Correlation of the Endoscopic Gastroesophageal Flap Valve with Pathologic Reflux.

BACKGROUND: The Hill classification characterizes the geometry of gastroesophageal junction and Hill grades (HGs) III and IV have a high association with pathologic reflux. This study aimed to understand the use of the Hill classification and correlate the prevalence of pathologic reflux across different HGs. STUDY DESIGN: A retrospective review of 477 patients who underwent upper endoscopy and BRAVO pH monitoring between August 2018 and October 2021 was performed. These charts were reviewed for endoscopic findings for hiatal hernia and association of HGs with pathologic reflux, defined as an abnormal esophageal acid exposure time (AET) of ≥4.9%. RESULTS: Of 477 patients, 252 (52.8%) had an HG documented on the endoscopy report. Of the 252 patients, 61 had HG I (24.2%), 100 had HG II (39.7%), 61 had HG III (24.2%), and 30 had HG IV (11.9%). The proportion of patients with abnormal AET increases with increasing HGs (p < 0.001) as follows: I (39.3%), II (52.5%), III (67.2%), and IV (79.3%). The mean overall AET is as follows: HG I (5.5 ± 6%), HG II (7.0 ± 5.9%), HG III (10.2 ± 10.3%), and HG IV (9.5 ± 5.5%). The proportion of patients with hiatal hernia was 18% for HG I, 28% for HG II, 39.3% for HG III, and 80% for HG IV. CONCLUSIONS: Use of the Hill classification in clinical practice is low. There is an association of increasing HGs with increasing proportion of patients with abnormal AET. There is a high proportion of patients within HGs I and II with documented pathologic reflux and the presence of a hiatal hernia as observed on endoscopic examination. Our study suggests that endoscopic grading of the gastroesophageal junction may not adequately differentiate between normal vs abnormal reflux status, particularly for HGs I and II.

Impact of COVID-19 Pandemic on Management and Outcomes of Acute Cholecystitis at US Academic Centers.

BACKGROUND: The COVID-19 pandemic has had wide-ranging effects on management of medical conditions. Many hospitals encountered staffing shortages, limited operating room availability, and shortage of hospital beds. There was increased psychological stress and fear of contracting COVID-19 infection, leading to delay in medical care for various disease processes. The objective of this study was to examine changes in management and outcomes attributed to the COVID-19 pandemic in patients presenting with acute calculus cholecystitis at US academic centers. STUDY DESIGN: Using the Vizient database, patients with the diagnosis of acute calculus cholecystitis who underwent intervention during the 15 months before the pandemic (prepandemic, October 2018 to December 2019) were compared with 15 months during the pandemic (pandemic, March 2020 to May 2021). Outcomes measures included demographics, characteristics, type of intervention, length of stay, in-hospital mortality, and direct cost. RESULTS: There were 146,459 patients with acute calculus cholecystitis identified (prepandemic: 74,605 vs pandemic: 71,854). Patients in the pandemic group were more likely to undergo medical management (29.4% vs 31.8%; p < 0.001) or percutaneous cholecystostomy tube placement (21.5% vs 18%; p < 0.001) and less likely to undergo laparoscopic cholecystectomy (69.8% vs 73.0%; p < 0.001). Patients in the pandemic group who underwent procedural intervention had longer length of stay (6.5 days vs 5.9 days; p < 0.001), higher in-hospital death (3.1% vs 2.3%; p < 0.001), and higher cost ($14,609 vs $12,570; p < 0.001). CONCLUSIONS: In this analysis of patients with acute calculus cholecystitis, there were distinct changes in the management and outcomes of patients due to the COVID-19 pandemic. Changes in the type of intervention and outcomes are likely related to delayed presentation with increases in the severity and complexity of the disease.

Analysis of Veno-Venous Extracorporeal Membrane Oxygenation for COVID-19 Compared to Non-COVID Etiologies.

OBJECTIVE: This study analyzed the characteristics and outcomes of veno-venous (V-V) extracorporeal membrane oxygenation (ECMO) for acute respiratory distress syndrome (ARDS) due to COVID-19 versus non-COVID causes at US academic centers. BACKGROUND DATA: V-V ECMO support has been utilized for COVID-19 patients with ARDS since the beginning of the pandemic. Mortality for ECMO in COVID-19 has been reported to be high but similar to reported mortality for ECMO support for non-COVID causes of respiratory failure. METHODS: Using ICD-10 codes, data of patients who underwent V-V ECMO for COVID-19 ARDS were compared with patients who underwent V-V ECMO for non-COVID causes between April 2020 and December 2022. The primary outcome was in-hospital mortality. Secondary outcome measures included length of stay and direct cost. Multivariate logistic regression modeling was performed to analyze differences in mortality between COVID and non-COVID groups, adjusting for other important risk factors (age, sex, and race/ethnicity). RESULTS: We identified and compared 6382 patients who underwent V-V ECMO for non-COVID causes to 6040 patients who underwent V-V ECMO for COVID-19. There was a significantly higher proportion of patients aged ≥ 65 years who underwent V-V ECMO in the non-COVID group compared with the COVID group (19.8% vs. 3.7%, respectively, P <0.001). Compared with patients who underwent V-V ECMO for non-COVID causes, patients who underwent V-V ECMO for COVID had increased in-hospital mortality (47.6% vs. 34.5%, P <0.001), length of stay (46.5±41.1 days vs. 40.6±46.1, P <0.001), and direct hospitalization cost ($207,022±$208,842 vs. $198,508±205,510, P =0.02). Compared with the non-COVID group, the adjusted odds ratio (OR) for in-hospital mortality in the COVID group was 2.03 (95% CI: 1.87-2.20, P <0.001). In-hospital mortality for V-V ECMO in COVID-19 improved during the study time period (50.3% in 2020, 48.6% in 2021, and 37.3% in 2022). However, there was a precipitous drop in the ECMO case volume for COVID starting in quarter 2 of 2022. CONCLUSIONS: In this nationwide analysis, COVID-19 patients with ARDS requiring V-V ECMO support had increased mortality compared with patients who underwent V-V ECMO for non-COVID etiologies.

Episodic Future Thinking about Smoking-Related Illness: A Preliminary Investigation of Effects on Delay Discounting, Cigarette Craving, and Cigarette Demand.

Cigarette smokers show excessive delay discounting (devaluation of delayed rewards), which may contribute to tobacco use disorder. Episodic future thinking (EFT), or mental simulation of future events, has been shown to reduce both delay discounting and laboratory smoking behavior. Traditionally, EFT involves vividly imagining positive future events. In this preliminary investigation, we examined the effects of EFT specifically about smoking-related illness (SRI) on delay discounting, cigarette craving, and behavioral economic demand for cigarettes. In a 2 (episodic thinking) × 2 (smoking-related illness) factorial design, we randomly assigned smokers from Amazon Mechanical Turk to one of two EFT groups: EFT alone or EFT + SRI; or one of two episodic "recent" thinking (ERT) control groups: ERT alone or ERT + SRI. Both EFT groups generated and imagined positive future events, while both ERT groups imagined real events from the recent past. Both EFT + SRI and ERT + SRI groups imagined these events while also experiencing SRI symptoms. Participants then completed assessments of delay discounting, cigarette craving, and measures of cigarette demand. We observed significant main effects on delay discounting of both EFT (reduced discounting) and SRI (increased discounting), as well as significant main effects of both EFT and SRI on cigarette craving (in both cases, reduced craving). No significant main effect of EFT was observed on cigarette demand measures, although we observed a main effect of SRI on quantity of demand when cigarettes were free (Q0) (reduced demand). In all analyses, we observed no significant EFT × SRT interactions, indicating that these variables operate independently of one another. These methods may be adapted for use in clinical treatment to aid in smoking cessation interventions.

Adolescent Trauma During the COVID Pandemic: Just Like Adults, Children, or Someone Else?

COVID-19 stay-at-home (SAH) orders were impactful on adolescence, when social interactions affect development. This has the potential to change adolescent trauma. A post-hoc multicenter retrospective analysis of adolescent (13-17 years-old) trauma patients (ATPs) at 11 trauma centers was performed. Patients were divided into 3 groups based on injury date: historical control (CONTROL:3/19/2019-6/30/2019, before SAH (PRE:1/1/2020-3/18/2020), and after SAH (POST:3/19/2020-6/30/2020). The POST group was compared to both PRE and CONTROL groups in separate analyses. 726 ATPs were identified across the 3 time periods. POST had a similar penetrating trauma rate compared to both PRE (15.8% vs 13.8%, P = .56) and CONTROL (15.8% vs 14.5%, P = .69). POST also had a similar rate of suicide attempts compared to both PRE (1.2% vs 1.5%, P = .83) and CONTROL (1.2% vs 2.1%, P = .43). However, POST had a higher rate of drug positivity compared to CONTROL (28.6% vs 20.6%, P = .032), but was similar in all other comparisons of alcohol and drugs to PRE and POST periods (all P > .05). Hence ATPs were affected differently than adults and children, as they had a similar rate of penetrating trauma, suicide attempts, and alcohol positivity after SAH orders. However, they had increased drug positivity compared to the CONTROL, but not PRE group.

Surgical Outcome in Laparoscopic Abdominal Surgical Operations with Clostridium Difficile Infection.

Introduction: Postoperative Clostridium difficile infection (CDI) has associated morbidity, but it is unknown how it impacts different operations. We sought to determine the incidence and postoperative morbidity following abdominal surgery.Method: The National Surgical Quality Improvement Program database (2015-2019) was utilized to evaluate adult (≥18 years-old) patients who developed CDI following laparoscopic abdominal operations. Univariate and multivariate analysis were performed to evaluate outcomes.Results: A total of 973 338 patients were studied and the overall incidence of CDI was .3% within 30 days of operation. Colorectal surgery had the highest incidence of CDI (1601/167 949,1.0%) with significantly longer mean length of stay (LOS) (8.0 days± 9.0, P < .01) compared to other surgical procedures. CDI patients also had a longer mean length of stay (6.6± 8.0 vs 2.1 ± 3.6 days, P < .01) and increased mortality (1.8% vs .2%, AOR: 4.64, CI: 3.45-5.67, P < .01) compared to patients without CDI.Conclusions: This national analysis demonstrates that CDI is a significant complication following abdominal surgery and is associated with increased LOS and mortality. Furthermore, laparoscopic colorectal surgery appears to have the greatest risk of CDI. Future research is needed to determine the exact cause in order to decrease the incidence of CDI by reconsidering the protocol of antibiotic use within the high-risk population.