Ulcer Bleeding in the United States: Epidemiology, Treatment Success, and Resource Utilization.

BACKGROUND AND GOALS: Peptic ulcer disease is the most frequent cause of upper gastrointestinal bleeding. We sought to establish the epidemiology and hemostasis success rate of the different treatment modalities in this setting. METHODS: Retrospective cohort study using the National Inpatient Sample. Non-elective adult admissions with a principal diagnosis of ulcer bleeding were included. The primary outcome was endoscopic, radiologic and surgical hemostasis success rate. Secondary outcomes were patients' demographics, in-hospital mortality and resource utilization. On subgroup analysis, gastric and duodenal ulcers were studied separately. Confounders were adjusted for using multivariate regression analysis. RESULTS: A total of 136,425 admissions (55% gastric and 45% duodenal ulcers) were included. The mean patient age was 67 years. The majority of patients were males, Caucasians, of lower income and high comorbidity burden. The endoscopic, radiological and surgical therapy and hemostasis success rates were 33.6, 1.4, 0.1, and 95.1%, 89.1 and 66.7%, respectively. The in-hospital mortality rate was 1.9% overall, but 2.4% after successful and 11.1% after failed endoscopic hemostasis, respectively. Duodenal ulcers were associated with lower adjusted odds of successful endoscopic hemostasis, but higher odds of early and multiple endoscopies, endoscopic therapy, overall and successful radiological therapy, in-hospital mortality, longer length of stay and higher total hospitalization charges and costs. CONCLUSIONS: The ulcer bleeding endoscopic hemostasis success rate is 95.1%. Rescue therapy is associated with lower hemostasis success and more than a ten-fold increase in mortality rate. Duodenal ulcers are associated with worse treatment outcomes and higher resource utilization compared with gastric ulcers.

Utilization and access to healthcare services among community-dwelling people living with spinal cord injury.

OBJECTIVE: Describe the utilization, accessibility, and satisfaction of primary and preventative health-care services of community-dwelling individuals with spinal cord injury (SCI). DESIGN: Cross sectional, in-person or telephonic survey, utilizing a convenience sample. SETTING: Community. PARTICIPANTS: Individuals with SCI greater than 12-months post injury. INTERVENTIONS: N/A. OUTCOME MEASURES: Demographic, injury related, and 34-item questionnaire of healthcare utilization, accessibility, and satisfaction with services. RESULTS: The final sample consisted of 142 participants (50 female, 92 male). Ninety-nine percent of respondents had a healthcare visit in the past 12-months with primary care physicians (79%), with SCI physiatrists (77%) and urologists (50%) being the most utilized. 43% of the sample reported an ER visit within the past 12-months, with 21% reporting multiple visits. People who visited the ER had completed significantly less secondary education (P = 0.0386) and had a lower estimate of socioeconomic status (P = 0.017). The majority of individuals (66%) were satisfied with their primary care physician and 100% were satisfied with their SCI physiatrist. Individuals who did not visit an SCI physiatrist were significantly more likely to live in a rural area (P = 0.0075), not have private insurance (P = 0.0001), and experience a greater decrease in income post injury (P = 0.010). CONCLUSION: The delivery of care for people with SCI with low socioeconomic status may be remodeled to include patient-centered medical homes where care is directed by an SCI physiatrist. Further increased telehealth efforts would allow for SCI physiatrists to monitor health conditions remotely and focus on preventative treatment.

Opposing effect of EGFRWT on EGFRvIII-mediated NF-κB activation with RIP1 as a cell death switch.

RIP1 is a central mediator of cell death in response to cell stress but can also mediate cell survival by activating NF-κB. Here, we show that RIP1 acts as a switch in EGFR signaling. EGFRvIII is an oncogenic mutant that does not bind ligand and is coexpressed with EGFRWT in glioblastoma multiforme (GBM). EGFRvIII recruits ubiquitin ligases to RIP1, resulting in K63-linked ubiquitination of RIP1. RIP1 binds to TAK1 and NEMO, forming an EGFRvIII-RIP1 signalosome that activates NF-κB. RIP1 is essential for EGFRvIII-mediated oncogenicity and correlates with NF-κB activation in GBM. Surprisingly, activation of EGFRWT with EGF results in a negative regulation of EGFRvIII, with dissociation of the EGFRvIII-RIP1 signalosome, loss of RIP1 ubiquitination and NF-κB activation, and association of RIP1 with FADD and caspase-8. If EGFRWT is overexpressed with EGFRvIII, the addition of EGF leads to a RIP1 kinase-dependent cell death. The EGFRWT-EGFRvIII-RIP1 interplay may regulate oncogenicity and vulnerability to targeted treatment in GBM.