Safety and outcomes of hip and knee replacement surgery in liver transplant recipients.

BACKGROUND: Liver transplant (LT) is becoming increasingly common with improved life expectancy. Joint replacement is usually a safe procedure; however, its safety in LT recipients remains understudied. AIM: To evaluate the mortality, outcome, and 90-d readmission rate in LT patients undergoing hip and knee replacement surgery. METHODS: Patients with history of LT who underwent hip and knee replacement surgery between 2016 and 2019 were identified using the National Readmission Database. RESULTS: A total of 5046119 hip and knee replacement surgeries were identified. 3219 patients had prior LT. Mean age of patients with no history of LT was 67.51 [95% confidence interval (CI): 67.44-67.58], while it was 64.05 (95%CI: 63.55-64.54) in patients with LT. Patients with history of LT were more likely to have prolonged length of hospital stay (17.1% vs 8.4%, P < 0.001). The mortality rate for patients with no history of LT was 0.22%, while it was 0.24% for patients with LT (P = 0.792). Patients with history of LT were more likely to have re-admissions within 90 d of initial hospitalization: 11.4% as compared to 6.2% in patients without history of LT (P < 0.001). The mortality rate between both groups during readmission was not statistically different (1.9% vs 2%, P = 0.871) respectively. CONCLUSION: Hip and knee replacements in patients with history of LT are not associated with increased mortality; increased re-admissions were more frequent in this cohort of patients. Chronic kidney disease and congestive heart failure appear to predict higher risk of readmission.

Incidence and Cross-Continents Differences in Endoscopic Retrograde Cholangiopancreatography Outcomes Among Patients With Cirrhosis: A Systematic Review and Meta-Analysis.

Background: There are conflicting data on the frequency and variability of endoscopic retrograde cholangiopancreatography (ERCP) outcomes in patients with cirrhosis. Our aim was to systematically review the literature on the incidence of post-ERCP adverse events in cirrhotic patients and to examine the differences across continents. Methods: We searched PubMed/MEDLINE, EMBASE, Scopus, and Cochrane databases to identify studies reporting adverse events after ERCP in patients with cirrhosis from conception to September 30, 2022. The random effects model was used to calculate odds ratios (ORs), mean differences (MDs), and confidence intervals (CIs). A P value < 0.05 was considered statistically significant. Heterogeneity was assessed using the Cochrane Q-statistic (I2). Results: Twenty-one studies that included 2,576 cirrhotic patients and 3,729 individual ERCPs were analyzed. The pooled overall rate of adverse events after ERCP in patients with cirrhosis was 16.98% (95% CI: 13.06-21.29%, P < 0.001, I2 = 86.55%). ERCPs performed in Asia had the highest ERCP adverse events with an overall complication rate of 19.90%, while the lowest overall adverse events were in North America at 13.04%. The pooled post-ERCP bleeding, pancreatitis, cholangitis and perforation were 5.10% (95% CI: 3.33-7.19%, P < 0.001, I2 = 76.79%), 3.21% (95% CI: 2.20-5.36%, P = 0.03, I2 = 42.25%), 3.02% (95% CI: 1.19-5.52%, P < 0.001, I2 = 87.11%), and 0.12% (95% CI: 0.00 - 0.45, P = 0.26, I2 = 15.76%), respectively. The pooled post-ERCP mortality rate was 0.22% (95% CI: 0.00-0.85%, P = 0.01, I2 = 51.86%). Conclusions: This meta-analysis shows that the overall complication rates after ERCP, bleeding, pancreatitis, and cholangitis are high in patients with cirrhosis. Because cirrhotic patients are more likely to have post-ERCP complications, with significant cross-continent variations, the risks and benefits of ERCP in this patient population should be carefully considered.

Transjugular Intrahepatic Portosystemic Shunt With or Without Gastroesophageal Variceal Embolization for the Prevention of Variceal Rebleeding: A Systematic Review and Meta-Analysis.

Background: The role of variceal embolization (VE) during transjugular intrahepatic portosystemic shunt (TIPS) creation for preventing gastroesophageal variceal rebleeding remains controversial. Therefore, we performed a meta-analysis to compare the incidence of variceal rebleeding, shunt dysfunction, encephalopathy, and death between patients treated with TIPS alone and those treated with TIPS in combination with VE. Methods: We performed a literature search using PubMed, EMBASE, Scopus, and Cochrane databases for all studies comparing the incidence of complications between TIPS alone and TIPS with VE. The primary outcome was variceal rebleeding. Secondary outcomes include shunt dysfunction, encephalopathy, and death. Subgroup analysis was performed based on the type of stent (covered vs. bare metal). The random-effects model was used to calculate the relative risk (RR) with the corresponding 95% confidence intervals (CIs) of outcome. A P value < 0.05 was considered statistically significant. Results: Eleven studies with a total of 1,075 patients were included (597: TIPS alone and 478: TIPS plus VE). Compared to the TIPS alone, the TIPS with VE had a significantly lower incidence of variceal rebleeding (RR: 0.59, 95% CI: 0.43 - 0.81, P = 0.001). Subgroup analysis revealed similar results in covered stents (RR: 0.56, 95% CI: 0.36 - 0.86, P = 0.008) but there was no significant difference between the two groups in the subgroup analysis of bare stents and combined stents. There was no significant difference in the risk of encephalopathy (RR: 0.84, 95% CI: 0.66 - 1.06, P = 0.13), shunt dysfunction (RR: 0.88, 95% CI: 0.64 - 1.19, P = 0.40), and death (RR: 0.87, 95% CI: 0.65 - 1.17, P = 0.34). There were similarly no differences in these secondary outcomes between groups when stratified according to type of stent. Conclusions: Adding VE to TIPS reduced the incidence of variceal rebleeding in patients with cirrhosis. However, the benefit was observed with covered stents only. Further large-scale randomized controlled trials are warranted to validate our findings.

Hospitalizations for alcoholic liver disease during the COVID-19 pandemic increased more for women, especially young women, compared to men.

BACKGROUND: Alcoholic liver disease (ALD) remains one of the major indications for liver transplantation in the United States and continues to place a burden on the national healthcare system. There is evidence of increased alcohol consumption during the coronavirus disease 2019 (COVID-19) pandemic, and the effect of this on the already burdened health systems remains unknown. AIM: To assess the trends for ALD admissions during the COVID-19 pandemic, and compare it to a similar pre-pandemic period. METHODS: This retrospective study analyzed all admissions at a tertiary health care system, which includes four regional hospitals. ALD admissions were identified by querying a multi-hospital health system's electronic database using ICD-10 codes. ALD admissions were compared for two one-year periods; pre-COVID-19 from April 2019 to March 2020, and during-COVID-19 from April 2020 to March 2021. Data were analyzed using a Poisson regression model and admission rates were compared using the annual quarterly average for the two time periods, with stratification by age and gender. Percent increase or decrease in admissions from the Poisson regression model were reported as incident rate ratios. RESULTS: One thousand three hundred and seventy-eight admissions for ALD were included. 80.7% were Caucasian, and 34.3% were female. An increase in the number of admissions for ALD during the COVID-19 pandemic was detected. Among women, a sharp rise (33%) was noted in those below the age of 50 years, and an increase of 22% in those above 50 years. Among men, an increase of 24% was seen for those below 50 years, and a 24% decrease in those above 50 years. CONCLUSION: The COVID-19 pandemic has had widespread implications, and an increase in ALD admissions is just one of them. However, given that women are often prone to rapid progression of ALD, this finding has important preventive health implications.

High prevalence of non-alcoholic fatty liver disease in patients with inflammatory bowel disease receiving anti-tumor necrosis factor therapy.

BACKGROUND: Non-alcoholic fatty liver disease (NAFLD) is common in patients with inflammatory bowel disease (IBD). This study evaluated the prevalence of NAFLD and the associated risk factors among IBD patients who received anti-tumor necrosis factor (TNF) therapy. METHODS: Adult IBD patients receiving anti-TNF therapy (infliximab, adalimumab, certolizumab, golimumab) were enrolled. Hepatic steatosis was assessed by abdominal ultrasound. Patients with a history of excessive alcohol or recent steroid use were excluded. Univariate and multivariate analysis were performed. RESULTS: Eighty patients, 55% male, mean age 42±15 years, were enrolled. The sonographic prevalence of NAFLD was 54% (43/80), significantly higher than the general prevalence in the US adult population (30%) (P<0.0001). NAFLD patients had a significantly higher proportion of males, as well as greater body weight and body mass index, compared to non-NAFLD. The Crohns disease activity index (CDAI) was significantly higher among patients with NAFLD. Multivariate analysis demonstrated that a higher CDAI was independently associated with NAFLD, with an odds ratio of 1.6 (95% confidence interval 1.05-2.44; P=0.03). CONCLUSIONS: The presence of IBD is strongly associated with NAFLD. We identified a high prevalence of NAFLD among IBD patients receiving anti-TNF. CDAI was independently associated with hepatic steatosis. Further studies are still needed to evaluate the pathophysiology of NAFLD development and disease progression among IBD populations.

Prevalence of non-alcoholic fatty liver disease on computed tomography in patients with inflammatory bowel disease visiting an emergency department.

BACKGROUND: Non-alcoholic fatty liver disease (NAFLD) is common in patients with inflammatory bowel disease (IBD). The purpose of this study was to further examine the prevalence of NAFLD in IBD patients. METHODS: We retrospectively reviewed the medical records of IBD patients who visited the emergency department because of abdominal pain between January 2009 and December 2014. These were compared with a group of 70 controls without IBD, matched for age and body mass index (BMI). Computed tomography data were analyzed for the presence or absence of hepatic steatosis. Patient with recent steroid or excessive alcohol use were excluded. Univariate and multivariate analyses were performed. RESULTS: NAFLD prevalence was 44% (31/70) in the IBD group vs. 16% (11/70) in controls (P<0.001). There was no significant difference between the 2 groups in age, sex distribution, BMI, presence of diabetes, or levels of serum transaminases, serum albumin or platelets. In multivariate analysis, the presence of IBD was independently associated with NAFLD (odds ratio 4.53, 95% confidence interval 2.00-10.26; P=0.002). CONCLUSIONS: The presence of IBD is strongly and independently associated with NAFLD. Systemic inflammation and alteration of the intestinal microbiome have been proposed as mechanisms, but further studies are needed to better elucidate the pathophysiology.

Dental Impaction in the Cecum: Case Report and Review of Gastrointestinal Foreign Body Impactions.

Approximately 20% of the adult population in the United States wears dentures. Foreign body ingestions, including dentures, are not uncommon. Although the majority of all ingested foreign bodies pass spontaneously through the gastrointestinal tract, impaction may occur, especially with physiologic constrictions, angulations, or stenosis. The esophagus is the most common site of impaction, whereas colonic impaction is extremely uncommon. We present a case of an 84-year-old male who was referred to the gastroenterology clinic for denture impaction, which lasted for two weeks. The patient had already failed to pass the denture following conservative treatment with laxatives, and repeated abdominal imaging showed the dental plate in the cecum. Colonoscopy was performed three weeks after the ingestion of his dentures, and tripod forceps were used to dislodge the end of the dental plate and ultimately remove it. The patient was asymptomatic for the entire period.

Gastric Metastasis from Renal Cell Carcinoma, Clear Cell Type, Presenting with Gastrointestinal Bleeding.

Renal cell carcinoma (RCC) accounts for 80-85% of all primary renal neoplasms. Although RCC can metastasize to any organ, gastric metastases from RCC are exceedingly rare. A 67-year-old male presented with melena and acute blood loss anemia. The patient had a history of RCC that had been treated with a radical nephrectomy. He had a recent myocardial infarction and was receiving double antiplatelet therapy. After hemodynamic stabilization, esophagogastroduodenoscopy showed a polypoid mass in the gastric fundus. The mass was excised. Histological and immunohistochemical evaluation were consistent with clear cell RCC. The polypoid lesion is consistent with a late solitary metastasis.

Lifestyle Choices Fuel Epidemics of Diabetes and Cardiovascular Disease Among Asian Indians.

Within the next 15years, India is projected to overtake China as the world's most populous nation. Due to the rapid pace of urbanization and modernization fueling population growth, in conjunction with a genetic predisposition to insulin resistance, India is suffering a rising epidemic of non-communicable diseases (NCDs), including coronary artery disease (CAD), type 2 diabetes mellitus (T2DM), and stroke. In addition to the genetic predisposition, major negative lifestyle factors are contributing to the alarming outbreak of cardiovascular disease (CVD) among the Asian Indian population; these factors include: 1) a diet high in added sugar, refined grains and other processed foods, 2) physical inactivity, 3) vitamin D deficiency (VDD), and 4) smoking/pollution. These risk factors are all highly modifiable, and steps to improve these issues should be taken urgently to avoid a worsening NCD crisis among the inhabitants of the South Asian subcontinent as well as for people with Asian Indian ethnicity worldwide.

Increased intrathoracic and hepatic visceral adipose tissue independently correlates with coronary artery calcification in asymptomatic patients.

BACKGROUND: Visceral adipose tissue (VAT) is associated with cardiac events, but it is not clear which, if any of the various measures of VAT independently correlate with coronary artery disease (CAD). METHODS: We studied 400 patients undergoing computed tomography to determine coronary artery calcium (CAC) score. VAT was measured in the form of epicardial adipose tissue (EAT) volume and thickness, intrathoracic adipose tissue volume (ITAV), and hepatic steatosis. RESULTS: Of the 400 subjects, the average CAC score was 112.2 ± 389.3. When each measure of VAT (EAT volume and thickness, ITAV, hepatic steatosis) was added to the traditional model (they were independently associated with greater risk of CAC score ≥100 AU as measured by IDI/NRI (P < .05). On univariable logistic regression analysis, each of the 4 measures of VAT showed association with greater risk of a CAC score of ≥100 AU (OR > 1). CONCLUSIONS: Each measure of VAT is a strong correlate of CAC score ≥100 AU in asymptomatic subjects-these VAT assessments correlate more significantly than do traditional CAD risk factors. This incremental power in the predictive models is likely the result of measurement of a fundamental expression of the metabolic syndrome and consequent proatherogenic derangements.

Association of coronary artery calcification with hepatic steatosis in asymptomatic individuals.

OBJECTIVE: To determine the association of coronary artery calcification with hepatic steatosis in asymptomatic volunteers. PATIENTS AND METHODS: The study group comprised 400 asymptomatic volunteers, enrolled from April 1, 2011, to September 30, 2012, without known coronary artery disease who were self-referred for screening noncontrast computed tomography to determine coronary calcium score (CCS). Computed tomographic images were used to determine the presence of hepatic steatosis. An a priori model was created to predict a CCS of 100 Agatston units (AU) or higher on the basis of Framingham risk factors, diabetes mellitus, and metabolic syndrome. Hepatic steatosis was then added to this model. Computation of the odds ratio (OR) for hepatic steatosis predicting a CCS of 100 AU or higher was performed. Finally, the OR for a CCS of 100 AU or higher being associated with hepatic steatosis was calculated. RESULTS: When hepatic steatosis was added to traditional coronary risk factors, it was independently associated with a CCS of 100 AU or higher (OR, 2.85). This was greater than the OR of Framingham factors, diabetes mellitus, or metabolic syndrome. A CCS of 100 AU or higher was independently associated with an increased risk for hepatic steatosis (OR, 2.4). This OR was higher than traditional hepatic steatosis risk factors or metabolic syndrome. CONCLUSION: Hepatic steatosis is a strong independent predictor of a CCS of 100 AU or higher in asymptomatic patients. It is associated with an increased risk of coronary artery disease beyond that expected from traditional coronary risk factors and/or metabolic syndrome. Additional studies are needed to clarify the role of hepatic steatosis as a possible independent risk factor for the development of coronary artery disease.

Review of cardiometabolic risk factors among current professional football and professional baseball players.

Data on the development of cardiovascular disease in professional football players are conflicting. Studies have documented a higher prevalence of obesity, lower high-density lipoprotein cholesterol levels, increased left ventricular and left atrial size, and higher prevalence of metabolic syndrome in former professional football linemen compared with nonlinemen. It has been suggested that former National Football League players are at risk for early cardiovascular disease and premature death. A print media report in 2006 indicated an increased prevalence of cardiovascular disease and early mortality in professional football players compared with professional baseball players. However, there has been little scientific evaluation of cardiovascular risk factors in professional baseball players. Our data suggest that there is increased cardiovascular disease risk in football players, but this is limited to heavier linemen. In preliminary studies, baseball players do not appear to demonstrate the same increased risk. However, caution should be used in the interpretation of increased cardiovascular disease risk, as it does not necessarily translate into early increased mortality.

Comparison of cardiovascular and metabolic risk factors in professional baseball players versus professional football players.

In 2006, a newspaper report indicated an increased prevalence of cardiovascular disease and early mortality in retired professional football players compared to professional baseball players. This study included 69 professional football players from a 2008 National Football League training camp and 155 professional baseball players from an American League 2009 spring training site who volunteered to participate in a study of cardiovascular and metabolic risk factors. The prevalence of body mass index > or =30 kg/m(2), waist circumference > or =100 cm, waist/height ratio >0.5, blood pressure > or =130/85 mm Hg, triglycerides > or =150 mg/dl, triglycerides/high-density lipoprotein cholesterol ratio >3.5, high-density lipoprotein cholesterol < or =40 mg/dl, and alanine aminotransferase > or =40 IU/L was determined in baseball players and compared to measurements obtained in a matched cohort from the National Health and Nutrition Examination Survey (NHANES), professional football players, and linemen and nonlinemen subsets. In conclusion, professional baseball players had favorable cardiovascular parameters, with the exception of an increased prevalence of hypertension, compared to the reference population, and professional baseball players had decreased measures of obesity, hyperglycemia, and the cardiometabolic syndrome compared to professional football lineman.

Elevated alanine aminotransferase in current national football league players: correlation with cardiometabolic syndrome markers, obesity, and insulin resistance.

OBJECTIVES: Media reports suggest increased cardiovascular mortality in former National Football League (NFL) players. We previously demonstrated that current heavier players already have cardiometabolic syndrome markers: blood pressure (BP) >or=130/85 mm Hg, fasting glucose >or=100 mg/dL, triglycerides >or=150 mg/dL, waist circumference >or=100 cm, and high-density lipoprotein (HDL) or=30 IU/L was significantly correlated with mean body mass index (BMI), BMI >or=30 kg/m, BP >or=130/85 mm Hg, waist circumference >or=100 cm, and triglycerides-to-HDL ratio >3.5. An elevated ALT was significantly more common in linemen. CONCLUSIONS: An elevated ALT was significantly associated with visceral obesity, hypertension, cardiometabolic syndrome markers, and insulin resistance in current NFL players.

Early cardiovascular mortality in professional football players: fact or fiction?

Present data about the increased incidence of early cardiovascular disease and mortality in National Football League (NFL) players is conflicting. These findings are particularly concerning given the escalating weight of current football players at the high school, collegiate, and professional levels. Recent studies have confirmed that heavier former NFL linemen have an increased prevalence of cardiovascular disease compared with an age- and sex-matched reference population. Former linemen had a higher prevalence of obesity, lower high-density lipoprotein cholesterol, increased left ventricular mass and left atrial area, and the metabolic syndrome, compared with nonlinemen. There have been sparse data on the cardiovascular health of current players. A recent analysis of one team demonstrated that the cardiometabolic syndrome and its individual components were significantly more common in linemen versus nonlinemen. Because current heavier NFL players already have evidence of the cardiometabolic syndrome and its individual markers, careful medical evaluation of former and active players is warranted to reduce their risks. This medically and ethically indicated intervention, however, might limit interpretation of future longitudinal studies designed to assess mortality endpoints.

Cardiometabolic abnormalities in current National Football League players.

Media reports suggested an increased prevalence of cardiovascular disease and premature death in former National Football League (NFL) players. The prevalence of cardiometabolic syndrome was determined in current active NFL players. The presence of cardiometabolic syndrome was defined as > or =3 of (1) blood pressure > or =130/85 mm Hg, (2) fasting glucose > or =100 mg/dl, (3) triglycerides > or =150 mg/dl, (4) waist circumference > or =100 cm, and (5) high-density lipoprotein cholesterol < or =40 mg/dl. Sixty-nine of 91 players (76%) from 1 NFL team were studied before the 2008 preseason training camp. Cardiometabolic syndrome markers, body mass index (BMI), waist-height ratio, and triglycerides/high-density lipoprotein cholesterol ratio were compared between 69 players and an age- and gender-matched reference population from NHANES (1999 to 2002) and by player position of linemen versus nonlinemen. Blood pressure > or =130/85 mm Hg, glucose > or =100 mg/dl, and BMI > or =30 kg/m(2) were significantly more prevalent in the 69 players than the NHANES cohort (28% vs 17%, p = 0.032; 19% vs 7%, p = 0.002; and 51% vs 21%, p <0.001, respectively), although cardiometabolic syndrome prevalence was similar in both groups. However, cardiometabolic syndrome prevalence, BMI > or =30 kg/m(2), and waist-height ratio >0.5 were significantly more common in the linemen versus the nonlinemen subgroup (22% vs 0%, p = 0.004; 100% vs 32%, p <0.001, and 95% vs 36%, p <0.001 respectively). In conclusion, cardiometabolic syndrome and its individual components were noted in current NFL players, particularly linemen.

Predictors of nonalcoholic steatohepatitis in patients undergoing bariatric surgery: when is liver biopsy indicated?

BACKGROUND: Nonalcoholic fatty liver disease is a frequent accompaniment of morbid obesity. A component of nonalcoholic fatty liver disease, steatosis, can, on occasion, lead to nonalcoholic steatohepatitis (NASH). Bariatric surgery has been shown to alter the course of this disease. Intraoperative liver biopsies might identify patients with NASH for more careful follow-up. We sought to determine noninvasive preoperative indicators of NASH. METHODS: The patients scheduled for bariatric surgery underwent a preoperative assessment. The study variables included age, gender, race, body mass index, diabetes mellitus, hypertension, and the results of serum liver function tests and triglyceride, cholesterol, iron, and prealbumin measurements. Univariate and multivariate analyses were performed to identify significant variables associated with NASH as determined by subsequent core liver biopsies taken during open Roux-en-Y gastric bypass. RESULTS: A total of 139 patients were entered into the study. NASH or NASH-associated fibrosis was found in 57 patients (41%). On univariate analyses, male gender (odds ratio [OR] 2.46, P = .06), diabetes mellitus (OR 2.60, P = .009), elevated serum triglyceride levels (OR 1.003, P = .02), elevated gamma glutamyl transferase (OR 1.015, P = .01), and decreased prealbumin (OR 0.94, P = .04) correlated with the presence of NASH. On multivariate analysis, only increased triglycerides (OR 1.004, P = .04) and decreased prealbumin (OR 0.88, P = .005) correlated with the presence of NASH. CONCLUSION: NASH is a frequent accompaniment of morbid obesity in patients undergoing bariatric surgery. Univariate and multivariate analyses of the clinical parameters studied could not identify strong predictors of biopsy-verified NASH. Therefore, intraoperative biopsy remains instrumental in diagnosing NASH and providing information for additional follow-up.