most common injured body region (55.8%). Most patients did not require blood tests or procedures (91.6% and 61.0%, respectively), and 91.2% of patients were treated in the emergency department and discharged. One patient required intensive care unit admission and another was dead on arrival. CONCLUSIONS: Most patients had mild injuries on presentation. The emergency department experienced a high influx of patients. Complications and deaths can occur from seemingly nonlethal weapons used during riots and warrant effective prehospital and hospital disaster planning.

Suffocation Injuries in the United States: Patient Characteristics and Factors Associated with Mortality.

INTRODUCTION: Asphyxiation or suffocation injuries can result in multi-organ damage and are a major cause of morbidity and mortality among different age groups. This study aims to describe characteristics of patients presenting with suffocation injuries to emergency departments (EDs) in the United States (U.S.) and to identify factors associated with mortality in this population. METHODS: We conducted a retrospective cross-sectional study using the 2013 U.S National Emergency Department Sample database. ED visits with primary diagnoses of intentional or accidental suffocation injury, and injury by inhalation and aspiration of foreign bodies or food (ICD-9-CM codes) were included. We performed descriptive statistics to describe the study population. This was followed by multivariate analyses to identify factors associated with mortality. RESULTS: We included a total of 27,381 ED visits for suffocation injuries. Most suffered from either inhalation and ingestion of food causing obstruction of respiratory tract or suffocation (51.6%), or suicide and self-inflicted injury by hanging, strangulation, and suffocation (39.4%). Overall mortality was 10.9%. Over half (54.7%) of the patients were between 19 and 65 years old. Males were more common than females (59.1% vs. 40.9%). Over half of the patients (54.9%) were treated and released from the ED. Factors associated with increased mortality included male gender, young age (4-18 years), diseases of the cardiac, respiratory, genitourinary and neurologic systems, intentional self-harm, and self-payer status. CONCLUSION: Mortality from suffocation injuries remains high with significant burden on children and adolescents and on patients with intentional injuries. Tailored initiatives targeting identified modifiable factors through implementation of behavioral and environmental change can reduce the risk of suffocation injury and improve clinical outcomes of affected victims.

Patient-Physician Communication in the Era of Mobile Phones and Social Media Apps: Cross-Sectional Observational Study on Lebanese Physicians' Perceptions and Attitudes.

BACKGROUND: The increased prevalence of virtual communication technology, particularly social media, has shifted the physician-patient relationship away from the well-established face-to-face interaction. The views and habits of physicians in Lebanon toward the use of online apps and social media as forms of patient communication have not been previously described. OBJECTIVE: The aim of this study is to describe the views of Lebanese physicians toward the use of social media and other online apps as means of patient communication. METHODS: This was a cross-sectional observational study using an online survey that addressed physicians' perceptions on the use of virtual communication in their clinical practice. The study took place between April and June 2016, and was directed toward physicians at the American University of Beirut Medical Center. RESULTS: A total of 834 doctors received the online survey, with 238 physicians completing the survey. Most of the participants were from medical specialties. Most responders were attending physicians. Less than half of the respondents believed that Web-based apps and social media could be a useful tool for communicating with patients. Email was the most common form of professional online app, followed by WhatsApp (an instant messaging service). The majority of participants felt that this mode of communication can result in medicolegal issues and that it was a breach of privacy. Participants strictly against the use of virtual forms of communication made up 47.5% (113/238) of the study sample. CONCLUSIONS: The majority of physicians at the American University of Beirut Medical Center are reluctant to use virtual communication technology as a form of patient communication. Appropriate policy making and strategies can allow both physicians and patients to communicate virtually in a more secure setting without fear of breaching privacy and confidentiality.