Sociodemographic Disparities in Sodium-Glucose Co-Transporter-2 Inhibitors and Glucagon-Like Peptide-1 Receptor Agonists Prescription Patterns Among Patients With Poorly Controlled Diabetes.

Introduction Sodium-glucose co-transporter-2 inhibitors (SGLT2Is) and glucagon-like peptide-1 receptor agonists (GLP-1RAs) are novel antihyperglycemic agents that reduce cardiovascular mortality through insulin-independent mechanisms. In this cross-sectional study, we investigated prescription patterns of these drugs and identified inequities in antihyperglycemic utilization. Methods Unique encounters for diabetes care between January 1, 2020, and December 31, 2020, were identified through a systematic query of our healthcare system's database. All patients ≥18 years old with a hemoglobin A1C level of ≥8% were included in the sample. Demographic data, SGLT2I or GLP-1RA prescription status, diabetes-related complications, and mortality were abstracted. Results A total of 2,746 patients were included in the sample. Among these individuals, 670 (24.4%) were prescribed either an SGLT2I or a GLP-1RA (users) and 2,076 (75.6%) were not prescribed either agent (non-users). There were significantly more males than females in the cohort, but there was no significant difference in the sex distribution between users and non-users. Compared to non-users, users were younger (mean age of 65.1 ± 9.4 years versus 66.4 ± 9.9 years, p-value = 0.005), more likely to be non-Hispanic (86.3% versus 13.7%), more likely to live in a middle-income zip code, and have private insurance. The mortality rate was lower among users when compared to non-users, but the difference did not reach statistical significance (2.7% versus 5.5%, p-value = 0.62). SGLT2I use was associated with a 60% lower risk of mortality. Conclusion Ethnicity, median household income, and insurance type influence the likelihood of being prescribed an SGLT2I or a GLP-1RA. Individuals prescribed either agent appear to have better mortality outcomes than those prescribed other medications. Further investigation may reveal underlying causes and potential solutions for disparities in prescription patterns.

Survival trends for left and right sided colon cancer using population-based SEER database: A forty-five-year analysis from 1975 to 2019.

BACKGROUND: Survival differences between left-sided colon cancer (LSCC) and right-sided colon cancer (RSCC) has been previously reported with mixed results, with various study periods not accounting for other causes of mortality. PURPOSE: We sought to assess the trends in colon cancer cause- specific survival (CSS) and overall survival (OS) based on sidedness. METHOD: Fine-Gray competing risk and Cox models were used to analyze Surveillance, Epidemiology, and End Results (SEER) population-based cohort from 1975 to 2019. Various interval periods were identified based on the timeline of clinical adoption of modern chemotherapy (1975-1989, interval period A; 1990-2004, B; and 2005-2019, C). RESULTS: Of the 227,637 patients, 50.1% were female and 46.2% were RSCC. RSCC was more common for African Americans (51.5%), older patients (age ≥65; 51.4%), females (50.4%), while LSCC was more common among Whites (53.1%; p < 0.001), younger patients (age 18-49, 64.6%; 50-64, 62.3%; p < 0.001), males (58.1%; p < 0.001). The Median CSS for LSCC and RCC were 19.3 and 16.7 years respectively for interval period A (1975-1989). Median CSS for interval periods B and C were not reached (more than half of the cohort was still living at the end of the follow-up period). Adjusted CSS was superior for LSCC versus RSCC for the most recent interval period C (HR 0.89; 0.86-0.92; p < 0.001). LSCC consistently showed superior OS for all study periods. Stage stratification showed worse CSS for localized and regional LSCC in the earlier study periods, but the risk attenuated over time. However, left sided distant disease had superior CSS per stage for all interval periods. OS was better for LSCC irrespective of stage, with gradual improvement over time. CONCLUSION: LSCC was associated with superior survival compared to right sided tumors. With the adoption of modern chemotherapy regimens, prognosis between LSCC and RSCC became more divergent in favor of LSCC. Colon cancer clinical trials should strongly consider tumor sidedness as an enrollment factor.

The Influence of Arrhythmias and Metabolic Profile on Inpatient Mortality in Patients with Left Ventricular Assist Devices.

Background: In patients with end-stage heart failure, durable Left Ventricular Assist Devices (LVADs) can be used as a bridge to transplant or destination therapy. LVADs have been shown to improve survival for patients with heart failure (HF). HF is associated with electrolyte abnormalities and the development of sustained arrhythmias. However, data on the influence of arrhythmias and electrolyte imbalances on inpatient outcomes in LVAD patients are lacking. Furthermore, previous works assessing inpatient outcomes focused mainly on the role of chronic comorbidities in those outcomes. Methods: In this cross-sectional study, we used discharge data from the National Inpatient Sample from 2019 to 2020 to assess the influence of acute arrhythmias on inpatient mortality in patients with LVADs. We also investigated the relationship between acute medical conditions and mortality. Results: There were 9418 (not survey-adjusted) hospitalizations with LVAD, among which 2539 (27%) died during the hospitalization. Univariate analysis of arrhythmias showed that ventricular arrhythmias (VAs)-ventricular fibrillation/flutter and ventricular tachycardia-as well as complete heart block were associated with significantly higher odds of mortality. Follow-up multivariable logistic analysis showed that these arrhythmias retain their increased association with death. Hyperkalemia and acidosis had increased adjusted odds of death (1.54 (95% confidence interval: 1.28-1.85) (p < 0.001) and 2.44 (CI: 2.14-2.77) (p < 0.001), respectively). Conclusions: VAs, complete heart block, hyperkalemia, and acidosis were associated with increased odds of all-cause mortality. Females had higher odds of inpatient mortality. These findings suggest that electrolyte management, maintenance of optimal acid-base balance, and interventions to treat sustained ventricular arrhythmias may be suitable therapeutic targets to reduce mortality in hospitalized patients with LVADs.

Anti-N-methyl-D-aspartate receptor-associated encephalitis: A review of clinicopathologic hallmarks and multimodal imaging manifestations.

Anti-N-methyl-D-aspartate receptor-associated encephalitis (NMDARE) is a rare immune-mediated neuroinflammatory condition characterized by the rapid onset of neuropsychiatric symptoms and autonomic dysfunction. The mechanism of pathogenesis remains incompletely understood, but is thought to be related to antibodies targeting the GluN1 subunit of the NMDA receptor with resultant downstream dysregulation of dopaminergic pathways. Young adults are most frequently affected; the median age at diagnosis is 21 years. There is a strong female predilection with a female sex predominance of 4:1. NMDARE often develops as a paraneoplastic process and is most commonly associated with ovarian teratoma. However, NMDARE has also been described in patients with small cell lung cancer, clear cell renal carcinoma, and other benign and malignant neoplasms. Diagnosis is based on correlation of the clinical presentation, electroencephalography, laboratory studies, and imaging. Computed tomography, positron emission tomography, and magnetic resonance imaging are essential to identify an underlying tumor, exclude clinicopathologic mimics, and predict the likelihood of long-term functional impairment. Nuclear imaging may be of value for prognostication and to assess the response to therapy. Treatment may involve high-dose corticosteroids, intravenous immunoglobulin, and plasma exchange. Herein, we review the hallmark clinicopathologic features and imaging findings of this rare but potentially devastating condition and summarize diagnostic criteria, treatment regimens, and proposed pathogenetic mechanisms.

Association between Psychiatric Disorders and the Incidence of Heart Failure in Women.

BACKGROUND: Depression and anxiety occur more frequently in women and are associated with an increased risk of cardiovascular disease. OBJECTIVES: Data on the association between these psychiatric conditions and the incidence of acute heart failure (HF) and how they influence heart failure outcomes in women are lacking. We investigated this potential relationship using data from the National Inpatient Sample. METHODS: We used ICD-10 codes to extract encounters for acute heart failure and/or the acute exacerbation of chronic heart failure, anxiety, and depression from the discharge data of the NIS from 2019 to 2020. We compared baseline characteristics and length of stay (LOS), cost of care (COC) and acute HF by depression/anxiety status for males and females and employed regression models to assess the influence of these psychiatric conditions on the outcomes. RESULTS: There were 6,394,136 encounters involving females, which represented 56.6% of the sample. The prevalence of depression and anxiety were 15.7% and 16.8%, respectively. Among females, the occurrence of acute CHF did not differ by depression or anxiety status. However, Takostubo cardiomyopathy was more prevalent in those with depression (0.3% vs. 0.2%, p = 0.003) and anxiety (0.3% vs. 0.2%, p = 0.03) compared to those without these conditions. Among those with depression, LOS was significantly longer (3 days IQR: 2-6, vs. 3 days IQR:2-5 days, p < 0.001). The COC was USD 1481 more in patients with depression. On the contrary, LOS and COC were significantly lower in those without anxiety. CONCLUSIONS: Depression was associated with an increased LOS among both men and women and an increased cost of care among women. Anxiety was associated with a decreased LOS and cost of care among women, which may be related to an increased rate of against medical advice (AMA) discharges among this population. Further research is necessary to identify optimal management strategies for depression and anxiety among patients hospitalized with HF.

A nationwide analysis of the outcomes in hospitalized patients with atrial fibrillation and temperature-related illnesses.

OBJECTIVES: The authors evaluated mortality and indices of cost of care among inpatients with Atrial Fibrillation (AF) and a diagnosis of a Temperature-Related Illness (TRI). The authors also assessed trends in the prevalence of TRIs among AF hospitalizations. METHODS: In this cross-sectional study, the authors used discharge data from the Nationwide Inpatient Sample (NIS) collected between January 2005 and September 2015 to identify patients with a diagnosis of AF and TRI. Outcomes of interest included in-hospital mortality, invasive mechanical ventilation, hospital length of stay, and cost of hospitalization. RESULTS: A total of 37,933 encounters were included. The median age was 79 years. Males were slightly overrepresented relative to females (54.2% vs. 45.8%, respectively). Although Blacks were only 6.6% of the cohort, they represented 12.2% of the TRI cases. Compared to non-TRI-related hospitalizations, a diagnosis of a TRI was associated with an increased likelihood of invasive mechanical ventilation (16.5% vs. 4.1%, p < 0.001), longer length-of-stay (5 vs. 4 days, p < 0.001), higher cost of care (10,082 vs. 8,607, in US dollars p < 0.001), and increased mortality (18.6% vs. 5.1%, p < 0.001). Compared to non-TRI, cold-related illness portends higher odds of mortality 4.68, 95% Confidence Interval (4.35-5.04), p < 0.001, and heat-related illness was associated with less odds of mortality, but this was not statistically significant 0.77 (0.57-1.03), p = 0.88. CONCLUSION: The occurrence of TRI among hospitalized AF patients is small but there is an increasing trend in the prevalence, which more than doubled over the decade in this study. Individuals with AF who are admitted with a TRI face significantly poorer outcomes than those admitted without a TRI including higher mortality. Cold-related illness is associated with higher odds of mortality. Further research is required to elucidate the pathogenic mechanisms underlying these findings and identify strategies to prevent TRIs in AF patients.

The impact of COVID-19 on mortality, length of stay, and cost of care among patients with gastrointestinal malignancies: A propensity score-matched analysis.

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the coronavirus 19 (COVID-19) pandemic have had a lasting impact on the care of cancer patients. The impact on patients with gastrointestinal (GI) malignancies remains incompletely understood. We aimed to assess the impact of COVID-19 on mortality, length of stay (LOS), and cost of care among patients with GI malignancies, and identify differences in outcomes based on primary tumor site. METHODS: We analyzed discharge encounters collected from the National Inpatient Sample (NIS) between March 2020 and December 2020 using propensity score matching (PSM) and COVID-19 as the treatment effect. RESULTS: Of the 87,684 patient discharges with GI malignancies, 1892 were positive for COVID-19 (C+) and eligible for matching in the PSM model. Following PSM analysis, C+ with GI tumors demonstrated increased incidence of mortality compared to their COVID-19-negative (C-) counterparts (21.3% vs. 11.9%, p < 0.001). C+ patients with colorectal cancer (CRC) had significantly higher mortality compared to those who were C- (40% vs. 24%; p = 0.035). In addition, C+ patients with GI tumors had a longer mean LOS (9.4 days vs. 6.9 days; p < 0.001) and increased cost of care ($26,048.29 vs. $21,625.2; p = 0.001) compared to C- patients. C+ patients also had higher odds of mortality secondary to myocardial infarction relative to C- patients (OR = 3.54, p = 0.001). CONCLUSIONS: C+ patients with GI tumors face approximately double the odds of mortality, increased LOS, and increased cost of care compared to their C- counterparts. Outcome disparities were most pronounced among patients with CRC.

Association between histamine 2 receptor antagonists and sepsis outcomes in ICU patients: a retrospective analysis using the MIMI-IV database.

BACKGROUND: Sepsis is marked by elevated histamine, which is a vasodilator that increases vascular permeability. Although human studies are lacking, murine models of sepsis have indicated potential protective effects of histamine 2 receptor antagonist administration (H2RAs). OBJECTIVE: To assess any association between H2RA use in sepsis-3 patients admitted to the ICU and mortality, mechanical ventilation, length of stay, and markers of renal, liver, and lung dysfunction. DESIGN: Retrospective cohort study. SETTING: Intensive care units of the Beth Israel Deaconess Medical Center (BIDMC) accessed via the MIMIC-IV database spanning an 11-year period from 2008 to 2019. PATIENTS (OR PARTICIPANTS): A total of 30,591 patients met the inclusion criteria for sepsis-3 on admission (mean age 66.49, standard deviation 15.92). MAIN MEASURES: We collected patient age, gender, ethnicity, comorbidities (contained within the Charlson comorbidity index), SOFA score, OASIS score, APS III score, SAPS II score, H2RA use, creatinine, BUN, ALT, AST, and P/F ratios. Primary outcomes were mortality, mechanical ventilation, and ICU length of stay. KEY RESULTS: A total of 30,591 patients met inclusion criteria over the 11-year sample period. The 28-day in hospital mortality rate was significantly lower among patients who received an H2RA (12.6% vs 15.1%, p < 0.001) as compared to those who did not receive an H2RA. Patients receiving an H2RA had significantly lower adjusted odds of mortality (0.802, 95% CI 0.741-0.869, p < 0.001), but significantly higher adjusted odds of invasive mechanical ventilation (4.426, 95% CI 4.132-4.741, p < 0.001) and significantly higher ICU LOS (3.2 days vs. 2.4 days, p < 0.001) as compared to the non-H2RA group. H2RA use was also associated with decreased severity of acute respiratory distress syndrome (ARDS) and lower serum creatinine. CONCLUSION: Among patients hospitalized in the ICU for sepsis, the use of an H2RA was associated with significantly lower odds of mortality, decreased severity of ARDS, and a lower incidence of renal insufficiency.

Effect of atrial fibrillation on mortality in SARS-CoV-2 patients: A propensity score-matched analysis of nationwide hospitalizations in the United States.

Background: Atrial fibrillation (AF) is one of the most common arrhythmias encountered in patients with SARS-CoV-2 infection. There are racial disparities in the incidence of AF and COVID-19. Several studies have reported an association between AF and mortality. However, it remains to be determined if AF represents an independent risk factor for COVID-19-related mortality. Methods: A propensity score-matched (PSM) analysis was performed using data from the National Inpatient Sample to assess the risk of mortality among patients hospitalized with SARS-CoV-2 infection and incident AF from March 2020 through December 2020. Results: AF was less common among patients who tested positive for SARS-CoV-2 as compared to those who tested negative (6.8% vs 7.4%, p < 0.001). White individuals with the virus had an increased incidence of AF but had lower mortality rates relative to Black and Hispanic patients. After PSM analysis, AF retained a significantly increased odds of mortality among patients with SARS-CoV-2 (OR: 1.35, CI: 1.29-1.41, p < 0.001). Conclusion: This PSM analysis shows that AF is an independent risk factor for inpatient mortality in those with SARS-CoV-2 infection and that White patients, while having a higher burden of SARS-CoV-2 and AF, demonstrate a significantly lower mortality rate as compared to their Black and Hispanic counterparts.

Efficacy of Cognitive Behavioral Therapy in Heart Failure Patients: A Systematic Review and Meta-Analysis.

BACKGROUND: Heart failure (HF) is a global disorder affecting around 6.2 million Americans aged 20 years and above. Neurovegetative disorders are common among such patients, and depression is a major problem that affects 20% to 40% of them. Cognitive behavioral therapy (CBT) is a type of treatment that produces the most favorable results compared to other psychotherapies, especially among patients with depression and anxiety. We aim to summarize and synthesize evidence regarding the efficacy of CBT for patients with HF. METHODS: We conducted this study by searching PubMed, Scopus, and Web of Science for relevant studies about CBT use in patients with HF. The outcomes were pooled as mean difference (MD) or standard MD with a 95% CI. The analysis was performed using the RevMan software. RESULTS: Combined data from 9 randomized controlled trials (1070 patients) revealed that CBT can alleviate both depression symptoms in HF patients when measured using different scales after 3 months of follow-up (standard MD, -0.18 [95% CI, -0.33 to -0.02]; P = 0.03) and the quality of life after 3 and 6 months of follow-up (MD, 4.92 [95% CI, 1.14-8.71]; P = 0.01 and MD, 7.72 [95% CI, 0.77-14.68]; P = 0.03, respectively). CONCLUSION: CBT is an effective type of psychotherapy for dealing with depression, mediocre quality of life, and defective physical functioning; therefore, it should be considered in HF patients' care.

Influence of HIV on in-hospital outcomes in patients with atrial fibrillation.

BACKGROUND: The development of highly active anti-retroviral therapy (HAART) has markedly prolonged the life expectancy of individuals with human immunodeficiency virus (HIV). The prevalence of age-related cardiovascular disease (CVD) and arrhythmias is therefore expected to increase among the HIV-positive population. OBJECTIVES: We aimed to assess the trends in prevalence, and inpatient outcomes among patients with HIV and atrial fibrillation (AF). METHODS: Using ICD-9-CM coding, we identified 38,252,858 HIV-negative and 31,224 HIV-positive encounters with AF from the National Inpatient Sample (NIS) database from January 2005 to September 2015. Trends in prevalence of HIV in AF patients, length and cost of hospital stay, and inpatient mortality, were determined. t-Test was used for continuous variables and Chi-square test for categorical variables. Final multivariable logistic regression models were constructed to determine predictors of outcomes. RESULTS: Among the 31,224 HIV-positive encounters, 78.6% were males. The median age was 56 years for HIV-positive patients and 78 years for HIV-negative patients. Black patients were markedly overrepresented among HIV-positive as compared to HIV-negative hospitalisations (48.6 vs. 7.6%). The prevalence of alcohol and drug use, smoking, chronic kidney disease, chronic liver disease, and cancer was higher among HIV-positive as compared to HIV-negative patients. The prevalence of HIV among the AF hospitalisations increased from 2005 to 2015. As compared to HIV-negative patients, individuals with HIV demonstrated increased inpatient mortality (9.2 vs. 5.1%), longer length of stay (6 [3-11] vs. 4 [2-7] days), and increased cost of treatment ($12,464 vs. $8606). CONCLUSION: The prevalence of HIV among patients with AF increased between 2005 and 2015. As compared to HIV-negative individuals with AF, a diagnosis of HIV was associated with increased inpatient mortality, length of stay, and cost of care. Future research on the underlying mechanisms of these findings is warranted to inform the treatment of AF in patients with HIV.

Race, age, and sex differences on the influence of obesity on colorectal cancer sidedness and mortality: A national cross-sectional study.

BACKGROUND AND OBJECTIVES: Colorectal cancer (CRC) sidedness is recognized as a prognostic factor for survival; left-sided colorectal cancer is associated with better outcomes than right-sided colon cancer (RsCC). We aimed to evaluate the influence of obesity on CRC sidedness and determine how race, age, and sex affect mortality among overweight and obese individuals. METHODS: A survey-weighted analysis was conducted using data obtained from the National Inpatient Sample between 2016 and 2019. RESULTS: Of the 24 549 patients with a diagnosis of CRC and a reported body mass index (BMI), 13.6% were overweight and 49.9% were obese. The race distribution was predominantly non-Hispanic Whites (69.7%), followed by Black (15.6%), Hispanic (8.7%), and other race (6.1%). Overweight (BMI: 25-29.9) and obese (BMI: ≥30) individuals were more likely to have RsCC (adjusted OR [aOR] = 1.28; 95% CI: 1.17-1.39, p < 0.001 and aOR = 1.45; 95% CI: 1.37-1.54, p < 0.001, respectively). Obese Black individuals were more likely to have RsCC as compared to their White counterparts (aOR = 1.23; 95% CI: 1.09-1.38). CONCLUSIONS: Obesity is associated with an increased risk of RsCC. In addition, racial disparities in CRC sidedness and outcomes are most pronounced among obese patients.

A nationwide analysis of the outcomes in hospitalized patients with atrial fibrillation and temperature-related illnesses

Abstract Objectives The authors evaluated mortality and indices of cost of care among inpatients with Atrial Fibrillation (AF) and a diagnosis of a Temperature-Related Illness (TRI). The authors also assessed trends in the prevalence of TRIs among AF hospitalizations. Methods In this cross-sectional study, the authors used discharge data from the Nationwide Inpatient Sample (NIS) collected between January 2005 and September 2015 to identify patients with a diagnosis of AF and TRI. Outcomes of interest included in-hospital mortality, invasive mechanical ventilation, hospital length of stay, and cost of hospitalization. Results A total of 37,933 encounters were included. The median age was 79 years. Males were slightly overrepresented relative to females (54.2% vs. 45.8%, respectively). Although Blacks were only 6.6% of the cohort, they represented 12.2% of the TRI cases. Compared to non-TRI-related hospitalizations, a diagnosis of a TRI was associated with an increased likelihood of invasive mechanical ventilation (16.5% vs. 4.1%, p< 0.001), longer length-of-stay (5 vs. 4 days, p <0.001), higher cost of care (10,082 vs. 8,607, in US dollars p <0.001), and increased mortality (18.6% vs. 5.1%, p <0.001). Compared to non-TRI, cold-related illness portends higher odds of mortality 4.68, 95% Confidence Interval (4.35-5.04), p <0.001, and heat-related illness was associated with less odds of mortality, but this was not statistically significant 0.77 (0.57-1.03), p= 0.88. Conclusion The occurrence of TRI among hospitalized AF patients is small but there is an increasing trend in the prevalence, which more than doubled over the decade in this study. Individuals with AF who are admitted with a TRI face significantly poorer outcomes than those admitted without a TRI including higher mortality. Cold-related illness is associated with higher odds of mortality. Further research is required to elucidate the pathogenic mechanisms underlying these findings and identify strategies to prevent TRIs in AF patients.

SVEAT score outperforms HEART score in patients admitted to a chest pain observation unit.

BACKGROUND: Timely and accurate identification of subgroup at risk for major adverse cardiovascular events among patients presenting with acute chest pain remains a challenge. Currently available risk stratification scores are suboptimal. Recently, a new scoring system called the Symptoms, history of Vascular disease, Electrocardiography, Age, and Troponin (SVEAT) score has been shown to outperform the History, Electrocardiography, Age, Risk factors and Troponin (HEART) score, one of the most used risk scores in the United States. AIM: To assess the potential usefulness of the SVEAT score as a risk stratification tool by comparing its performance to HEART score in chest pain patients with low suspicion for acute coronary syndrome and admitted for overnight observation. METHODS: We retrospectively reviewed medical records of 330 consecutive patients admitted to our clinical decision unit for acute chest pain between January 1st to April 17th, 2019. To avoid potential biases, investigators assigned to calculate the SVEAT, and HEART scores were blinded to the results of 30-d combined endpoint of death, acute myocardial infarction or confirmed coronary artery disease requiring revascularization or medical therapy [30-d major adverse cardiovascular event (MACE)]. An area under receiving-operator characteristic curve (AUC) for each score was then calculated. C-statistic and logistic model were used to compare predictive performance of the two scores. RESULTS: A 30-d MACE was observed in 11 patients (3.33% of the subjects). The AUC of SVEAT score (0.8876, 95%CI: 0.82-0.96) was significantly higher than the AUC of HEART score (0.7962, 95%CI: 0.71-0.88), P = 0.03. Using logistic model, SVEAT score with cut-off of 4 or less significantly predicts 30-d MACE (odd ratio 1.52, 95%CI: 1.19-1.95, P = 0.001) but not the HEART score (odd ratio 1.29, 95%CI: 0.78-2.14, P = 0.32). CONCLUSION: The SVEAT score is superior to the HEART score as a risk stratification tool for acute chest pain in low to intermediate risk patients.

Prognostic Factors and Survival in Gastrointestinal Extrapulmonary Small Cell Carcinoma: A Retrospective Cohort Study.

BACKGROUND: Gastrointestinal extrapulmonary small cell carcinoma (GI EPSCCa) is a rare, aggressive neuroendocrine tumor. Factors affecting survival, including the prognostic significance of primary tumor site, remain under investigation. METHODS: Data from the surveillance, epidemiology, and end results (SEER) program were extracted to identify patients diagnosed with GI EPSCCa between 2000 and 2018. Cox proportional hazard models were used to assess prognostic factors based on primary tumor site. RESULTS: A total of 1687 patients were included in the survival analysis. The distribution of the primary tumor location was as follows: 31.5% colorectum (CRC), 22.1% esophageal, 20.6% pancreatic, 13.3% hepatobiliary (HB), 10.6% stomach, and 1.8% small intestine (SI). Esophagogastric and SI EPSCCa were more common among Black individuals, whereas CRC, HB, and pancreatic EPSCCa were more common among White patients (p = 0.012). There were no racial differences in OS for GI EPSCCa. HB EPSCCa was associated with inferior OS compared with esophageal tumors (adjusted hazard ratio [aHR] 1.21, 95% confidence interval [CI] 1.00-1.46; p = 0.048), and SI EPSCCa was associated with prolonged survival compared with esophageal EPSCCa (aHR 0.76, 95% CI 0.48-1.20; p = 0.237) but did not reach statistical significance. Surgical intervention and a treatment period after 2006 were associated with superior OS. CONCLUSIONS: The prognosis for GI ESPCCa varies based on site. Chemotherapy, radiation, and surgical resection are associated with improved outcomes; however, the prognosis for patients with EPSCCa remains dismal. Prospective studies are needed to guide therapy for this aggressive tumor.

Association between Empagliflozin Use and Electrocardiographic Changes.

Empagliflozin, a sodium-glucose transporter 2 inhibitor, has been shown to bind to late sodium channels in mice cardiomyocytes. We sought to investigate the electrocardiographic (ECG) features associated with empagliflozin use in patients with diabetes mellitus. We compared ECG features of 101 patients before and after initiation of empagliflozin and found that empagliflozin was associated with a significant increase in QRS duration among diabetes patients with heart failure.

Hemostatic instantaneous coagulation on echocardiogram: a defining feature of the last heartbeat (a case report).

There is a paucity of detailed descriptions of echocardiographic features of the dying heart in the literature. A 64-year-old man on chronic hemodialysis presented with cardiac arrest after missing dialysis for three weeks. He received resuscitation efforts but died while his last heartbeats were fortuitously recorded by echocardiography. Rapid echo image acquisition during pulse check of a cardiopulmonary resuscitation attempt provided a unique opportunity for documenting the echocardiographic features of a dying heart. There was a rapid progressive dense echogenicity first in the left ventricular chamber and subsequently in all other chambers, which coincided with the final heartbeats. There is no prior documentation of this observation in the literature. We hereby illustrate and characterize this observation we term as Hemostatic Instantaneous Coagulation on Echo (HICE). HICE may be the defining feature of the dying heart and may guide the decision to discontinue resuscitation interventions.

Early-onset pancreatic cancer: a review of molecular mechanisms, management, and survival.

OBJECTIVES: Early-onset pancreatic cancer (EOPC) - defined as pancreatic cancer diagnosed before the age of 50 years - is associated with a poor prognosis as compared to later-onset pancreatic cancer (LOPC). Emerging evidence suggests that EOPC may exhibit a genetic signature and tumor biology that is distinct from that of LOPC. We review genetic mutations that are more prevalent in EOPC relative to LOPC and discuss the potential impact of these mutations on treatment and survival. MATERIALS AND METHODS: Using PubMed and Medline, the following terms were searched and relevant citations assessed: "early onset pancreatic cancer," "late onset pancreatic cancer," "pancreatic cancer," "pancreatic cancer genes," and "pancreatic cancer targeted therapy." RESULTS: Mutations in CDKN2, FOXC2, and SMAD4 are significantly more common in EOPC as compared to LOPC. In addition, limited data suggest that PI3KCA mutations are more frequently observed in EOPC as compared to LOPC. KRAS mutations are relatively rare in EOPC. CONCLUSIONS: Genetic mutations associated with EOPC are distinct from those of LOPC. The preponderance of the evidence suggest that poor outcomes in EOPC are related both to advanced stage of presentation and unique tumor biology. The molecular and genetic features of EOPC warrant further investigation in order to optimize management.