Trends in the Utilization of Herbal and Dietary Supplements in Patients with Chronic Liver Disease During the SARS-CoV2 Pandemic.

Background: We studied the pattern of herbal and dietary supplement (HDS) use in patients with chronic liver disease (CLD) during the first year of the COVID-19 pandemic. Methods: A questionnaire/survey was sent to hepatology patients with CLD under the care of hepatologists at Johns Hopkins University School of Medicine. Results: The 5 most taken dietary supplements during the pandemic included vitamin B12 (27.7%), vitamin C (32.4%), vitamin D (54.6%), zinc (25.4%) and green tea extract (20.8%). Most participants (82.3%) did not discuss their HDS use with their hepatology providers. Conclusions: Healthcare providers should be mindful of potential HDS use in patients with CLD.

Case Report of a Missed Small Bowel Adenocarcinoma on an Upper Endoscopy-A Review of Small Bowel Diagnostic Modalities.

Background: Small bowel neoplasms (SBN) are rare but pose a significant diagnostic challenge. The routine upper endoscopy delays the diagnosis, and most cases require multiple investigations increasing the health care burden. Case summary: A 74-year-old man presented with two months of progressively worsening postprandial bilious emesis and epigastric abdominal pain. He underwent outpatient evaluation with upper endoscopy and a computed tomographic enterography. The first endoscopy did not enable us to recognize the small bowel mass, leading to a diagnostic delay of two months. He subsequently developed a complete intestinal obstruction. A Second look upper endoscopy done with a push enteroscopy showed an apple core-like mass suggestive of a possible malignant neoplasm at the distal duodenum/proximal jejunum. Conclusion: Therefore, more sensitive, and specific diagnostic modalities like push enteroscopy, capsule endoscopy, and deep enteroscopy should be considered in case upper endoscopy is not conclusive.

Causes and Predictors of 30-Day Readmission in Patients With COVID-19 and ST-Segment-Elevation Myocardial Infarction in the United States: A Nationwide Readmission Database Analysis.

Background Rates, causes, and predictors of readmission in patients with ST-segment-elevation myocardial infarction (STEMI) during COVID-19 pandemic are unknown. Methods and Results All hospitalizations for STEMI were selected from the US Nationwide Readmissions Database 2020 and were stratified by the presence of COVID-19. Primary outcome was 30-day readmission. Multivariable hierarchical generalized logistic regression analysis was performed to compare 30-day readmission between patients with STEMI with and without COVID-19 and to identify the predictors of 30-day readmissions in patients with STEMI and COVID-19. The rate of 30-day all-cause readmission was 11.4% in patients with STEMI who had COVID-19 and 10.6% in those without COVID-19, with the adjusted odds ratio (OR) not being significantly different between the two groups (OR, 0.88 [95% CI, 0.73-1.07], P=0.200). Of all 30-day readmissions in patients with STEMI and COVID-19, 41% were for cardiac causes. Among the cardiac causes, 56% were secondary to acute coronary syndrome, while among the noncardiac causes, infections were the most prevalent. Among the causes of 30-day readmissions, infectious causes were significantly higher for patients with STEMI who had COVID-19 compared with those without COVID-19 (29.9% versus 11.3%, P=0.001). In a multivariable model, congestive heart failure, chronic kidney disease, low median household income, and length of stay ≥5 days were found to be associated with an increased risk of 30-day readmission. Conclusions Post-STEMI, 30-day readmission rates were similar between patients with and without COVID-19. Cardiac causes were the most common causes for 30-day readmissions, and infections were the most prevalent noncardiac causes.

Impact of Gender, Race, and Insurance Status on Inhospital Management and Outcomes in Patients With COVID-19 and ST-Elevation Myocardial Infarction (a Nationwide Analysis).

There is a paucity of data exploring the impact of gender, race, and insurance status on invasive management and inhospital mortality in patients with COVID-19 with ST-elevation myocardial infarction (STEMI) in the United States. The National Inpatient Sample database for the year 2020 was queried to identify all adult hospitalizations with STEMI and concurrent COVID-19. A total of 5,990 patients with COVID-19 with STEMI were identified. Women had 31% lower odds of invasive management and 32% lower odds of coronary revascularization than men. Black patients had lower odds of invasive management (odds ratio [OR] 0.61, 95% confidence interval [CI] 0.43 to 0.85, p = 0.004) than White patients. Black and Asian patients had lower odds of percutaneous coronary intervention (Black: OR 0.55, 95% CI 0.38 to 0.80, p = 0.002; Asian: OR 0.39, 95% CI 0.18 to 0.85, p = 0.018) than White patients. Uninsured patients had higher odds of getting percutaneous coronary intervention (OR 1.78, 95% CI 1.05 to 2.98, p = 0.031) and lower odds of inhospital mortality (OR 0.41, 95% CI 0.19 to 0.89, p = 0.023) than privately insured patients. Patients with out-of-hospital STEMI had 19 times higher odds of invasive management and 80% lower odds of inhospital mortality than inhospital STEMI. In conclusion, we note important gender and racial disparities in invasive management of patients with COVID-19 with STEMI. Surprisingly, uninsured patients had higher revascularization rates and lower mortality than privately insured patients.

Risk of Gastrointestinal Bleeding in Patients with End-Stage Renal Disease: The Link between Gut, Heart, and Kidneys.

Patients with end-stage renal disease (ESRD) have a five times higher risk of gastrointestinal bleed (GIB) and mortality than the general population. Aortic stenosis (AS) has been associated with GIB from intestinal angiodysplasia. In this retrospective analysis, we obtained data from the 2012 and 2019 National Inpatient Sample. The primary outcome of interest was all-cause in-hospital mortality and risk factors of mortality in patients with ESRD with GIB with aortic valve disorders especially AS. We identified all patients (≥18 years of age) with ESRD (n = 1,707,452) and analyzed based on discharge diagnosis of valvular heart disease (n = 6521) in patients with GIB compared with those without GIB (n = 116,560). Survey statistical methods accounting for strata and weighted data were used for analysis using survey packages in R (version 4.0). Baseline categorical data were compared using Rao-Scott chi square test, and continuous data were compared using Student's t-test. Covariates were assessed using univariate regression analysis, and factors with p value less than 0.1 in the univariate analysis were entered in the final model. The univariate and multivariable associations of presumed risk factors of mortality in ESRD with GIB patients were performed by Cox proportional hazards model censored at length of stay. Propensity score matching was done using MatchIt package in R (version 4.3.0). 1 : 1 nearest neighbour matching was done with propensity scores estimated through logistic regression, in which occurrence of GIB, valvular lesions, and AS was regressed according to other patient characteristics. Among patients with ESRD with valvular heart diseases, AS was found to be associated with increased risk of GIB (adj.OR = 1.005; 95% CI 1.003-1.008; p < 0.01). ESRD patients with AS showed increased risk of lower GIB (OR = 1.04; 95% CI 1.01-1.06; p = 0.02), colonic angiodysplasia (OR = 1.03; 95% CI 1.01-1.05; p < 0.01), stomach and duodenal angiodysplasia (OR = 1.03; 95% CI 1.02-1.06; p < 0.01), need for blood transfusion add pressors as compared to those without AS. However, there was no increased risk of mortality (OR = 0.97; 95% CI 0.95-0.99; p < 0.01).

A Case of Concurrence of Clonorchis Sinensis and Pancreatic Adenocarcinoma-A Diagnostic Dilemma.

Clonorchis Sinensis, a common liver fluke, is known to cause biliary disease and can present with a wide array of symptoms. It's mostly found in Asian countries due to consumption of undercooked or raw fish. Although Cholangiocarcinoma is a known serious complication of this disease, Pancreatic neoplasms are rare and have seldom been reported. Here, we report a case of an 80-year-old man who presents with pancreatic adenocarcinoma associated with Clonorchis Sinensis infection.

Thyrotoxic periodic paralysis-still a diagnostic challenge.

Thyrotoxic periodic paralysis is a life-threatening complication characterized by acute paralysis of proximal muscles with severe hypokalemia in patients with a known or undiagnosed history of thyrotoxicosis. A 24-year-old man was brought to the emergency room with 1 month of progressively worsening lower-extremity weakness followed by urinary retention. He demonstrated severe motor weakness in proximal muscles with absent reflexes. Laboratory testing showed a dangerously low potassium of 1.3 mmol/L. Further testing to establish an etiology revealed a new diagnosis of thyrotoxicosis, and the patient was also started on the antithyroid medication methimazole and propranolol. Immediate oral and intravenous potassium supplementation was initiated to normalize the serum potassium levels to 4.7 mmol/L; that was followed by the gradual recovery of his motor function. This case report highlights the need for early consideration of endocrine and metabolic causes of acute flaccid paralysis.

Fish Bone-Induced Pancreatitis.

Fish bone-induced pancreatitis is an uncommon cause of pancreatitis, with only a few reported cases in the literature. The patients with the highest risk for fish bone-induced pancreatitis include those from cultures where unfilleted fish is a culinary delicacy. The etiology of foreign body-induced pancreatitis is very common, secondary to inflammation of the duodenal papilla or bile duct obstruction. CT imaging is key for visualization of the fish bone, as radiography rarely detects fish bones. Complications of fish bone-induced pancreatitis include thrombosis of the superior mesenteric vein, bacteremia (with Peptostreptococcus), pancreatic granuloma, and gastrointestinal perforation. Management of fish bone-induced pancreatitis includes either endoscopic resection or exploratory laparotomy, followed by supportive care until pancreatitis resolves. Here, we present a case of pancreatitis secondary to accidental fish bone ingestion, identified during upper gastrointestinal endoscopy and managed by bone removal and supportive care.

Pseudo Hyperaldosteronism Secondary to Herbal Medicine Use.

Glycyrrhizic acid, better known as licorice, is commonly found in various food and cosmetic products. Excessive consumption is known to cause a syndrome of apparent mineralocorticoid excess or pseudo hyperaldosteronism. Patients typically present with resistant hypertension and hypokalemia mimicking symptoms of primary hyperaldosteronism however laboratory workup will reveal low or normal levels of plasma renin and aldosterone in the serum. While diagnosis of licorice toxicity is relatively straight forward, the challenge lies in determining the culpable agent. We report the case of a Chinese man who initially presented with resistant hypertension and hypokalemia refractory to therapy and was later diagnosed with pseudo hyperaldosteronism secondary to licorice toxicity.

What Happens When the Digested Screw Does Not Come Out of Ileum?

Adults with foreign body ingestion are mainly secondary to psychiatric disorders, alcoholic intoxication, and secondary gains. Conservative management without any intervention is successful in 80% of the ingested foreign bodies. Risk factors for complication include sharp objects, objects larger than 6 mm, recurrent ingestion, and previous gastrointestinal tract surgeries. Sharp objects specifically account for 35% perforation rates and impactions, most commonly at the ileocecal valve. There is limited evidence on the role of colonoscopy after the distal migration of foreign bodies into the ileum and colon. In our case report, we present a case of a 53-year-old-male with a history of recurrent foreign body ingestion secondary to a multitude of psychiatric disorders. It describes multiple foreign body ingestions, leading to failure of a screw at the ileocecal valve at day 5 of ingestion, despite conservative management with serial bowel preparations and abdominal radiographs. There is limited evidence on the management of foreign bodies after distal migration to the ligament of Trietz. Existing literature and guidelines suggest surgically managing the sharp foreign bodies after the failure of conservative management for three to five days. In the case report, we have attempted to emphasize the noninvasive, colonoscopic approach as initial management in removing impacted foreign bodies. This abstract has been presented and accepted at the American college of gastroenterology meeting held from October 22, 2021, to October 27, 2021, in Las Vegas as a poster.

Development and characterization of surface engineered PPI dendrimers for targeted drug delivery.

In this study, we reported folate-conjugated polypropylene imine dendrimers (FA-PPI) as efficient carrier for model anticancer drug, methotrexate (MTX), for pH-sensitive drug release, selective targeting to cancer cells, and anticancer activity. In the in vitro drug release studies this nanoconjugate of MTX showed initial rapid release followed by gradual slow release, and the drug release was found to be pH sensitive with greater release at acidic pH. The ex vivo investigations with human breast cancer cell lines, MCF-7, showed enhanced cytotoxicity of MTX-FA-PPI with significantly enhanced intracellular uptake. The biofate of nanoconjugate was determined in Wistar rat where MTX-FA-PPI showed 37.79-fold increase in the concentration of MTX in liver after 24 h in comparison with free MTX formulation.

Malposition of Subclavian Venous Catheter Leading to Chest Complications.

Although Central Venous Catheter (CVC) placement is a relatively simple procedure but its insertion and maintenance are associated with significant risks. Malposition (defined as any CVC tip position outside the superior vena cava) may be associated with catheter insertion and may require immediate intervention. It may result in complications like haemothorax, pleural effusions, pneumothorax, sepsis, thrombosis and cardiac tamponade. This case report presents timely detection of the complication after placement of CVC. Everyone should be aware of the complications and monitor consistently appropriate position of catheter tips.