Subtypes of Venous Thromboembolism in Inflammatory Bowel Disease: A Nationwide Assessment.

Background: Data detailing the risk of Venous Thromboembolism (VTE) subtypes among individuals with Inflammatory bowel disease (IBD) remain limited.Aims: We looked to assess the odds of VTE subtypes among hospitalized individuals with IBD as compared to those without IBD. Materials & Methods: Using the Nationwide Inpatient Sample database, we applied a multivariable regression analysis to compare the odds of primary VTE-related hospitalizations among individuals with and without IBD from 2016 to 2020, including deep venous thrombosis (DVT), pulmonary embolism (PE), portal vein thrombosis (PVT), Budd Chiari syndrome (BCS), renal vein thrombosis (RVT), and cerebral venous sinus thrombosis (CVST). Results: Overall, there were 15,565 primary VTE-related hospitalizations among individuals with IBD, as compared to 1,449,164 among individuals without IBD. Having IBD increased the odds for DVT (aOR = 1.34, 95%CI: 1.25-1.43), PVT (aOR = 3.16, 95%CI: 2.65-3.76), and CVST (aOR=1.45, 95%CI: 1.05-2.00), without significant increase in the odds of a PE, BCS, or RVT. Further, individuals with ulcerative colitis (UC) were at a higher risk for the majority of VTE-subtypes as compared to those with Crohn's disease (CD). Among individuals with a VTE-related hospitalization, the presence of IBD was not associated with increased mortality (aOR = 0.77, 95%CI: 0.40-1.50), but was associated with an increased length of stay (CD - 4.8 days, UC - 5.3 days, without IBD - 4.3 days, p<0.01). Conclusions: Clinicians should retain a high index of suspicion when evaluating VTE-related symptoms among individuals with IBD, as the presence of IBD confers a higher risk of DVT, PVT and CVST related-hospitalizations, and longer stays as compared to individuals without IBD.

Adverse Events and Device Failures Associated with Pancreatic Stents: A Comprehensive Analysis Using the FDA's MAUDE Database.

INTRODUCTION: Pancreatic duct stents (PDS) are widely used for the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. However, there is a paucity of data regarding the adverse events associated with PDS placement. This study aims to investigate the reported adverse events and device failures related to PDS, utilizing the Manufacturer and User Facility Device Experience (MAUDE) database maintained by the U.S. Food and Drug Administration (FDA). METHODS: Post-marketing surveillance data from January 2013 to December 8, 2023, were extracted from the FDA's MAUDE database to analyze the reports pertaining to the use of commonly used PDS. The primary outcomes of interest were device issues and patient-related adverse events. Statistical analysis was performed using Microsoft Excel 2010, with the calculation of pooled numbers and percentages for each device and patient adverse event. RESULTS: A total of 579 device issues and 194 patient-related adverse events were identified. Device issues were primarily attributed to stent deformation (n = 72; 12.4%), followed by migration of the device into the pancreatic duct or expulsion out of the duct (n = 60; 10.4%), and stent fracture/breakage (n = 55; 9.4%). Among the patient-reported adverse events, inflammation was the most common (n = 26; 13.4%), followed by reports of stents becoming embedded in tissue (n = 21; 10.8%) and stent occlusion/obstruction (n = 16; 8.2%). The most prevalent device failures associated with Advanix stents were material deformation, with perforation (n = 3, 30%) being the most frequently reported adverse event. Concerning Geenen stents, migration or expulsion of the device (n = 34, 16.9%) constituted the most common device-related adverse events, while inflammation (n = 20, 16.7%) was the most frequently reported patient-related issue. For Zimmon stents, migration or expulsion of the device (n = 22, 8.8%) were the most frequently reported device-related problems, whereas perforation (n = 7, 10.9%) and bleeding (n = 7, 10.9%) were the most frequent patient-related adverse events. CONCLUSION: Our findings highlight important device and patient adverse events that endoscopists and referring providers should be aware of before considering pancreatic stent placement.

Maternal, obstetrical, and neonatal outcomes in celiac disease.

OBJECTIVES: Some studies have suggested a link between celiac disease (CD) and adverse maternal, obstetrical, and neonatal outcomes. Using a large database, we evaluated the effect of CD on pregnancy outcomes. METHODS: We conducted a retrospective cohort study using the National Inpatient Sample (NIS) of all deliveries from 2015 to 2019 in the United States. Using ICD-10 codes, we identified pregnant patients who had CD and those who did not. A multivariate logistic regression was used to generate odds ratios (ORs) with 95% confidence intervals (CIs) for maternal, obstetrical, and neonatal outcomes. RESULTS: Of 12,039,222 deliveries between 2015 and 2019, there were 10,555 births in women with CD. Pregnant women with CD were more likely to be white and older compared to those without CD. Pregnant women with CD were significantly more likely to carry a diagnosis of gestational hypertension (OR 1.26; 95% CI 1.04-1.52), preeclampsia (1.28; 1.08-1.53), and severe preeclampsia (1.62; 1.25-2.09). They were less likely to have a full-term uncomplicated delivery (OR 0.11; 95% CI, 0.05-0.20), while being more likely to require device-assisted delivery (1.25; 1.04-1.50) and sustain 3rd or 4th degree vaginal lacerations (1.56; 1.21-2.02). Babies of pregnant women with CD were more likely to be small for gestational age (SGA) (OR 1.29; 95% CI 1.03-1.61). CONCLUSIONS: CD in pregnancy appears to be associated with increased adverse maternal, obstetrical, and neonatal outcomes. Clinicians should discuss these increased risks with CD patients who are planning to conceive.

Inpatient outcomes of inflammatory bowel disease in hospitalized patients with COVID-19: analysis of a nationally representative sample.

Purpose: To compare the risks of adverse outcomes, including mortality, gastrointestinal bleeding, and venous thromboembolism, between COVID-19 patients with inflammatory bowel disease (IBD) and those without IBD. Methods: We analyzed data from the National Inpatient Sample between January and December 2020. The study included adult patients with Crohn's disease (CD) and ulcerative colitis (UC) who contracted COVID-19. Inpatient outcomes were compared between the IBD and non-IBD COVID-19 cohorts. Results: Out of 1,050,045 COVID-19 hospitalizations, 0.28% had CD (2954 patients) and 0.26% had UC (2794 patients). After adjusting for confounding factors, UC patients had a significantly higher risk of deep vein thrombosis compared to non-IBD patients, with an adjusted odds ratio (aOR) of 2.55 (P < 0.001). However, CD patients did not show a significant association with deep vein thrombosis (aOR 1.29, P = 0.329). There were no significant associations between IBD patients (both UC and CD) and pulmonary embolism, nonvariceal gastrointestinal bleeding, or in-hospital mortality. UC patients had a longer average hospital stay (8.25 days) compared to non-IBD patients (adjusted mean difference 0.89, P = 0.007). Healthcare resource utilization was similar among the three groups. Conclusion: Our national study on COVID-19 hospitalizations indicates that patients with IBD have comparable rates of gastrointestinal bleeding, pulmonary embolism, and mortality as those without IBD. However, patients with UC hospitalized with COVID-19 have a higher risk of deep vein thrombosis than COVID-19 patients hospitalized without UC. Further research is needed to better understand the relationship between COVID-19 and IBD.

The National Burden of Colorectal Cancer in the United States from 1990 to 2019.

CRC accounts for approximately a tenth of all cancer cases and deaths in the US. Due to large differences in demographics among the different states, we aim to determine trends in the CRC epidemiology and across different states, age groups, and genders. CRC rates, age-adjusted to the standard US population, were obtained from the GBD 2019 database. Time trends were estimated as annual percentage change (APC). A pairwise comparison was conducted between age- and gender-specific trends using the tests of parallelism and coincidence. Age-specific trends were also assessed in two age subgroups: younger adults aged 15-49 years and older adults aged 50-74 years. We also analyzed the prevalence, incidence, mortality, and DALYs in the US between 1990 and 2019. A total of 5.53 million patients were diagnosed with CRC in the US between 1990 and 2019. Overall, CRC incidence rates have significantly increased in younger adults (11.1 per 100,000 persons) and decreased in older adults (136.8 per 100,000 persons) (AAPC = 1.2 vs. -0.6; AAPC difference = 1.8, p < 0.001). Age-specific trends were neither identical (p < 0.001) nor parallel (p < 0.001), suggesting that CRC incidence rates are different and increasing at a greater rate in younger adults compared to older adults. However, for both men and women (49.4 and 35.2 per 100,000 persons), incidence rates have decreased over the past three decades at the same rate (AAPC = -0.5 vs. -0.5; AAPC difference = 0, p = 0.1). Geographically, the southern states had the highest mortality rates with Mississippi having the highest rate of 20.1 cases per 100,000 population in 2019. Massachusetts, New York, and the District of Colombia had the greatest decreases in mortality over the study period (-42.1%, -41.4%, and -40.9%). Decreased mortality was found in all states except Mississippi, where the mortality of CRC increased over the study period (+1.5%). This research provides crucial insights for policymakers to tailor resource allocation, emphasizing the dynamic nature of CRC burden across states and age groups, ultimately informing targeted strategies for prevention and intervention.

Cannabis use and cyclical vomiting syndrome: An open debate.

INTRODUCTION: Cyclical vomiting syndrome (CVS) carries a significant financial burden on the U.S. healthcare system due to the recurrent emergency department visits and inpatient hospitalizations. We aimed to update the literature on the predictors of hospital utilization and readmission among individuals admitted with CVS. METHODS: This is a retrospective nationwide study of patients hospitalized with a primary diagnosis of CVS. Using weighted data from the National Inpatient Sample (NIS) and the National Readmission Database (NRD), we conducted a multivariate regression analysis to assess predictors of length of stay (LOS), and 30-day readmission. RESULTS: Primary admissions for CVS totaled 35,055 in the NIS, and 31,240 in the NRD. 2012 patients (6.4%) were readmitted within 30 days. On multivariate regression, cannabis use was associated with reduced LOS (adjusted Mean Difference (aMD) = -0.53 days, 95% CI: -0.68 to -0.38), and 30-day readmissions (adjusted Hazard Ratio (aHR) = 0.63, 95% CI: 0.54-0.73). DISCUSSION: Cannabis use among CVS admissions was associated with reduced LOS and 30-day readmissions; these results could be in fact driven by Cannabis Hyperemesis Syndrome (CHS)-related hospitalizations and the effect of cannabis cessation on decreased symptomatology. ICD-10 coding for CHS should be transitioned to specific codes to improve the differentiation between CVS and CHS-related hospitalizations.

Inpatient Outcomes of Gastric Antral Vascular Ectasia in Those With Aortic Stenosis: A Retrospective Study of 85,000 Hospitalizations.

GOALS: To investigate the outcomes of hospitalized patients with gastric antral vascular ectasia (GAVE) in the setting of aortic stenosis (AS). BACKGROUND: Although AS is associated with gastrointestinal arteriovenous malformations, its association with GAVE, a rare cause of upper gastrointestinal bleeding, remains unknown. STUDY: The National Inpatient Sample database from the years 2016 to 2019 was searched for patients admitted with a diagnosis of GAVE, with and without a history of AS. Univariate and multivariate logistic regression analysis was performed to determine the risk of mortality and in-hospital complications in the GAVE/AS group compared with the GAVE-only group. RESULTS: Patients with AS had a 2-fold increase in the risk of GAVE [odds ratio (OR): 2.08, P < 0.001], with no statistically significant difference in inpatient mortality between the study groups (OR: 1.36, P = 0.268). Patients with GAVE-AS had a higher risk of hypovolemic shock (OR: 2.00, P = 0.001) and acute coronary syndromes (OR: 2.25, P < 0.001) with no difference in risk of cardiogenic shock (P = 0.695), acute kidney injury (P = 0.550), blood transfusion (P = 0.270), sepsis (P = 0.598), respiratory failure (P = 0.200), or in-hospital cardiac arrest (P = 0.638). The cost of care in patients with GAVE-AS was increased by a mean of $4729 (P = 0.022), with no increase in length of stay (P = 0.320) when compared with patients with GAVE-only. CONCLUSIONS: Patients with AS have a 2-fold increase in the risk of development of GAVE. Patients with AS admitted for GAVE-related bleeding are at higher rates of hypovolemic shock, acute coronary syndrome, and higher resource utilization when compared with admitted patients with GAVE without AS.

Autoimmune Hepatitis and Obstetrical Outcomes: A Nationwide Assessment.

INTRODUCTION: Previous research identified AIH as linked to unfavorable obstetrical outcomes in a US nationwide retrospective study from 2012-2016. Our aim is to update the literature and strengthen the AIH-pregnancy outcomes relationship. METHODS: Using the National Inpatient Sample database in the US, from 2016 to 2020, we compared pregnant females with a diagnosis of AIH to those with and without other chronic liver diseases (CLD), using ICD-10-CM codes. Baseline characteristics were analyzed using T-test and Chi-Square, and multivariate regression was used to estimate the differences in maternal outcomes adjusted for age, race, insurance status, geographical location, hospital characteristics, and comorbid conditions. RESULTS: Out of 19,392,328 hospitalizations for pregnant females ≥ 18 years old from 2016 to 2020, 1095 had AIH, 179,655 had CLD, and 19,206,696 had no CLD. No mortality was observed among individuals with AIH. When compared to individuals without CLD, AIH was associated with an 82% increase in the odds of preterm delivery (AIH: 8% vs. Without CLD: 5%, adjusted Odds Ratio = 1.82, 95% CI 1.06-3.14), with no significant differences in gestational diabetes mellitus, hypertensive complications, and postpartum hemorrhage, and a 0.6 day longer hospital stay. Furthermore, there were no significant differences in outcomes between AIH and CLD. CONCLUSIONS: Our study reinforces the association of AIH with adverse obstetrical outcomes (e.g., preterm delivery), however, we found that there is no difference in GDM and hypertensive complications, as suggested in prior studies. Therefore, further investigations are needed to clarify the association between AIH and these obstetrical complications.

Determinants and outcomes of acute pancreatitis in patients hospitalized for COVID-19: Early pandemic experience.

OBJECTIVES: To examine the predictors and outcomes associated with the development of acute pancreatitis (AP) in patients hospitalized with Coronavirus Disease 2019 (COVID-19). METHODS: This is an observational analysis of the 2020 National Inpatient Sample Database. The study includes adult patients who were admitted with a confirmed diagnosis of COVID-19 and stratifies them based on the presence or absence of AP during their hospitalization. Predictors of AP development between the two groups and differences in outcomes are examined. Multivariate logistic regression analysis using Stata/BE 17.0 is conducted, with adjustments made for age, sex, race, and Charlson Comorbidity Index (CCI). Statistical significance is determined at a p-value of <0.05. RESULTS: Significant factors associated with an increased risk of AP in COVID-19 patients include Hispanic ethnicity, higher Charlson Comorbidity Index (CCI) score, residence in states located in the southern region, history of chronic kidney disease, chronic liver disease, malnutrition, portal hypertension, and alcohol use. COVID-19 patients who developed AP were also found to be at higher risk of adverse outcomes, including mortality, acute coronary syndrome, acute kidney injury, sepsis, septic shock, in-hospital cardiac arrest, invasive mechanical ventilation, upper gastrointestinal bleeding, prolonged length of stay, and increased healthcare cost. CONCLUSIONS: In hospitalized patients with COVID-19, the presence of AP is associated with increased mortality and morbidity. Risk factors for developing AP in this population include Hispanic ethnicity, residence in the southern region, higher Charlson Comorbidity Index (CCI) score, history of chronic kidney disease, chronic liver disease, malnutrition, portal hypertension, and alcohol use.

Racial Disparities in Liver Transplantation for Hepatocellular Carcinoma in the United States: An Update.

BACKGROUND: Previous studies have demonstrated a disparity in liver transplantation (LT) for hepatocellular carcinoma (HCC) among races in the United States (U.S.). AIMS: We aimed to update the literature on the odds, trends, and complications of LT in the treatment of hepatocellular carcinoma (HCC), among individuals of different racial backgrounds. METHODS: This is a nationwide study of adult individuals admitted for LT with a primary diagnosis of HCC. Using weighted data from the National Inpatient Sample (NIS) database, we compared the odds of LT among different races from 2016 to 2020, using a multivariate regression analysis. We further assessed the trends and outcomes of LT among races. RESULTS: A total of 112,110 adult were hospitalized with a primary diagnosis of HCC. 3020 underwent LT. When compared to Whites, the likelihood of undergoing LT for HCC was significantly reduced in Blacks (OR = 0.60, 95% CI = 0.46-0.78). Further, Blacks had increased mortality rates (7% in Blacks vs. 1% in Whites, p < 0.001), sepsis (11% in Blacks vs. 3% in Whites, p = 0.015), and acute kidney injury (AKI) (54% in Blacks vs. 31% in Whites, p < 0.001) following LT. CONCLUSIONS: Individuals identifying as Blacks were less likely to undergo LT for HCC, and more likely to develop complications. Further initiatives are warranted to mitigate the existing disparities among racial groups.

Vanishing Lung Syndrome, or Idiopathic Giant Bullous Emphysema, with Pneumothorax, and Subcutaneous Emphysema in a 58-Year-Old Female Smoker with Chronic Obstructive Pulmonary Disease.

BACKGROUND Vanishing lung syndrome (VLS), also known as idiopathic giant bullous emphysema, is a rare manifestation of chronic obstructive pulmonary disease (COPD) and usually occurs in middle-aged smokers. This report presents a 58-year-old female smoker with COPD and VLS who presented with spontaneous pneumothorax. The pneumothorax was managed with a chest tube and was later complicated by massive subcutaneous emphysema. CASE REPORT A 58-year-old woman with a past medical history of long-term smoking and COPD presented with worsening shortness of breath. Upon initial evaluation, she had tachypnea and hypoxia (SpO2 93%). Chest radiography revealed a new right-sided pneumothorax on top of extensive bullous disease, which the patient already had. The drainage of the pneumothorax was successful with a pigtail catheter. However, during the following night, after insertion of the pigtail catheter, the patient developed massive subcutaneous emphysema, which was confirmed with imaging. The patient remained hemodynamically stable, and diffuse subcutaneous crepitus was present on examination. The pigtail catheter was repositioned, resulting in complete resolution of the subcutaneous emphysema in the following 2 weeks. CONCLUSIONS This case highlights the importance of a timely diagnosis and management of the possible presentations and complications of VLS. Complications such as pneumothorax are life-threatening and require urgent management, taking precedence over the curative treatment for VLS, surgical bullectomy.

The Impact of Inflammatory Bowel Disease on Mortality and Other Outcomes of Hospitalized Patients With Diabetic Ketoacidosis: An Observational Study of the United States National Inpatient Sample.

Background Recent studies have shown an increased risk of diabetes mellitus in patients with Inflammatory bowel disease. However, the impact of IBD on outcomes of patients with diabetic ketoacidosis remains unknown. Methods This is an observational analysis of the National Inpatient Sample Database. The authors identified patients with a diagnosis of diabetic ketoacidosis and inflammatory bowel diseases. Outcomes studied were differences in risk of mortality, in-hospital outcomes and healthcare resources utilization. Multivariate logistic analysis was performed and results were adjusted for patient and hospital characteristics and comorbidities. Results No significant difference in mortality was observed in the DKA-IBD group when compared to the DKA-only group (aOR 0.55, p = 0.560). Similarly, inflammatory bowel disease had no impact on risk of sepsis (aOR 1.06, p = 0.742), acute kidney injury (aOR 1.08, p = 0.389), acute coronary syndrome (aOR 0.70, p = 0.397), ischemic stroke (aOR 1.53, p = 0.094), acute respiratory failure (aOR 1.00, p = 0.987), invasive mechanical ventilation (aOR 0.54, p = 0.225), deep vein thrombosis (aOR 1.68, p = 0.275), pulmonary embolism (aOR 2.16, p = 0.279) or cardiac arrest (aOR 1.35, p = 0.672) in diabetic ketoacidosis patients. The study group had a significant increase in length of stay (adjusted mean difference 0.63, p = 0.002) and charge of care (adjusted mean difference 3,950$, p = 0.026). Conclusion Inflammatory bowel disease is not associated with risk difference in mortality or morbidity in admitted patients with diabetic ketoacidosis, however, it does contribute to increased healthcare resources utilization.

Impact of Atrial Fibrillation on Patients With Inflammatory Bowel Disease Admitted for Colectomy.

Introduction Inflammatory bowel disease (IBD) is a chronic, relapsing, inflammatory disorder of the gastrointestinal tract. Patients with IBD may undergo a segmental or total colectomy, depending upon the extent of the disease. It is estimated that approximately 20 to 30 percent of patients with advanced ulcerative colitis will eventually require surgical resection. The incidence and prevalence of Atrial Fibrillation (AF) are increasing globally. There is plausible evidence linking inflammation to the initiation and perpetuation of AF. Given the importance of systemic inflammation in the pathogenesis of AF, an increased risk of the development of other diseases related to systemic inflammation can be expected. Objective Study how AF can affect the outcome of the patients in a population database hospitalized due to IBD flare and in whom colectomy was performed.  Methodology Data from the National Inpatient Sample database from 2016 to 2019 were used to obtain baseline demographic numbers and outcome variables. T-tests and chi-square tests were used to compare data. Univariate and multivariate logistic regression was used to calculate Odds ratios for comorbidities.  Results The study identified 27,165 patients with IBD who had colectomy during the same admission, among whom 2,045 also had AF. AF patients had a statistically significant longer mean LOS than patients without AF (16.79 vs. 11.24 days, p-value 0.001). AF patients also had significantly higher hospital charges ($222,109 vs. $142,011, p-value < 0.001). The mortality rate in IBD undergoing colectomy patients with AF was higher than in patients without AF (13.45% vs. 2.69%, p-value < 0.001), which was also reflected in multivariate analysis with an odds ratio of 2.27 (p-value < 0.001) after adjusting for age, gender, race, and comorbidities. Conclusion Our study showed that a national cohort of IBD patients with a history of colectomy had increased mortality and morbidity in the presence of AF. A finding that can guide physicians to allocate more time to optimizing the management of AF in this group of patients decreases the risk of complications, length of stay, and overall mortality.

Effect of Hospital Teaching Status on Mortality and Procedural Complications of Percutaneous Paracentesis in the United States: A Four-Year Analysis of the National Inpatient Sample.

Objectives Numerous previous studies investigated the impact of medical training settings on outcomes of hospitalized patients. However, the impact of teaching hospital status on outcomes of percutaneous paracentesis, to the best of our knowledge, has never been studied before. Methods Hospitalized patients who underwent percutaneous paracentesis were identified from the National Inpatient Sample database from 2016 to 2019 across the United States (US) teaching and non-teaching hospitals. Outcomes studied were differences in risk of mortality, postprocedural outcomes, and healthcare resource utilization. Multivariate logistic analysis was performed using STATA software (StataCorp LLC, College Station, Texas, US) and results were adjusted for patient and hospital characteristics and comorbidities. Results Inpatient mortality rates were significantly higher in patients undergoing paracentesis at US teaching hospitals (adjusted odds ratio (aOR) 1.29, 95%CI 1.23-1.35, p<0.001) compared to non-teaching hospitals. Similarly, higher risk of procedural complications including hemoperitoneum (aOR 1.90, 95%CI 1.65-2.20, p<0.001), hollow viscus perforation (aOR 1.97, 95%CI 1.54-2.51, p<0.001), and vessel injury/laceration (aOR 15.3, 95%CI 2.12-110.2, p=0.007) were noticed in the study group when compared to controls. Furthermore, hospital teaching status was associated with prolonged mean length of stay (9.33 days vs 7.42 days, adjusted mean difference (aMD) 1.81, 95%CI 1.68-1.94, p<0.001) and increased charge of care ($106,014 vs $80,493, aMD $24,926, 95%CI $21,617-$28,235, p <0.001) Conclusion Hospitalized patients undergoing paracentesis in US teaching hospitals have an increased risk of mortality, postprocedural complications, prolonged length of stay, and increased charge of care when compared to non-teaching hospitals.

The Relationship Between Obstructive Sleep Apnea (OSA) and Gastroesophageal Reflux Disease (GERD) in Inpatient Settings: A Nationwide Study.

INTRODUCTION: Several studies identified a link between gastroesophageal reflux disease (GERD) and obstructive sleep apnea (OSA). GERD is a condition in which acid reflux from the stomach to the esophagus causes troublesome symptoms. On the other hand, OSA is defined as a sleep-related breathing disorder in which airflow significantly decreases or ceases due to upper airway obstruction, leading to arousal from sleep. OSA was found to be associated with GERD. In this study, we aim to study the characteristics and concurrent risk factors associated with GERD and OSA in a large population-based study. METHODS: Patients with the diagnosis of GERD were extracted from the National Inpatient Database (NIS) for the years 2016 to 2019. Patients' age, gender, race, and hospital information, including region and bed size, were extracted and considered as baseline characteristics. The comorbidities included are hypertension (HTN), atrial fibrillation (AFib), congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), pulmonary hypertension (PHTN), obesity, and smoking. Patients younger than 18 years old were excluded from this study.  Results: Out of 22,677,620 patients with the diagnosis of GERD, 12.21% had a concurrent diagnosis of OSA (compared to 4.79% in patients without GERD, p-value <0.001). The mean age of patients with GERD and OSA was 64.47 years vs 65.42 years in patients without OSA (p-value <0.001). The GERD and OSA group had almost identical gender distribution compared to the GERD only group, as it was predominantly female patients. The white and black races were slightly more prevalent in the GERD and OSA group compared to the GERD only group. Regarding comorbidities, the prevalence of obesity was more clear in the GERD and OSA group. It was noted that the group of patients who carry a diagnosis of GERD and OSA have more prevalence of diabetes (DM), hypertension (HTN), obesity, atrial fibrillation (Afib), congestive heart failure (CHF), and pulmonary hypertension (PHTN). Patients with GERD and OSA were 21% less likely to be older than 65 years rather than younger (95% CI: 0.79-0.8, p-value <0.001), 35% less likely to be females (95% CI: 0.65-0.65, p-value <0.001), and 22% less likely to be non-white (95% CI: 0.77-0.8, p-value <0.001). Obesity was found to be the strongest association with this population, followed by PHTN, CHF, DM, HTN, Afib, and lastly smoking. CONCLUSION:  Patients with GERD and OSA were found more likely to be female, white, living in the southern part of the United States, obese, diabetes mellitus type 2, and being active smokers.

A Rare Case of Ascariasis-Induced Cholangitis Complicated With Klebsiella pneumoniae Bacteremia and Liver Microabscesses.

Ascariasis, which is caused by Ascaris lumbricoides, is the most common gastrointestinal parasitic infection worldwide, with occasional invasion of the biliary tract leading to a variety of complications. In rare cases, pathogens carried on the surface of A. lumbricoides can complicate the course of the disease and lead to superimposed bacterial infections. In this article, we present a case of ascariasis-induced cholangitis complicated with Klebsiella pneumoniae bacteremia and multiple hepatic microabscesses. This article, which shows an association that was not reported in the literature before, aims to increase the awareness of clinicians for the possibility of the association between ascariasis and superimposed bacterial infection, specifically with K. pneumoniae.

Non-islet cell tumor hypoglycemia as an initial presentation of hepatocellular carcinoma coupled with end-stage liver cirrhosis: A case report and review of literature.

BACKGROUND: Non-islet cell tumor hypoglycemia (NICTH) is a rare cause of persistent hypoglycemia seen in patients with hepatocellular carcinoma (HCC). It is likely to be underdiagnosed especially in the patients with poor hepatic function and malnutrition. Herein, we report a rare case of NICTH as the initial presentation of HCC in a patient with chronic hypoglycemia due to end-stage liver cirrhosis. CASE SUMMARY: A 62-year-old male with chronic fasting hypoglycemia secondary to end-stage hepatitis C-related cirrhosis, presented with altered mental status and dizziness. He was found to have severe hypoglycemia refractory to glucose supplements. Imaging studies and biopsy discovered well differentiated HCC without metastasis. Further evaluation showed low insulin, C-peptide and beta-hydroxybutyrate along with a high insulin-like growth factor-2/insulin-like growth factor ratio, consistent with the diagnosis of NICTH. As patient was not a candidate for surgical resection or chemotherapy, he was started on prednisolone with some improvements in the glucose homeostasis, but soon decompensated after a superimposed hospital acquired pneumonia. CONCLUSION: NICTH can occur as the sole initial presentation of HCC and is often difficult to correct without tumor removal. Clinicians should maintain high clinical suspicion for early recognition of paraneoplastic NICTH in patients at risk for HCC, even those with chronic fasting hypoglycemia in the setting of severe hepatic failure and malnutrition.

Bilateral Nephrectomy, the Forgotten Measure in the Treatment of Refractory Hypertension in Patients With End-Stage Renal Disease: A Case Report and Literature Review.

It's not uncommon for patients with end-stage renal disease (ESRD) to develop hypertension that is resistant to antihypertensive medications and volume control, making it a challenge to control blood pressure in those patients. In this article, we present a 71-year-old female with a history of ESRD on intermittent hemodialysis (IHD), who developed refractory hypertension despite the use of seven antihypertensive agents in addition to IHD. The patient underwent bilateral nephrectomy as a last resort therapy for managing resistant hypertension, which led to a significant improvement in blood pressure (BP) and decreasing the number and doses of antihypertensive agents. This article aims to raise the awareness and alertness of clinicians to the efficacy of bilateral nephrectomy as rescue therapy for refractory hypertension in hemodialysis patients.

Critical Finding of Wellens' Syndrome in a Patient who Presented With a Fibular Fracture.

Diagnosing myocardial infarction is not always straightforward; there are many insidious presentations that can be overlooked resulting in deadly consequences. We present a 76-year-old male who came to the ED complaining of right ankle pain. A routine electrocardiogram (ECG) done was noted to have biphasic T waves in leads V2 and V3 which was characteristic of Wellens' syndrome. Subsequent workup showed an increase in troponin T levels in a chest pain-free setting. The patient underwent urgent cardiac catheterization which showed significant triple vessel coronary artery disease, with 90% proximal occlusion of the left anterior descending artery, eventually requiring coronary artery bypass grafting (CABG). Timely diagnosis and management prevented serious consequences of his underlying severe coronary artery disease.