Modifiable Risk Factors in Hispanic Adults With Gastric Cancer in the United States.

BACKGROUND: Hispanics make up 19% of the U.S. population and are experiencing rising rates of cancer, primarily due to an increase in infection-related cancers (gastric, hepatic, cervical) and advanced cancers secondary to delayed screening (colorectal, cervical, breast). There is an increased incidence of gastric cancer (associated with infection, obesity, alcohol, and tobacco use) in Hispanics, especially at a young age, highlighting the need to consider ethnicity as a risk factor. METHODS: This study utilized the 2016-2019 National Inpatient Sample database to examine all patients admitted with gastric cancer. Individuals were stratified by race, age, and comorbidities, including modifiable risk factors that are associated with gastric cancer. RESULTS: There were 5,785 (7.44%) patients aged 18-44, 28,370 (36.49%) aged 45-64, and 43,590 (56.07%) over 65 years of age. Notably, 34.3% of the youngest group were Hispanic, contrasted with 19.7% and 12.9% in the older groups, respectively. Younger Hispanic patients showed a higher prevalence of H. pylori infection (8.6%) compared with older Hispanics (3.6% in the middle age group and 2.1% in the oldest, p<0.01). There was a high prevalence of obesity, tobacco use, and gastric ulcers in this cohort. Other risk factors such as alcohol use and gastric polyps were present at a lesser prevalence. CONCLUSIONS: This study reveals that Hispanic patients tend to have a younger age of onset of gastric cancer, coupled with an increased incidence of H. pylori infection at a younger age. This finding underscores the potential benefit of H. pylori screening among asymptomatic young Hispanics with the aim of reducing gastric cancer morbidity and mortality in this population.

An artificial intelligence-generated model predicts 90-day survival in alcohol-associated hepatitis: A global cohort study.

BACKGROUND AND AIMS: Alcohol-associated hepatitis (AH) poses significant short-term mortality. Existing prognostic models lack precision for 90-day mortality. Utilizing artificial intelligence in a global cohort, we sought to derive and validate an enhanced prognostic model. APPROACH AND RESULTS: The Global AlcHep initiative, a retrospective study across 23 centers in 12 countries, enrolled patients with AH per National Institute for Alcohol Abuse and Alcoholism criteria. Centers were partitioned into derivation (11 centers, 860 patients) and validation cohorts (12 centers, 859 patients). Focusing on 30 and 90-day postadmission mortality, 3 artificial intelligence algorithms (Random Forest, Gradient Boosting Machines, and eXtreme Gradient Boosting) informed an ensemble model, subsequently refined through Bayesian updating, integrating the derivation cohort's average 90-day mortality with each center's approximate mortality rate to produce posttest probabilities. The ALCoholic Hepatitis Artificial INtelligence Ensemble score integrated age, gender, cirrhosis, and 9 laboratory values, with center-specific mortality rates. Mortality was 18.7% (30 d) and 27.9% (90 d) in the derivation cohort versus 21.7% and 32.5% in the validation cohort. Validation cohort 30 and 90-day AUCs were 0.811 (0.779-0.844) and 0.799 (0.769-0.830), significantly surpassing legacy models like Maddrey's Discriminant Function, Model for End-Stage Liver Disease variations, age-serum bilirubin-international normalized ratio-serum Creatinine score, Glasgow, and modified Glasgow Scores ( p < 0.001). ALCoholic Hepatitis Artificial INtelligence Ensemble score also showcased superior calibration against MELD and its variants. Steroid use improved 30-day survival for those with an ALCoholic Hepatitis Artificial INtelligence Ensemble score > 0.20 in both derivation and validation cohorts. CONCLUSIONS: Harnessing artificial intelligence within a global consortium, we pioneered a scoring system excelling over traditional models for 30 and 90-day AH mortality predictions. Beneficial for clinical trials, steroid therapy, and transplant indications, it's accessible at: https://aihepatology.shinyapps.io/ALCHAIN/ .

Hemospray Versus Conventional Therapy for Non-variceal Upper Gastrointestinal Bleeding: A Systematic Review and Meta-Analysis.

Hemospray (TC-325; Cook Medical, Winston-Salem, NC) has been used effectively in hemostasis in non-variceal upper gastrointestinal (GI) bleeding. Current guidelines suggest using Hemospray as a temporizing measure or adjunct technique. This systematic review and meta-analysis aimed to evaluate the efficacy and safety of Hemospray as a modality for primary hemostasis. We searched MEDLINE, CENTRAL, and CINAHL (Cumulative Index of Nursing and Allied Health Literature) databases from inception to August 1, 2022. Three independent reviewers performed a comprehensive review of all original articles describing the application of Hemospray as the primary method of hemostasis in non-variceal upper GI bleeding patients. Three reviewers independently reviewed and abstracted data and assessed study quality using the Cochrane risk of bias tool. Primary outcomes were (1) primary hemostasis rate, (2) rebleeding rate until hospital discharge or death, (3) need for surgery, and (4) overall mortality rate. Of the 211 studies identified, 146 underwent title and abstract review, and four were included in the systematic review. Pooled results from 303 patients showed that compared to standard of care, Hemospray has significantly higher odds of primary hemostasis (OR: 3.48, 95% CI: 1.09-11.18, p = 0.04). There was no statistically significant difference in terms of rebleeding rates (OR: 0.79, 95% CI: 0.24-2.55, p = 0.69), need for surgery (OR: 1.62, 95% CI: 0.35-7.41, p = 0.54), or overall mortality (OR: 1.08, 95% CI: 0.56-2.08, p = 0.83). This systematic review and meta-analysis prove that Hemospray is a better modality of primary hemostasis in non-variceal upper GI bleeding when used as a primary method. At the same time, there is no significant difference in complications, including rebleeding, need for surgical intervention, and all-cause mortality.

A Curious Case of Vanishing Hepatocellular Carcinoma (HCC).

Hepatocellular carcinoma (HCC) is the third most common cause of cancer-related mortality worldwide. Spontaneous regression of HCC is rare with few documented cases in literature. The mechanism of this phenomenon is unknown, but tumor hypoxia and systemic inflammatory response have been suggested as possible etiologies. This article aims to shed more light on this rare phenomenon and provides an opportunity to review the proposed pathophysiology of spontaneous HCC regression. In this case report, we describe an interesting case of a 39-year-old male with HCC who underwent spontaneous regression.

Hospitalization Trends and Outcomes of Eosinophilic Esophagitis in the United States: A Decade-Long Nationwide Analysis.

Background Eosinophilic esophagitis (EoE) is a chronic antigen-mediated esophageal disease characterized by infiltration of the esophageal mucosa by eosinophils. The prevalence of EoE continues to rise worldwide. However, certain aspects of the epidemiology and pathogenesis remain unclear. Methods This study examined the hospitalization trends of EoE using an extensive inpatient database in the United States, the National (Nationwide) Inpatient Sample (NIS), to identify hospitalizations between 2010 and 2019. We assessed patient demographics as well as hospital-specific variables using the NIS. We obtained the prevalence rate of EoE for each year and used joinpoint regression analysis to obtain trends after adjusting the rate for age and gender. We also sought to characterize the outcomes of these hospitalizations by obtaining the mortality rate, length of stay (LOS), and total hospital charges (THC). Results Of 305 million hospitalizations included in the study, 33,878 were for EoE. The prevalence rate per 100,000 hospitalizations of EoE increased from 6.6 in 2010 to 15.5 in 2019. The annual percentage change obtained from the joinpoint regression analysis was 13.3% from 2010 to 2014 and 7.2% from 2014 to 2019. Most of the hospitalizations were among the male gender and young adults. Almost 95% of hospitalizations across the study period were seen in urban hospitals. We did not notice any significant trend in the mortality rates or length of stay over the study period. The THC increased significantly across the study period. Conclusion There has been an upward trend in the average prevalence rate of EoE over the decade from 2010 to 2019 which almost parallels that of inflammatory bowel disease. This represents a significant burden of disease for a condition that was initially recognized in the late 20th century.

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.

Independent Predictors and Causes of Thirty-Day Gastrointestinal Readmissions Following COVID-19-Related Hospitalizations: Analysis of the National Readmission Database.

Background: The coronavirus disease 2019 (COVID-19) pandemic led to significant mortality and morbidity in the United States. The burden of COVID-19 was not limited to the respiratory tract alone but had significant extrapulmonary manifestations. We decided to examine the causes, predictors, and outcomes of gastrointestinal (GI)-related causes of 30-day readmission following index COVID-19 hospitalization. Methods: We used the National Readmission Database (NRD) from 2020 to identify hospitalizations among adults with principal diagnosis of COVID-19. We identified GI-related hospitalizations within 30 days of index admission after excluding elective and traumatic admissions. We identified the top causes of GI-related readmission, and the outcomes of these hospitalizations. We used a multivariate Cox regression analysis to identify the independent predictors of readmission. Results: Among 1,024,492 index hospitalizations with a primary diagnosis of COVID-19 in the 2020 NRD database, 644,903 were included in the 30-day readmission study. Of these 3,276 (0.5%) were readmitted in 30 days due to primary GI causes. The top five causes of readmissions we identified in this study were GI bleeding, intestinal obstruction, acute diverticulitis, acute pancreatitis, and acute cholecystitis. Multivariate Cox regression analysis done adjusting for confounders showed that renal failure, alcohol abuse, and peptic ulcer disease were associated with increased odds of 30-day readmission from GI-related causes. Conclusions: GI manifestations of COVID-19 are not uncommon and remain an important cause of readmission. Targeted interventions addressing the modifiable predictors of readmission identified will be beneficial in reducing the burden on already limited healthcare resources.

Trends and Disparities in Colonic Diverticular Disease Hospitalizations in Patients With Morbid Obesity: A Decade-Long Joinpoint Analysis.

Objective We aimed to describe epidemiologic trends in outcomes of colonic diverticular disease (CDD) hospitalizations in morbidly obese patients. Methods We searched the United States National Inpatient Sample databases from 2010 through 2019, obtained the incidence rate of morbid obesity (MO) among CDD hospitalizations, and used Joinpoint analysis to obtain trends in these rates adjusted for age and sex. Hospitalizations involving patients less than 18 years of age were excluded. Trends in mortality rate, mean length of hospital stay (LOS), and mean total hospital charge were analyzed. Multivariate regression analysis was used to obtain trends in adjusted mortality, mean LOS, and mean total hospital charge. Results We found an average annual percent change of 7.5% (CI = 5.5-9.4%, p < 0.01) in the adjusted incidence of MO among hospitalizations for CDD over the study period. We noted a 7.2% decline in mortality (p = 0.011) and a 0.1 days reduction in adjusted LOS (p < 0.001) over the study period. Hospitalizations among the middle-aged and elderly had adjusted odds ratios of 7.18 (95% CI = 2.2-23.3, p = 0.001) and 24.8 (95% CI = 7.9-77.9, p < 0.001), respectively, for mortality compared to those in young adults. The mean LOS was 0.29 days higher in females compared to males (p < 0.001). Conclusion The incidence of MO increased among CDD hospitalizations while mortality and mean LOS reduced over the study period. Outcomes were worse in older patients, with an increased mean LOS in females compared to males.

Contrasting Strategies in Bouveret's Syndrome: A Series of Two Cases.

Bouveret's syndrome is a rare complication of cholelithiasis, characterized by gastric outlet obstruction caused by a migrated gallstone. Diagnosis of Bouveret's syndrome necessitates urgent treatment as it carries a high mortality rate. The treatment of Bouveret's syndrome has traditionally been surgical. However, there have been increasing reports of successful endoscopic therapy for Bouveret's syndrome. This case series aims to compare and contrast two cases of Bouveret's syndrome. The gallstone was retrieved via endoscopic access in one case while the other was removed with surgery. For each case, we discuss the various factors that contributed to the decision of which treatment modality to use. In addition, we propose an endoscopic technique that may improve the safety and success rate of endoscopic treatment of Bouveret's syndrome.

Association of Candida esophagitis with acute esophageal necrosis.

Acute esophageal necrosis (AEN) is a clinical rarity and its pathogenesis is poorly understood. It usually presents as upper gastrointestinal bleeding and is associated with poor outcomes. We report a case of a 53-year-old man with diabetes and cirrhosis who presented with diabetic ketoacidosis and had an upper gastrointestinal bleed during the hospital stay from AEN associated with Candida esophagitis. In addition to the standard supportive therapy, such patients require antifungal therapy. This case underscores how a rare disease can present like a common disease and prove to be a management challenge if the differential is not kept broad.

Readmissions After Biliary Acute Pancreatitis: Analysis of the Nationwide Readmissions Database.

Background: Acute pancreatitis is a common inflammatory condition that involves the pancreas. Gallstones and alcohol are the most common etiologies in the USA. Cholecystectomy is the cornerstone procedure in the management of biliary acute pancreatitis (BAP). In this study, we examined the causes and predictors of readmissions following BAP based on the procedure performed. Methods: Using the Nationwide Readmissions Database (NRD) and the International Classification of Diseases, Tenth Revision, Clinical Modification/Procedure Coding System (ICD10-CM/PCS), we retrospectively studied BAP hospitalizations (2016 - 2018). The first hospitalization within the year was marked as index hospitalization. Index hospitalizations were categorized based on whether an endoscopic retrograde cholangiopancreatography (ERCP) and/or a cholecystectomy was performed into no procedure group, ERCP group, cholecystectomy group, and both procedures group. We subsequently identified readmissions within 30 days. Using this categorization, we studied reasons, rates, and predictors of readmissions. Results: A total of 127,318 index hospitalizations were included. The cholecystectomy group constituted the largest share of this cohort (43.5%). Using the no procedure group as a reference, analysis of the outcomes showed that the cholecystectomy group had the lowest inpatient mortality (adjusted odds ratio (aOR): 0.18, P < 0.001), while both procedures group had the highest total hospital charges (adjusted mean difference (aMD): 42,249, P < 0.001). Acute pancreatitis without necrosis or infection was the most frequent principal diagnosis for readmission (18.7%). Analysis of readmission predictors showed that both procedures group had the lowest risk for readmission (adjusted hazard ratio (aHR): 0.40, P < 0.001). Females were less likely to be readmitted compared to males (aHR: 0.82, P < 0.001) and elderly were less likely to be readmitted compared to young adults (aHR: 0.82, P < 0.001). Patients discharged against medical advice were more likely to be readmitted (aHR: 1.76, P < 0.001). Conclusion: Undergoing both ERCP and cholecystectomy for BAP resulted in significantly higher hospital charges with no additional mortality benefit. However, it decreased the readmission risk significantly. Acute pancreatitis without necrosis or infection was the most frequent reason for readmissions.

Trends of Alcohol Withdrawal Delirium in the Last Decade: Analysis of the Nationwide Inpatient Sample.

Background: Alcohol use disorder, high-risk drinking, and emergency visits for acute and chronic complications of alcohol use have been increasing in the USA recently. Approximately half of patients with alcohol use disorder experience alcohol withdrawal when they reduce or stop drinking. Though alcohol withdrawal is usually mild, 20% of patients experience more severe manifestations such as hallucinations, seizures, and delirium. In this study, we utilized the Nationwide Inpatient Sample to examine the trends of alcohol withdrawal delirium (AWD) in the period 2010 - 2019. Methods: This was a retrospective longitudinal trends study involving hospitalizations with AWD in the USA from 2010 to 2019. We searched the databases for hospitalizations using the International Classification of Diseases (ICD) codes (291.0 and F10231). We involved all hospitalizations complicated by AWD and hospitalizations with AWD as the principal diagnosis for admission. We excluded hospitalizations involving patients under the age of 18. We calculated the crude admission rate and the incidence of AWD per million adult hospitalizations during each calendar year. In addition, we analyzed trends of inpatient mortality, length of stay (LOS), and total hospital charges (THC). Results: The incidence of AWD per million hospitalizations increased from 2,671.8 in 2010 to 3,405.6 in 2019, with an annual percentage change (APC) of 3.1% (P < 0.001). Similarly, AWD admission rate per million hospitalizations increased from 1,030.3 in 2010 to 1,556.0 in 2019, with an average APC of 5.0% (P < 0.001). There were statistically significant trends of increasing inpatient mortality, THC, and LOS over the studied period. In general, female gender, younger age, and Black race were associated with better clinical outcomes. Conclusions: Our study showed an increase in the incidence and admission rates of AWD. Mortality, LOS, and THC increased over the studied period. Younger age, female gender, and Black race were associated with better clinical outcomes.

Not All Gastric Ulcers Are Malignant.

Eosinophilic granulomatosis with polyangiitis (EGPA) is a small- and medium-vessel vasculitis that majorly involves the respiratory tract but can potentially involve any organ system of the body. Involvement of the gastrointestinal (GI) tract can present on a spectrum. We present an interesting case of a 44-year-old man with a history of asthma and sinusitis who presented with non-specific GI symptoms and weight loss. The patient got diagnosed with EGPA. Endoscopic workup of the GI complaints revealed gastric ulcer and erosions of the upper GI tract. Biopsies of the lesions demonstrated eosinophilic infiltration suggestive of EGPA. This report represents a rare case of GI involvement of EGPA that could be histologically confirmed.

Trends of Readmissions for Gastrointestinal Bleeding After Alcoholic Hepatitis: Analysis of the Nationwide Readmission Database.

Background: Alcohol consumption is associated with numerous hepatic manifestations, including alcoholic fatty liver disease, alcoholic hepatitis (AH), and liver cirrhosis. AH is a common and serious complication of alcohol use. Gastrointestinal bleeding (GIB) remains one of the most common causes of death in these patients. In this article, we studied the trends of GIB after AH. Methods: This was a retrospective interrupted trend study. We analyzed the 2010, 2012, 2014, 2016, and 2018 Nationwide Readmission Databases. The first AH hospitalization in the year was marked as index hospitalization. We identified subsequent hospitalizations with GIB within 30 days and marked them as readmissions. A multivariate regression analysis was used to calculate the risk-adjusted odds of trends for GIB readmissions, including esophageal varices bleeding (EVB), upper GIB, lower GIB, and all GIB. Results: The volume of index hospitalizations increased from 10,248 in 2010 to 16,479 in 2018. Similarly, all readmissions increased from 1,838 in 2010 to 3,908 in 2018. Of all readmissions, EVB increased from 3.9% in 2010 to 5.9% in 2018 (odds ratio (OR) trend 1.10; P < 0.001). Readmissions for upper GIB increased from 2.4% in 2010 to 7.8% in 2018 (OR trend 1.22; P < 0.001). On the other hand, lower GIB readmissions decreased from 7.2% in 2010 to 4.7% in 2018 (OR trend 0.95; P = 0.015). There was no statistically significant trend for all GIB readmissions (OR trend 1; P = 0.915). Conclusion: Further studies are needed to evaluate the patterns of lower GIB in patients with liver disease and the recent trends of corticosteroids use in AH patients.

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.

Effectiveness and safety of SARS-CoV-2 vaccine in Inflammatory Bowel Disease patients: a systematic review, meta-analysis and meta-regression.

INTRODUCTION: There are concerns regarding the effectiveness and safety of SARS-CoV-2 vaccine in inflammatory Bowel Disease (IBD) patients. This systematic review and meta-analysis comprehensively summarises the available literature regarding the safety and effectiveness of SARS-CoV-2 vaccine in IBD. METHODS: Three independent reviewers performed a comprehensive review of all original articles describing the response of SARS-CoV-2 vaccines in patients with IBD. Primary outcomes were (1) pooled seroconversion rate SARS-CoV-2 vaccination in IBD patients (2) comparison of breakthrough COVID-19 infection rate SARS-CoV-2 vaccination in IBD patients with control cohort and (3) pooled adverse event rate of SARS-CoV-2 vaccine. All outcomes were evaluated for one and two doses of SARS-CoV-2 vaccine. Meta-regression was performed. Probability of publication bias was assessed using funnel plots and with Egger's test. RESULTS: Twenty-one studies yielded a pooled seroconversion rate of 73.7% and 96.8% in IBD patients after one and two doses of SARS-CoV-2 vaccine respectively. Sub-group analysis revealed non-statistically significant differences between different immunosuppressive regimens for seroconversion. Meta-regression revealed that the vaccine type and study location independently influenced seroconversion rates. There was no statistically significant difference in breakthrough infection in IBD patients as compared to control after vaccination. CONCLUSION: In summary, the systematic review and meta-analysis suggest that SARS-CoV-2 vaccine is safe and effective in IBD patients.

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.

Outcomes of Non-Variceal Upper Gastrointestinal Bleed Stratified by Hospital Teaching Status: Insights From the National Inpatient Sample.

BACKGROUND: Non-variceal upper gastrointestinal bleeding (NVUGIB) is a significant cause of mortality and morbidity in the USA. Currently, there are limited data on the inpatient outcomes of patients admitted with a diagnosis of NVUGIB stratified according to teaching hospital status. We analyzed data from the National Inpatient Sample (NIS) intending to evaluate these outcomes. METHODS: We queried the NIS 2016 and 2017 databases for NVUGIB hospitalizations by teaching hospital status. The primary outcome was inpatient mortality while secondary outcomes were rate of endoscopy for hemostasis, rate of early endoscopy (endoscopy in 1 day or less), mean time to endoscopy, rate of complications including acute kidney injury (AKI), acute respiratory failure (ARF), need for blood transfusion, development of sepsis, need for endotracheal intubation and mechanical ventilation as well as healthcare utilization. RESULTS: There were over 71 million weighted discharges in the combined 2016 and 2017 NIS database. A total of 94,900 NVUGIB cases were identified with 63.4% admitted in teaching hospitals. The in-hospital mortality for patients admitted with an NVUGIB in teaching hospitals was 1.98% compared to 1.5% in non-teaching hospitals (adjusted odds ratio (aOR): 1.38, 95% confidence interval (CI): 1.08 - 1.77, P = 0.010) when adjusted for biodemographic and hospital characteristics as well as comorbidities. Patients admitted with a diagnosis of NVUGIB in teaching hospitals had a 10% adjusted increased odds of getting endoscopy for hemostasis (27.0% vs. 24.5%, aOR: 1.10, 95% CI: 1.02 - 1.19, P = 0.016) compared to patients in non-teaching hospitals. There was, however, no difference in early endoscopy between the two groups. CONCLUSION: Patients admitted at teaching hospitals for an NVUGIB had worse outcomes during hospitalizations including mortality, median length of stay, and total hospital charges when compared to NVUGIB patients managed at non-teaching hospitals.

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.

Efficacy and safety of primary needle-knife fistulotomy in biliary cannulation: a systematic review and meta-analysis.

We aimed to conduct a systematic review and meta-analysis on the efficacy and safety of primary needle-knife fistulotomy (NFK) in biliary cannulation. An electronic bibliographic search of digital dissertation databases was performed from inception till March 2020. All prospective studies, including randomized trials evaluating the use of NFK as a primary cannulation technique in biliary cannulation, were analyzed. The primary outcome was a successful cannulation rate and the secondary outcomes were post-ERCP pancreatitis rate and overall post-ERCP complication rate. A total of four prospective studies, including three randomized trials, were included for the analysis. The pooled cannulation success rate for primary NFK was 95.7% (95% CI. 83.1-99.0, P < 0.001). When compared with standard wire-guided cannulation, the analysis did not show any difference between the two techniques in terms of cannulation success (OR, 3.59, 95% CI, 0.34-37.39; P = 0.28; low certainty of evidence). The overall rate of post-ERCP pancreatitis with primary NFK was 1.5 % (95% CI, 0.6-3.9, P < 0.001). When compared with conventional wire-guided technique, the odds of developing post-ERCP pancreatitis with NFK were 0.22 (95% CI, 0.04-1.04, P = 0.06; moderate certainty of evidence). To conclude, NKF seems to be an effective means of biliary cannulation in expert hands. Although it may be associated with a lower rate of post-ERCP pancreatitis, the current strength and quality of evidence to support its use as a primary cannulation strategy is low. It may be considered in ERCPs at higher risk of pancreatitis by experienced endoscopists.