Gender Disparity in Academic Gastroenterology: Beginning of the End of the Underrepresentation of Women?

BACKGROUND: Though there are an increasing number of female medical graduates, women remain underrepresented in academic medicine. There have been several reasons to explain this gender disparity, including marital status, number of children, number of hours worked, job flexibility, perceptions of women as inferior leaders, gender bias, sexual harassment, and unsupportive academic climates. AIMS: This study aimed to investigate the relationship between scholarly productivity and the representation of female gastroenterologists in academia. Specifically, scholarly productivity measured by the h-index and academic rank were explored to determine if there were gender disparities in academic productivity and rank in gastroenterology. METHODS: Gastroenterology departmental listings were obtained from the Fellowship and Residency Interactive Database of the American Medical Association. The Scopus database was used to record each physician's h-index. Statistical analyses were conducted with Wilcoxon rank-sum test, which compared matched samples by academic rank, and ANOVA tests, which compared multiple academic ranks. RESULTS: Out of 1703 academic gastroenterologists, women account for 25% of academic physicians. Women have statistically lower h-indices at the level of Assistant Professor (p = 0.0012), and at the level of Chair (p = 0.01). There was no difference in h-indices between male and female at the rank of Associate Professor and Professor. CONCLUSIONS: While these results mirror patterns appreciated in other fields of medicine, the results at the rank of Chair may suggest that despite the lower h-index compared to their male counterparts, females are perceived as having strong inherent leadership skills outside of academic productivity that are also conducive to leading a department and may be contributing to their rise to Chair.

Gastric per-oral endoscopic myotomy versus pyloromyotomy for gastroparesis: An international comparative study.

BACKGROUND AND AIM: Gastroparesis is a potentially debilitating gastric motility disorder with limited treatment options. Highest efficacy treatments include gastric per-oral endoscopic myotomy (GPOEM) and surgical pyloromyotomy. This study compares the efficacy and safety of GPOEM versus laparoscopic pyloromyotomy for refractory gastroparesis. METHODS: Patients who underwent GPOEM or laparoscopic pyloromyotomy for refractory gastroparesis from four centers across the USA and Latin America were included in a dedicated registry. Data collected included patient demographics, imaging, laboratory values, clinical success, gastroparesis cardinal symptom index, procedure time, pre-op and post-op gastric emptying times, adverse events, and hospital length of stay. RESULTS: A total of 102 patients were included (mean age 47; 32.4% male): GPOEM n = 39, surgical pyloromyotomy n = 63.Technical success was 100% in both groups. Clinical success was 92.3% in the GPOEM group and 82.5% in the surgery group (P = 0.164). The GPOEM group had a significantly higher post-op GSCI score reduction by 1.3 units (P < 0.00001), post-op retention reduction at 2 h by 18% (P < 0.00001), post-op retention reduction at 4 h by 25% (P < 0.00001) and a lower procedure time by 20 min (P < 0.00001) as compared with surgery. GPOEM also had a lower hospital length of stay by 2.8 days (P < 0.00001). Adverse events were significantly fewer in the GPOEM group (13%) compared with surgery group (33.3%; P = 0.021). Mean blood loss in the GPOEM group was only 3.6 mL compared with 866 mL in the surgery group. CONCLUSIONS: The GPOEM may be a less invasive, safer, and more efficacious procedural treatment for refractory gastroparesis as compared with surgical pyloromyotomy.

Incidence of Non-variceal Upper Gastrointestinal Bleeding Worsens Outcomes with Acute Coronary Syndrome: Result of a National Cohort.

INTRODUCTION: Upper gastrointestinal bleeding (UGIB) is a feared complication of acute coronary syndrome (ACS) and has been shown to increase morbidity and mortality. Our aim was to assess the incidence of non-variceal UGIB in patients with ACS in a national cohort and its impact on in-hospital mortality, length of stay (LOS), and cost of hospitalization. METHODS: This was a retrospective cohort study analyzing the 2016 Nationwide Inpatient Sample (NIS) utilizing ICD 10 CM codes. Principal discharge diagnoses of ACS (STEMI, NSTEMI, and UA) in patients over 18 years old were included. Non-variceal UGIB with interventions including endoscopy, angiography, and embolization were also evaluated. Primary outcome was the national incidence of concomitant non-variceal UGIB in the setting of ACS. Secondary outcomes included in-hospital mortality, length of stay, and cost of stay. RESULTS: A total of 661,404 discharges with principal discharge diagnosis of ACS in 2016 were analyzed. Of the included cohort, 0.80% (n = 5324) were complicated with non-variceal UGIB with increased frequency in older patients (OR 1.03, 95% CI 1.03-1.04; p = 0.0001). Despite endoscopic evaluation, 17.35% (n = 744) underwent angiography. After adjustment of confounders, inpatient mortality was significantly higher in patients with UGIB (OR 2.07, 95% CI 1.63-2.63, p = 0.0001). Non-variceal UGIB also led to significantly longer LOS (10.38 days vs 4.37 days, p = 0.0001) and cost of stay ($177,324 vs $88,468, p = 0.0001). DISCUSSION: Our study shows that the national incidence of non-variceal UGIB complicating ACS is low at less than 1%, but resulted in significantly higher inpatient mortality, LOS, and hospitalization charges.

Renal Failure is Associated With Increased Mortality and Hospital Utilization in Patients Admitted With Nonalcoholic Steatohepatitis.

GOALS: We aimed to investigate the mortality and hospital utilization outcomes of hospitalized nonalcoholic steatohepatitis (NASH) patients with and without kidney failure in a nationwide cohort. BACKGROUND: NASH is a common medical condition associated with significant morbidity and mortality. A paucity of data exists regarding the impact of kidney failure (defined as acute and chronic kidney failure) on outcomes of NASH hospitalizations. MATERIALS AND METHODS: We conducted a retrospective cohort study using the 2016 Nationwide Inpatient Sample dataset of adult patients hospitalized for NASH, stratified for the presence of renal failure. The primary outcome was inpatient mortality, predictors were analyzed using multivariate logistic regression. Secondary outcomes were the length of stay and mean total hospitalization charges. RESULTS: The overall sample included 7,135,090 patients. Among 6855 patients admitted for NASH, 598 or 8.7% had comorbid kidney failure. After multivariate regression analysis, NASH patients with renal failure had increased in-hospital mortality [odds ratio=28.72, 95% confidence interval (CI): 8.99-91.73], length of stay (ß=3.02, 95% CI: 2.54-3.5), total hospital charges (ß=$37,045, 95% CI: $31,756.18-$42,335.62). Positive predictors of mortality in the renal failure group were Charlson Comorbidity Index ≥3 [adjusted odds ratio (aOR)=3.46, 95% CI: 1.04-11.51], variceal bleeding (aOR=3.02, 95% CI: 1.06-8.61), and hepatic encephalopathy (aOR=26.38, 95% CI: 1.29-540.56). Predictors of decreased mortality were Medicaid (aOR=0.047, 95% CI: 0.28-0.79) and private insurance (aOR=0.56, 95% CI: 0.38-0.83). CONCLUSIONS: The prevalence of renal failure in NASH hospitalizations is associated with markedly increased mortality, hospital costs, and length of stay. As a result, clinicians should be vigilant in treating kidney failure in this population.

Gastrointestinal fistula endoscopic closure techniques.

With the improvement in flexible endoscopic technology and the availability of new endoscopic devices, current endoscopic therapies spare many patients who would otherwise undergo surgical repair of gastrointestinal fistulas. These endoscopic techniques include gastrointestinal stents, endoscopic suturing, cardiac septal occluders, endo-sponge, vacuum therapy and others. This review elaborates on the indications, evidence, procedural details, efficacy, and complications of various endoscopic techniques for the management of gastrointestinal fistulas.

Inverse Association of Coffee with Liver Cancer Development: An Updated Systematic Review and Meta-analysis.

BACKGROUND AND AIMS: Coffee consumption has been suggested to reduce the risk for hepatocellular carcinoma (HCC). While several studies report inverse correlation with coffee drinking, others have suggested more than 2 cups of coffee every day decrease the risk of liver cancer or HCC. However, controversy exists about the exact dose that would provide protective benefit. Therefore, we aimed to carry out a systematic review and meta-analysis of all studies that investigated the association of coffee consumption and risk of HCC and/or liver cancer. Our outcomes were the evaluation of the association of coffee with HCC or liver cancer development along with the amount of coffee needed to prevent HCC or liver cancer. METHODS: We performed a PubMed/MEDLINE/EMBASE/Ovid/Google Scholar search of original articles published in English from 1996 to June 2019, on case-control or cohort or prospective studies that associated coffee with liver cancer or HCC. We calculated the relative risk (RR) of the two conditions for coffee drinking and then stratified this into increments of one cup of coffee per day. Twenty studies were identified. The analysis was performed using random effects models from the methods of DerSimonian and Laird with inverse variance weighting. The Cochrane Q and the I 2 statistics were calculated to assess heterogeneity between studies. A p<0.10 value for chi-square test and I 2 <20% were interpreted as low-level heterogeneity. Probability of publication bias was assessed using funnel plots and with the Egger's test. RESULTS: The overall RR was 0.69 (95%CI 0.56-0.85; p<0.001) with significant heterogeneity between the studies. We performed subgroup analysis over the increments of 1 cup of coffee. Higher doses of coffee consumption were associated with a significant decrease in the risk of developing HCC or liver cancer. The funnel plot did not show significant publication bias. CONCLUSIONS: Our systematic review and meta-analysis suggests that drinking coffee provides benefits with a reduction in the risk of HCC or liver cancer. Higher doses of coffee have higher benefits in terms of risk reduction. However, further biological and epidemiological studies are required to determine the exact mechanism and to study specific subgroups such as viral hepatitis B or C related HCC.

Portal Hypertension and Chronic Kidney Disease Significantly Increase the Risk of Early Unplanned Readmissions in GAVE- Related Admissions.

BACKGROUND AND AIMS: Gastric antral vascular ectasia (GAVE) is an uncommon cause of non-variceal upper gastrointestinal bleeding that is characterized by dilation of blood vessels in the antrum of the stomach. Various co-morbidities are associated with the development of GAVE, but the impact of co-morbidities on unplanned GAVE readmissions is unclear. The aim of this study was to assess the national incidence, 30-day mortality rate, and 30-day readmissions related to GAVE. Secondary outcomes were evaluation of predictors of early readmission, hospital length of stay (LOS) and total hospitalization charges. METHODS: Using the 2016 National Readmission Database, we analyzed discharges for GAVE. ICD-10 CM codes were utilized to identify associated comorbidities and inpatient procedures during the index admission. 30-day readmissions were identified for GAVE. Secondary measures of outcomes including LOS and hospitalization charges were also calculated. Risk factors for early readmission were also evaluated using multivariate analysis to adjust for confounders. RESULTS: A total of 18,375 index admissions for GAVE were identified. 20.49% (n=3,720) of the discharged patients were readmitted within 30 days. 30-day mortality of GAVE-related admissions was 1.82% (n=335). Early readmissions accounted for 20,157 hospital days along with $189 million in hospitalization costs. Multivariate analysis revealed that the presence of portal hypertension (OR 1.63; 95% CI 1.37-1.93; p=0.0001) and chronic kidney disease (CKD) (OR 1.62, 95% CI 1.44-1.82; p<0.0001) significantly increased the odds of early readmission. CONCLUSIONS: Our analysis demonstrates that the overall 30-day mortality rate of GAVE-related admissions is relatively low, but the 30-day readmission rate is significantly high. Patients with comorbid CKD and portal hypertension have a significantly higher risk of readmission. Further studies are required to determine if therapeutic interventions such as argon plasma coagulation or radiofrequency ablation during the index admission may prevent readmissions in these specific subgroups.

A tissue-specific enhancer of the C. elegans nhr-67/tailless gene drives coordinated expression in uterine stem cells and the differentiated anchor cell.

The nhr-67 nuclear receptor gene of Caenorhabditis elegans encodes the ortholog of the Drosophila tailless and vertebrate Tlx genes. In C. elegans, nhr-67 plays multiple roles in the development of the uterus during L2 and L3 larval stages. Four pre-VU cells are born in the L2 stage and form the precursor complement for the ventral surface of the mature uterus. One of the four pre-VU cells becomes the anchor cell (AC), which exits the cell cycle and differentiates, while the remaining three VU cells serve as stem cells that populate the ventral uterus. The nhr-67 gene functions in the development of both VU cell lineages and AC differentiation. Hypomorphic mutations in nhr-67 identify a 276bp region of the distal promoter that is sufficient to activate nhr-67 expression in pre-VU cells and the AC. The 276bp region includes 8 conserved potential cis-acting sites, including two E boxes and a nuclear receptor binding site. Mutational analysis demonstrates that the two E boxes are required for expression of nhr-67 in uterine precursor cells. The E/daughterless ortholog HLH-2 binds these sites as a homodimer, thus playing a central role in activating nhr-67 expression in the uterine precursors. At least two other binding activities, one of which may be the nhr-25/Ftz-F1 nuclear receptor transcription factor, also contribute to uterine precursor cell expression. The organization of the nhr-67 uterine precursor enhancer is compared to similar conserved enhancers in the egl-43, lag-2, and lin-3 genes, which contain the same HLH-2-binding E boxes and are similarly expressed in both pre-VU cells and the AC. This basic regulatory module allows the coordinated expression of at least four genes. Expression of genes in different cells that must coordinate to form a mature organ is driven by a shared set of promoter elements, which integrate multiple transcription factor inputs.

Transient Acquired Hypoventilation Syndrome Secondary to Uncal Herniation Is Successfully Treated with Bilevel Noninvasive Positive Pressure Ventilation.

BACKGROUND: To describe an unusual presentation of acquired hypoventilation syndrome treated successfully with noninvasive positive pressure ventilation. CASE PRESENTATION: We report a case report of a 48-year-old male who presented to the emergency room for recurrent syncope. He was found to have a ventricular colloid cyst causing uncal herniation. The patient was noted to be intermittently apneic and bradypnic. Transient hypoventilation was successfully treated with noninvasive positive pressure ventilation and the patient made a full neurological recovery following transcallosal resection of the colloid cyst. Subsequently, the hypoventilation resolved. CONCLUSION: With prompt surgical intervention, full neurological recovery is possible after cerebral uncal herniation. In rare circumstances, this can result in transient alveolar hypoventilation. Bilevel noninvasive positive pressure ventilation can be used to successfully manage the hypoventilation.