Systematic Review with Meta-analysis: Efficacy and Safety of Upadacitinib in Managing Moderate-to-Severe Crohn's Disease and Ulcerative Colitis.

BACKGROUND: In the panorama of therapeutic strategies for inflammatory bowel diseases, oral upadacitinib stands out for its potential to improve short-term and long-term patient outcomes. OBJECTIVE: This meta-analysis aspires to collate and assess the available evidence regarding the efficacy and safety of upadacitinib in managing moderate-to-severe Crohn's disease and ulcerative colitis. METHODS: A meta-analysis was conducted using studies sourced from MEDLINE/PubMed, Cochrane Library, Scopus, and Embase, published from January 2010 to March 2024. Peer-reviewed articles that reported data on the effects of upadacitinib in adult patients with Crohn's disease and ulcerative colitis were included based on established inclusion and exclusion criteria. RESULTS: Eight studies, encompassing a total of 2818 patients treated with upadacitinib, were included. In primary outcomes, for patients with Crohn's disease who were using upadacitinib, the weighted pooled clinical remission rate was found to be 45.8% (95% confidence interval [CI] 0.39-0.52), while for patients with ulcerative colitis who were using upadacitinib, the rate was 25.4% (95% CI 0.17-0.36). The pooled clinical response rate for Crohn's disease was 53.6% (95% CI 0.50-0.57), and for ulcerative colitis it was 72.6% (95% CI 0.69-0.76). The pooled serious adverse event rate was 6.0% (95% CI 0.07-0.09). CONCLUSIONS: Upadacitinib demonstrates significant efficacy in achieving clinical remission and response in patients with moderate-to-severe Crohn's disease and ulcerative colitis, as shown by clinical remission rates of 44.9% and 36.0%, respectively. The treatment also maintains a favorable safety profile with a serious adverse event rate of 7.8%, making it an effective option for those resistant or intolerant to traditional immunosuppressants or tumor necrosis factor antagonists.

Portopulmonary hypertension: A focused review for the internist.

Portopulmonary hypertension, ie, pulmonary arterial hypertension in a patient with portal hypertension, affects transplant eligibility and has a poor prognosis. The pathogenesis remains an area of active research, with various mechanisms proposed. Diagnosing it requires a detailed history, physical examination, laboratory tests, and echocardiographic evaluation, followed by a careful hemodynamic assessment.

The preconception health status of nongravid women aged 18 to 45 years in Arima, Trinidad: a cross-sectional study.

BACKGROUND: Preconception care (PCC) is the term used for activities and interventions designed to address and prevent problems related to pregnancy, the neonatal period and childhood. This study assessed maternal health status prior to conception in Trinidad by means of a screening tool, physical measurements, and laboratory samples. METHODS: A cross-sectional study was conducted among women aged 18-45 years at a primary care centre in Arima, Trinidad. A de novo PCC screening tool was used to assess 13 domains of high-risk pregnancy in participants. These domains included dietary details, gynaecological and obstetric histories, and genetic and vaccination histories, among others. Blood pressure, weight, height, and waist circumference were recorded, and a capillary blood sample was used to determine random blood glucose and HbA1c levels. All data were coded and entered into SPSS ver. 21. RESULTS: A total of 400 nongravid participants were recruited, of whom 366 were included in the final analysis. Most (96.7%) had one or more risk factors for adverse pregnancy outcomes. These included overweight (27%), obesity (35%), central obesity (69.4%), and impaired glucose tolerance/diabetes mellitus (IGT/DM) (26.2%). Additionally, a sedentary lifestyle and diet high in processed food/fats were self-reported by 74.9% and 88.8% of participants, respectively. Only 13.1% had planned to conceive, and of those who had no immediate plans to conceive, 76.4% were currently sexually active, and many (60.7%) did not use birth control techniques. More than half (57.1%) had never had a pap smear. On the other hand, 86.3% knew their HIV status. Self-reported percentages for vaccination were as follows: MMR (100%), tetanus (17.5%), hepatitis B (11.5%) and influenza (2.7%). The majority (82.8%) of participants had not visited the dentist in the past year, with 35.9% of these individuals reporting symptoms of periodontitis. Segments of the population had multiple risk factors; for example, 23.7% of participants were overweight or obese and had an elevated HbA1c level. CONCLUSIONS: Unexpectedly, most participants had a risk factor for an adverse pregnancy outcome, and many had multiple risk factors. There is a strong case for enhanced preconception care for women in Trinidad.

Rheumatoid Vasculitis as an Initial Presentation of Rheumatoid Arthritis.

Rheumatoid vasculitis is a rare, extra-articular manifestation that can be seen in long-standing rheumatoid arthritis. Here we present the case of a 51-year-old man who presented with arthralgias, skin rash, dyspnoea and generalized leg swelling and who was diagnosed with rheumatoid arthritis flare. LEARNING POINTS: Extra-articular manifestations like rheumatoid vasculitis and pericarditis rarely present as initial manifestations of rheumatoid arthritis.A high index of suspicion is required to make the diagnosis, especially in an adult who presents with multiorgan manifestations, rash, and a high titre of rheumatoid factor and anti-CCP antibody levels.

Safety and Feasibility of Same-Day Discharge After Left Atrial Appendage Closure With the WATCHMAN Device.

BACKGROUND: As the use of left atrial appendage closure (LAAC) becomes more widespread, improvements in resource utilization and cost-effectiveness are necessary. Currently, there are limited data on same-day discharge (SDD) after LAAC. We aimed to evaluate the safety and feasibility of SDD versus non-SDD in patients with nonvalvular atrial fibrillation who underwent LAAC. METHODS: We retrospectively studied 211 patients who underwent the WATCHMAN procedure in a tertiary hospital (June 2016 to June 2019). The primary safety outcome was the composite of stroke, systemic embolism, major bleeding requiring transfusion, vascular complications requiring endovascular intervention, or death through 7 days (periprocedural) and 45 days post-procedure. The secondary outcomes were the individual components of the primary outcome and all-cause readmission. We compared the clinical outcomes of patients who had SDD and non-SDD post-procedure. RESULTS: Patients with procedure-related complications on the day of LAAC and patients who were admitted for acute clinical events before LAAC were excluded. One hundred ninety patients were included in the final analysis. Seventy-two of 190 (38%) patients had SDD, and 118 of 190 (62%) had non-SDD. There were no statistically significant differences in the primary safety outcome through 7 days (1.4% versus 5.9%; P=0.26) and 45 days post-procedure (2.8% versus 9.3%; P=0.14) between the two groups. The secondary outcomes were similar in both groups. No patients had device-related thrombus on transesophageal echocardiography at 45 days. Only 1 patient from the non-SDD group had clinically significant peri-device flow (>5 mm) at 45 days. CONCLUSIONS: In a selected cohort of patients who underwent successful elective LAAC with WATCHMAN without same-day procedure-related complications, the primary safety outcome and secondary outcomes through 7 and 45 days post-procedure were similar in the SDD and non-SDD groups. Our findings are hypothesis generating and warrant further investigation in prospective trials.

Arrhythmias in patients with in-hospital alcohol withdrawal are associated with increased mortality: Insights from 1.5 million hospitalizations for alcohol withdrawal syndrome.

BACKGROUND: Atrial arrhythmias are commonly noted in patients with alcohol withdrawal syndrome (AWS), requiring inpatient admission. OBJECTIVE: The burden of arrhythmias and the association with in-hospital outcomes are incompletely defined in patients hospitalized with AWS. METHODS: The nationwide inpatient sample database was accessed from September 2015 to December 2018 to identify hospitalizations for AWS. We studied a cohort of patients with arrhythmias noted during hospitalization using the appropriate International Classification of Diseases, Tenth Revision billing codes. We compared patient characteristics, outcomes, and hospitalization costs between alcohol withdrawal hospitalizations with and without documented arrhythmias. Propensity score matching (PSM) and multivariate regression were performed to control confounders and develop odds ratios (OR), respectively. RESULTS: Among 1,511,155 hospitalization with AWS, 146,825 (9.72%) had concurrent arrhythmias. After PSM, we identified 135,540 cases in each group. Hospitalizations with AWS and concurrent arrhythmias had higher in-hospital mortality (4.19% vs 1.95%, OR 1.76, confidence interval [CI] 1.67-1.85, P < .0001). The most common arrhythmia was atrial fibrillation (66.7%). Arrhythmias in AWS were also associated with poorer in-hospital outcomes, including a higher risk of acute heart failure (8.40% vs 4.58%, OR 1.97, CI 1.90-2.05, P < .0001), acute kidney injury (21.32% vs 15.27%, OR 1.39, CI 1.36-1.43, P < .0001), and acute respiratory failure (9.19% vs 5.49%, OR 1.70, CI 1.64-1.76, P < .0001) requiring intubation. The length of hospital stay (6 days vs 4 days P < .0001) and cost of hospital care ($12,615 [$6683-$27,330] vs $7860 [$4482-$15,868], P < .0001) were higher in AWS with arrhythmias. CONCLUSION: Arrhythmia in AWS is associated with higher in-hospital mortality and poorer in-hospital outcomes.

Clinical characteristics and outcomes of critically ill patients with COVID-19 in a tertiary community hospital in upstate New York.

Background: There are limited reports describing critically ill COVID-19 patients in the state of New York. Methods: We conducted a retrospective analysis of 32 adult critically ill patients admitted to a community hospital in upstate New York, between 14 March and 12 April 2020. We collected demographic, laboratory, ventilator and treatment data, which were analyzed and clinical outcomes tabulated. Results: 32 patients admitted to the intensive care unit (ICU) were included, with mean (±SD) follow-up duration 21 ± 7 days. Mean (±SD) age was 62.2 ± 11.2 years, and 62.5% were men. 27 (84.4%) of patients had one or more medical co-morbidities. The mean (±SD) duration of symptoms was 6.6 (±4.4) days before presentation, with cough (81.3%), dyspnea (68.7%), and fever (65.6%) being the most common. 23 (71.9%) patients received invasive mechanical ventilation. 5 (15.6%) died, 11 (34.4%) were discharged home, and 16 (50%) remained hospitalized, 8 (25%) of which were still in ICU. Mean (±SD) length of ICU stay was 10.2 (±7.7) days, and mean (±SD) length of hospital stay was 14.8 (±7.7) days. Conclusion: Majority of patients were of older age and with medical comorbidities. With adequate resource utilization, mortality of critically ill COVID-19 patients may not be as high as previously suggested. Abbreviations: ACE-i: Angiotensin converting enzyme inhibitor; ARB: Angiotensin receptor blocker; ARDS: Acute Respiratory Distress Syndrome; BiPAP: Bilevel positive airway pressure; CABG: Coronary artery bypass graft; CFR: Case fatality rate; COVID-19: Coronavirus disease 19; CPAP: Continuous positive airway pressure; CRP: C - Reactive Protein; CT: Computed tomography; DVT: Deep vein thrombosis; ECMO: Extra Corporeal Membrane Oxygenation; ESICM: European Society of Intensive Care Medicine; FiO2: Fraction of inspired O2; HFNC: High Flow Nasal Cannula; HITF: Hypoxia-Inducible Transcription Factor; IBM: International Business Machines; ICU: Intensive Care Unit; IL: Interleukin; IMV: Invasive Mechanical Ventilation; IQR: Interquartile Range; ISTH: International Society of Thrombosis Hemostasis; NIV: Non Invasive Ventilation; NY: New York; PAI: Plasminogen activator inhibitor; PaO2: partial pressure of arterial oxygen; PCV: Pressure Control Ventilation; PEEP: Positive End Expiratory Pressure; RGH: Rochester General Hospital; RRH: Rochester Regional Health; RT-PCR: Reverse transcriptase polymerase chain reaction; RSV: Respiratory Syncytial virus; SARS-CoV-2: Severe Acute Respiratory Syndrome Coronavirus 2; SD: Standard Deviation; STEMI: ST segment elevation myocardial infarction; TNF: Tumor necrosis factor; USA: USA; VTE: Venous thromboembolism.

An update on the 2019-nCoV outbreak.

Cases of 2019-nCoV are now being reported in different regions around the globe, concerning for a possible SARS like epidemic that infected for than 8000 people in 2002-03. Though, major health authorities are still working on understanding the virus and its transmission, here we present a brief report regarding the 2019-nCoV outbreak and what is known so far.

The Slipping Slipper Sign: A Poor Man's Test for Severe Diabetic Peripheral Neuropathy.

BACKGROUND: Neuropathic feet are at very high risk for infection and amputation. The slipping slipper sign (SSS) is elicited by a simple questionnaire test reported to detect the presence of severe diabetic peripheral neuropathy. This test can be administered by non-medical staff. In this study, subjects with and without the SSS were evaluated by nerve conduction studies (NCS) and ultrasound measurements of the right sural nerve diameters as well as with traditional scoring systems for peripheral and autonomic neuropathy. OBJECTIVE: To demonstrate that the Slipping Slipper Sign can be used as an index of severe diabetic peripheral neuropathyMethod:This was a prospective cross sectional study in which 74 patients with diabetes (38 positive and 36 negative for SSS) underwent ultrasonography and NCS of the right sural nerve by an examiner blinded to SSS status. Findings were evaluated against demography, clinical history, anthropometry as well as traditional clinical and autonomic neuropathic scores. RESULTS: Patients without the SSS [median (IQR) = 10.0 years (4.0-20.3)] had a significantly shorter duration of diabetes compared with those with the SSS [median (IQR) = 15.0 years (8.5-25.0)], p = 0.028. The frequencies of retinopathy (36.8% vs 2.8%, p <  0.05) and cerebrovascular accidents (18.4% vs 13.9 %, p <  0.05) were higher among those with SSS compared with those without. Differences in nerve conduction characteristics were markedly significant. The amplitude of the sural sensory nerve action potential (SNAP) was ([median (IQR)] 0 microvolts vs 4.0 microvolts (0.0-10.8) p <  0.002) between those with and without SSS, respectively whilst none of patients with SSS had a recordable SNAP vs 78% without a SSS. Similarly, maximal thickness of the right sural nerve at the ankle 3.0 mm (2.3-3.4) vs 3.5 mm (3.0-3.9), and leg 3.4 mm (2.7-3.8) vs 3.9 mm (3.3-4.2) was reduced, p <  0.01 in patients with the SSS compared with those with a negative SSS. CONCLUSION: The SSS identifies feet with objective neurophysiological and imaging characteristics of severe neuropathy.

Spontaneous tumor lysis syndrome in squamous cell carcinoma of the lung.

Tumor lysis syndrome (TLS) is an oncologic emergency, more commonly occurring in patients with hematologic malignancies receiving cancer-directed therapy due to massive cellular breakdown. Spontaneous TLS is rare and occurs in the absence of cancer-directed therapy. Herein, we present a case of spontaneous TLS associated with squamous cell carcinoma.

Splenic artery pseudoaneurysm presenting with massive rectal bleeding.

Splenic artery pseudoaneursym is relatively rare and its rupture is usually fatal. We report a case of a 48-year-old male with 2 prior episodes of alcoholic pancreatitis that presented with massive per rectal bleeding from rupture of a splenic artery pseudoaneurysm into the transverse colon. Gold standard of diagnosis is CT angiography of the abdomen. We present the first case in the literature where a diagnosis has been made with noncontrast CT of the abdomen and described the radiologic features that facilitated this diagnosis.

Gallstone ileus 1 year after cholecystectomy.

Post-cholecystectomy gallstone ileus (GSI) is very rare with only 16 cases reported in the literature. This condition poses diagnostic challenges both because of its rarity and since the gallbladder had been previously removed. A high index of suspicion is needed for diagnosis. We report a case of a 37-year-old female who presented with GSI 12 months post-cholecystectomy.