Malnutrition Imparts Worse Outcomes in Patients Admitted for Acute Pancreatitis.

Purpose Cessation of enteral nutrition is usually a part of the early stage of acute pancreatitis (AP) treatment. To our knowledge, there is no large database study that examines the effects of preexisting malnutrition on the morbidities of patients admitted for acute pancreatitis. We aimed to investigate the effects of malnutrition on patients admitted for acute pancreatitis. Methods Data between 2008 and 2014 from the National Inpatient Sample (NIS) database was extracted. Inclusion criteria included patients with a primary diagnosis of AP using the International Classification of Diseases, Ninth Revision (ICD-9) codes, and ages greater than 17. Exclusion criteria included ICD-9 codes for chronic pancreatitis. The study group consisted of patients with a primary diagnosis of AP and a concurrent diagnosis of malnutrition. In-hospital mortality was compared using univariate and multivariate analyses to generate odds ratios. Elixhauser comorbidity scores predicting mortality and readmission were calculated based on weighted scores from 29 different comorbidities and compared using univariate analysis. Results Patients with malnutrition were significantly more likely to experience in-hospital mortality, sepsis, severe sepsis, septic shock, and respiratory failure. Malnutrition was found to increase mortality. Female sex and Black or Hispanic race showed lower mortality. Conclusion We hypothesize that there are likely other preexisting comorbidities that lead to malnutrition before the onset of pancreatitis. Malnutrition can cause impaired healing and the ability to recover from acute inflammation, which may be why the study group had a higher rate of sepsis.

Outcomes of gout in patients with cirrhosis: A national inpatient sample-based study.

BACKGROUND: Hyperuricemia is a prerequisite for the development of gout. Elevated serum uric acid (UA) levels result from either overproduction or decreased excretion. A positive correlation between serum UA levels, cirrhosis-related complications and the incidence of nonalcoholic fatty liver disease has been established, but it is unknown whether hyperuricemia results in worsening cirrhosis outcomes. We hypothesize that patients with cirrhosis will have poorer gout outcomes. AIM: To explore the link between cirrhosis and the incidence of gout-related complications. METHODS: This was a cross-sectional study. The national inpatient sample was used to identify patients hospitalized with gout, stratified based on a history of cirrhosis, from 2001 to 2013 via the International Classification of Diseases, Ninth Revision, Clinical Modification codes. Primary outcomes were mortality, gout complications and joint interventions. The χ 2 test and independent t-test were performed to assess categorical and continuous data, respectively. Multiple logistic regression was used to control for confounding variables. RESULTS: Patients without cirrhosis were older (70.37 ± 13.53 years vs 66.21 ± 12.325 years; P < 0.05). Most patients were male (74.63% in the cirrhosis group vs 66.83%; adjusted P < 0.05). Patients with cirrhosis had greater rates of mortality (5.49% vs 2.03%; adjusted P < 0.05), gout flare (2.89% vs 2.77%; adjusted P < 0.05) and tophi (0.97% vs 0.75%; adjusted P = 0.677). Patients without cirrhosis had higher rates of arthrocentesis (2.45% vs 2.21%; adjusted P < 0.05) and joint injections (0.72% vs 0.52%; adjusted P < 0.05). CONCLUSION: Gout complications were more common in cirrhosis. Those without cirrhosis had higher rates of interventions, possibly due to hesitancy with performing these interventions given the higher complication risk in cirrhosis.

Pre-existing Opioid Use Worsens Outcomes in Patients With Diverticulitis.

Background and objective Diverticulitis occurs in 10-25% of patients with diverticulosis. Although opioids can decrease bowel motility, there is scarce data on the effect of chronic opioid use on the outcomes of diverticulitis. In this study, we aimed to explore the outcomes of diverticulitis in patients with pre-existing opioid use. Methods Data between 2008 and 2014 from the National Inpatient Sample (NIS) database was extracted using the International Classification of Diseases, 9th Revision (ICD-9) codes. Univariate and multivariate analyses were used to generate odds ratios (OR). Elixhauser Comorbidity Index (ECI) scores predicting mortality and readmission were calculated based on weighted scores from 29 different comorbidities. Scores were compared between the two groups using univariate analysis. Inclusion criteria included patients with a primary diagnosis of diverticulitis. Exclusion criteria included patients less than 18 years of age, and a diagnosis of opioid use disorder in remission. Studied outcomes included inpatient mortality, complications (including perforation, bleeding, sepsis event, ileus, abscess, obstruction, and fistula), length of hospital stay, and total costs.  Results A total of 151,708 patients with diverticulitis and no active opioid use and 2,980 patients with diverticulitis and active opioid use were hospitalized in the United States from 2008 to 2014. Opioid users had a higher OR for bleeding, sepsis, obstruction, and fistula formation. Opioid users had a lower risk of developing abscesses. They had longer lengths of stay, higher total hospital charges, and higher Elixhauser readmission scores. Conclusion Hospitalized diverticulitis patients with comorbid opioid use are at an elevated risk of in-hospital mortality and sepsis. This could be attributed to complications from injection drug use predisposing opioid users to these risk factors. Outpatient providers caring for patients with diverticulosis should consider screening their patients for opioid use and try offering them medication-assisted treatment to reduce their risk of poor outcomes.

Disparities in Emergency Department Waiting Times for Acute Gastrointestinal Bleeding: Results From the National Hospital Ambulatory Medical Care Survey, 2009-2018.

OBJECTIVE: The primary aim of this study was to assess waiting time (WT) across different racial groups to determine whether racial disparities exist in patients presenting with gastrointestinal bleeding (GIB) to the United States emergency departments (EDs). METHODS: Using the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2009 to 2018, we compared WT of patients with GIB across different racial/ethnic groups, including nonhispanic white (NHW), African American (AA), Hispanic White (HW), and Nonhispanic other. Multinomial logistic regression was applied to adjust the outcomes for possible confounders. We also assessed the trend of the WT over the study interval and compared the WT between the first (2009) and last year (2018) of the study interval. RESULTS: There were an estimated 7.8 million ED visits for GIB between 2009 and 2018. Mean WT ranged from 48 minutes in NHW to 68 minutes in AA. After adjusting for gender, age, geographic regions, payment type, type of GI bleeding, and triage status, multinomial logistic regression showed significantly higher waiting time for AA patients than NHW (OR 1.01, P =0.03). The overall trend showed a significant decrease in the mean WT ( P value<0.001). In 2009, AA waited 69 minutes longer than NHW ( P value<0.001), while in 2018, this gap was erased with no statistically significant difference ( P value=0.26). CONCLUSION: Racial disparities among patients presenting with GIB are present in the United States EDs. African Americans waited longer for their first visits. Over time, ED wait time has decreased, leading to a decline in the observed racial disparity.

Trends Regarding Racial Disparities Among Malnourished Patients With Percutaneous Endoscopic Gastrostomy (PEG) Tubes.

INTRODUCTION: Percutaneous endoscopic gastrostomy (PEG) is performed in patients who cannot tolerate oral intake and who may require more than 30 days of nutritional support. These patients are at high risk for malnutrition, which itself can contribute to worsening clinical status. Racial disparities regarding access to sources of nutrition have been established. We aim to determine if such racial disparities regarding the diagnosis of malnutrition exist in this high-risk population. METHODS: The National Inpatient Sample (NIS) was queried for patients with International Classification of Diseases, Ninth Revision (ICD-9) diagnoses coding for PEG tube placement with or without a diagnosis of malnutrition. Results were stratified by race. Rates of PEG tube complications were assessed. Categorical and continuous data were assessed via chi-squared and analysis of variance (ANOVA) tests respectively. Binary and multiple logistic regression was used to control for confounders. RESULTS: Black patients had the highest rates of malnutrition diagnoses, mechanical complications from gastrostomy placement, and the lowest rates of palliative care discussions. Asian or Pacific Islander patients had the highest rates of aspiration pneumonia, gastrointestinal bleeding, the greatest mortality rates, and the longest hospital stays. DISCUSSION: Racial minorities had worse outcomes while Caucasians had shorter hospital stays and lower complication rates. Such disparities can be multifactorial in etiology, with lack of nutritional access, poor doctor-patient communication, and differential rates of insurance coverage contributing to poorer outcomes among racial minorities. More change is required to promote equity when managing patients with end-of-life diseases necessitating methods of nutritional support.

Effects of Systemic Lupus Erythematosus on Clinical Outcomes and In-Patient Mortality Among Hospitalized Patients With Diverticulitis.

Purpose Though there are studies on other autoimmune diseases, the literature is deficient on the associations between systemic lupus erythematosus (SLE) and diverticulitis. This study aims to evaluate the effects of SLE on clinical outcomes and in-patient mortality in patients with diverticulitis. Methods The National Inpatient Sample (NIS) database was used to identify adult patients with diverticulitis-related hospitalizations from 2012 to 2014 using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Primary outcomes were mortality, hospital charges, and length of stay (LOS). Secondary outcomes were effects on the complications associated with diverticulitis. Chi-squared tests and independent t-tests were used. Multivariate analysis was performed to assess the primary outcomes after adjusting for confounding variables. Results There were 2,553,320 diverticulitis-related hospitalizations from 2012 to 2014, of which 13,600 patients had SLE. The average LOS was 5.2 days, mortality rate was 0.8%, and total hospital charges per patient were $43,970. SLE was associated with a statistically significant longer LOS and higher hospital costs. SLE was statistically significant for having higher perforation rates but lower rates for morality, abscesses, and fistula formation. Differences in complications such as sepsis, gastrointestinal bleeding, and surgical intervention requirement were non-significant. Conclusion Since SLE causes a high inflammatory state, one would expect higher rates of complications and possibly higher mortality rates in those with concomitant diverticulitis. However, although there was a higher LOS and hospital cost, the mortality rate was lower and only a complication of perforation was found to be higher in SLE patients.

Malnutrition Imparts Worse Outcomes in Patients With Diverticulitis: A Nationwide Inpatient Sample Database Study.

Introduction Studies show that malnutrition can lead to worsening morbidity and mortality in patients. However, to our knowledge, no large database study has been conducted describing the effects of malnutrition in patients with diverticulitis. In this article, we aim to assess the impact of pre-existing malnutrition on outcomes of patients admitted for diverticulitis. Methods Data between 2008 and 2014 from the Nationwide Inpatient Sample database were extracted. Inclusion criteria for both groups included patients with a primary diagnosis of diverticulitis using the International Classification of Diseases, Ninth Revision codes. Exclusion criteria included all patients less than 18 years of age. The test group consisted of patients with a primary diagnosis of diverticulitis and a concurrent diagnosis of malnutrition. In-hospital mortality, length of stay, total cost, and complications, including various forms of sepsis, perforation, bleeding, and GI bleeding, were compared between the two groups. Univariate and multivariate analyses were used to generate odds ratios. Multivariate analysis included age, sex, race, income quartile, and calculated Elixhauser scores. Elixhauser comorbidity scores predicting mortality and readmission were calculated based on weighted scores from 29 different comorbidities. Scores were compared between the two groups using univariate analysis. Results There were a total of 1,520,919 patients in the study, of which 427,679 (2.8%) had a pre-existing diagnosis of malnutrition. On univariate analysis, there was a significant increase in mortality in patients with malnutrition (OR: 10.2, p < 0.01). Additionally, patients with malnutrition appeared to have longer lengths of stay (mean: 12.9, p < 0.01) and greater cost of hospitalization (mean: 194436.82, p < 0.01). Patients with malnutrition had greater rates of sepsis events (OR: 12.0, p < 0.01), perforation (OR: 2.8, p < 0.01), and GI bleed (OR: 1.84, p < 0.01). On multivariate analysis, malnutrition appeared to significantly increase mortality (OR: 3.3, p < 0.01). Discussion Patients who present with diverticulitis with malnutrition appear to have significantly worse outcomes. We hypothesize that malnutrition leads to a shift in the gut microbiota, resulting in increased inflammation. As a result, these patients may have an increased risk of worse outcomes, such as sepsis and death. Addressing nutrition in patients with diverticulosis or those with a history of diverticulitis may improve outcomes. This abstract was previously presented at the Digestive Disease Week Conference on May 22, 2022. Abstracts accepted at the conference were published in supplements of the journals Gastroenterology and GIE: Gastrointestinal Endoscopy.

Acute Tension Hydrothorax in a Cirrhotic Patient With Hepatic Hydrothorax Without Ascites.

We describe a case of a 50-year-old man with alcohol cirrhosis status post transjugular intrahepatic portosystemic shunt (TIPS) who presented with dyspnea, refractory hepatic hydrothorax (HH), and no ascites who subsequently developed acute tension hydrothorax (TH). Urgent ultrasound-guided thoracentesis was performed with a significant improvement of symptoms. Further management consisted of a chest tube placement, subsequently removed with a plan for intermittent thoracentesis as needed, diuretic therapy, and salt restriction. HH occurs in 5%-10% of patients with cirrhosis, and TH in these patients is a rare entity that requires prompt recognition and drainage as it may be life-threatening.

A mathematical model of COVID-19 using fractional derivative: outbreak in India with dynamics of transmission and control.

Since the first case of 2019 novel coronavirus disease (COVID-19) detected on 30 January, 2020, in India, the number of cases rapidly increased to 3819 cases including 106 deaths as of 5 April, 2020. Taking this into account, in the present work, we have analysed a Bats-Hosts-Reservoir-People transmission fractional-order COVID-19 model for simulating the potential transmission with the thought of individual response and control measures by the government. The real data available about number of infected cases from 14 March, 2000 to 26 March, 2020 is analysed and, accordingly, various parameters of the model are estimated or fitted. The Picard successive approximation technique and Banach's fixed point theory have been used for verification of the existence and stability criteria of the model. Further, we conduct stability analysis for both disease-free and endemic equilibrium states. On the basis of sensitivity analysis and dynamics of the threshold parameter, we estimate the effectiveness of preventive measures, predicting future outbreaks and potential control strategies of the disease using the proposed model. Numerical computations are carried out utilising the iterative Laplace transform method and comparative study of different fractional differential operators is done. The impacts of various biological parameters on transmission dynamics of COVID-19 is investigated. Finally, we illustrate the obtained results graphically.