Performance characteristics of EUS-FNA biopsy for adrenal lesions: A meta-analysis.

BACKGROUND AND OBJECTIVE: The role of EUS-FNA biopsy (EUS-FNAB) for detection of metastatic lesions (mets) to adrenals has not been evaluated systematically. Our aim is to systematically evaluate the performance characteristics of EUS-FNAB in detecting metastasis to the adrenal glands. MATERIALS AND METHODS: We performed a systematic search on PubMed and OvidSP from January 1990 to July 2016 using various search terms for EUS and adrenal lesion. Only articles published in English literature were included in the study. Studies with fewer than 10 patients were excluded from the study. Publication bias was assessed using Begg-Mazumdar test and visual inspection of funnel plots. RESULTS: Eight studies including 360 adrenal lesions that underwent EUS-FNAB were identified. Of these, 137 FNABs were conclusive for malignancy. Sensitivity of EUS-FNAB in detecting metastasis to the adrenals was 95% (95% confidence interval [CI]: 90%-98%) and specificity was 99% (95% CI: 96%-100%). Pooled positivity of EUS-FNAB in detecting lung cancer metastasis to the adrenals was 44% (95% CI: 31.5%-57.3%). No evidence of publication bias was noted. CONCLUSION: Our study demonstrates that EUS-FNAB is highly sensitive and specific in detecting metastasis to adrenals. It also shows that up to about half of the patients with lung cancer and adrenal lesions on imaging have metastasis, a finding with profound implications on lung cancer staging and treatment.

Concomitant Psychiatric and Nonalcohol-Related Substance Use Disorders Among Hospitalized Patients with Alcoholic Liver Disease in the United States.

BACKGROUND: Despite that the epidemiological studies on the comorbidity of alcohol misuse and psychiatric disorders have been studied, less is known about the magnitude of these disorders among patients with alcoholic liver disease (ALD). Our aim was to determine the prevalence of psychiatric and substance use disorders among hospitalized ALD patients in the United States. METHODS: We utilized a single-level clinical classification software to identify patients with ALD and psychiatric/substance use disorders from the 2011 National Inpatient Sample data. The primary outcome was the prevalence of these disorders among hospitalized patients with ALD (n = 74,972) compared to those with chronic liver diseases not caused by alcohol (n = 350,140) and those without underlying liver diseases (n = 1,447,063). RESULTS: The prevalence of adjustment disorder, anxiety disorder, posttraumatic stress disorder, and depression was significantly higher among hospitalized patients with ALD when compared to those with chronic liver diseases not caused by alcohol (all with p-values <0.05). Younger age, female gender, and White race were the independent predictors of psychiatric/substance use disorders among hospitalized patients with ALD. CONCLUSIONS: Hospitalized patients with ALD have significantly high prevalence of concomitant psychiatric and substance abuse disorders when compared to those with chronic liver diseases not caused by alcohol and those without underlying liver diseases. Screening and appropriate intervention should be implemented as part of routine clinical care for these patients.

Hepatocellular Carcinoma: A Decade of Hospitalizations and Financial Burden in the United States.

BACKGROUND: Despite a rise in the prevalence of hepatocellular carcinoma (HCC), data on HCC-related hospitalizations and financial burden are limited. The aim of this study was to evaluate temporal trends of HCC-related hospitalizations and evaluate its financial influence. MATERIALS AND METHODS: Patients with the diagnosis of HCC, as reported by International Classification of Diseases-Ninth Revision code, were identified from the National Inpatient Sample databases from 2002-2011. The national estimates of hospitalizations were derived using appropriate sample weights. The change in total average charges per each hospitalization over the study period was calculated after adjusting for inflation. RESULTS: Hospitalizations related to HCC have increased from 24,024 in 2002 to 50,609 in 2011. Of these admissions, HCC was the principal diagnosis in 10,762 and 16,350 subjects in 2002 and 2011, respectively. Most were white males (male: 70%; white: 55%). The overall inpatient mortality was significantly decreased from 13.5% in 2002 to 9.9% in 2011 (P < 0.01). The same trend was also observed for the length of hospital stay (6.5 versus 5.6 days in 2002 and 2011, respectively). The inflation-adjusted cost per hospitalization increased by approximately 47% during the study period. CONCLUSIONS: Despite the decrease in mortality rate and length-of-stay, hospitalizations and financial burden associated with HCC continued to increase between 2002 and 2011 in the United States.

Trends in Outcomes, Financial Burden, and Mortality for Acute Exacerbation of Chronic Obstructive Pulmonary Disease (COPD) in the United States from 2002 to 2010.

Chronic obstructive pulmonary disease (COPD) is the cause of substantial economic and social burden. We evaluated the temporal trends of hospitalizations from acute exacerbation of COPD and determined its outcome and financial impact using the National (Nationwide) Inpatient Sample (NIS) databases (2002-2010). Individuals aged ≥ 18 years were included. Subjects who were hospitalized with primary diagnosis of COPD exacerbation and those who were admitted for other causes but had underlying acute exacerbation of COPD (secondary diagnosis) were captured by International Classification of Diseases-Ninth Revision (ICD-9) codes. The hospital outcomes and length of stay were determined. Multivariate logistic regression was used to identify the independent predictors of inpatient mortality. Overall acute exacerbation of COPD-related hospitalizations accounted for nearly 3.31% of all hospitalizations in the year 2002. This did not change significantly to year 2010 (3.43%, p = 0.608). However, there was an increase in hospitalization with secondary diagnosis of COPD. Elderly white patients accounted for most of the hospitalizations. Medicare was the primary payer source for most of the hospitalizations (73-75%). There was a significant decrease in inpatient mortality from 4.8% in 2002 to 3.9% in 2010 (slope -0.096, p < 0.001). Similarly, there was a significant decrease in average length of stay from 6.4 days in 2002 to 6.0 days in 2010 (slope -0.042, p < 0.001). Despite this, the hospitalization cost was increased substantially from $22,187 in 2002 to $38,455 in 2010. However, financial burden has increased over the years.

The Association Between Nonalcoholic Fatty Liver Disease and Metabolic Abnormalities in The United States Population.

BACKGROUND: Prevalence of nonalcoholic fatty liver disease (NAFLD) and rate of advanced fibrosis among individuals with metabolic syndrome (MetS) and its individual metabolic abnormalities needs better understanding in the United States population. We aim to study these by using a large United States population database, the Third National Health and Nutrition Examination Survey (NHANES III). METHODS: A total of 11,674 individuals were included in our study cohort. NAFLD was defined as presence of moderate to severe hepatic steatosis on liver ultrasound in absence of viral hepatitis, significant alcohol use, elevated transferrin level, and medication use leading to hepatic steatosis. Advanced fibrosis among those with NAFLD was determined using noninvasive method, the NAFLD fibrosis score. MetS was defined based on the National Cholesterol Education Program Adult Treatment Panel III definition. RESULTS: The prevalence of NAFLD among included study cohort was 18.2% (95% confidence interval, 16.5-19.9). Individuals with metabolic abnormalities demonstrated higher prevalence (MetS, 43.2%; increased waist circumference, 31.2%; impaired fasting glucose/diabetes, 41.2%; high triglyceride level, 34.7%; low high-density lipoprotein, 27.8%; high blood pressure, 29.2%). The individuals with MetS had significantly higher NAFLD prevalence compared with controls (adjusted odds ratio, 11.5; 95% confidence interval, 8.9-14.7). The severity of hepatic steatosis was also noted to increase with higher number of metabolic abnormalities. Among individual metabolic abnormalities, increased waist circumference, impaired fasting glucose/diabetes, high triglyceride, and low high-density lipoprotein levels were found to be independently associated with NAFLD. Individuals with impaired fasting glucose/diabetes and those with 5 metabolic abnormalities had higher rate of advanced fibrosis (18.6% and 30.3%, respectively). Prevalence of NAFLD among individuals without any metabolic abnormality was 6.1%. CONCLUSION: Prevalence of NAFLD and rate of advanced fibrosis are significantly high among individuals with metabolic abnormalities.

Insulin Resistance is Associated With Significant Liver Fibrosis in Chronic Hepatitis C Patients: A Systemic Review and Meta-Analysis.

BACKGROUND: The role of insulin resistance (IR) on fibrosis progression in hepatitis C virus (HCV) patients has not been systematically evaluated. Therefore, this systemic review aimed to summarize the available epidemiologic evidence to evaluate the strength of association between IR and advanced liver fibrosis in these patients. METHODS: We performed a systemic literature search in PubMed, OvidSP, and MEDLINE from January 1990 to April 2015 without language restriction using the following search terms: insulin resistance, liver fibrosis, cirrhosis, diabetes mellitus, and chronic hepatitis C. Publication bias was assessed using the Begg and Egger tests and with a visual inspection of funnel plot. All analyses were performed using Comprehensive Meta-Analysis, version 2 software. RESULTS: A total of 3659 participants with HCV infection from 14 studies were included in the analysis. After adjusting for publication bias, the relative risk (RR) for significant hepatic fibrosis among HCV subjects with IR was 1.63 [95% confidence interval (CI), 1.34-2.01]. Subgroup analysis by genotypes showed RR of 2.16 (95% CI, 1.52-3.06) for genotype 1; however, the association was no longer significant when we analyzed the data for HCV genotype 3; RR=1.40 (95% CI, 0.8-2.45). CONCLUSION: Our study showed significant association between IR and significant hepatic fibrosis in patients with HCV genotype 1 infection.

Trends in Alcoholic Hepatitis-related Hospitalizations, Financial Burden, and Mortality in the United States.

BACKGROUND: Alcoholic hepatitis (AH) is the most florid manifestation of alcoholic liver disease which accounts for significant morbidity, mortality, and financial burden. Aim of this study is to evaluate temporal trend of hospitalizations from AH and evaluate its financial impact. METHODS: The National Inpatient Sample databases (from 2002 to 2010) which are collected as part of Healthcare Cost and Utilization Project by Agency for Healthcare Research and Quality were utilized. Individuals aged 21 years and older were included. The hospitalizations with primary diagnosis of AH were captured by ICD-9 codes. The national estimates of hospitalization were derived using sample weights provided by National Inpatient Sample. Simple linear regression method was used to assess trends in mortality and length of stay over time. RESULTS: We observed the increased in total cases of AH-related hospitalization from 249,884 (0.66% of total admission in 2002) to 326,403 (0.83% of total admission in 2010). The significant increase in the total admission rate was attributable mainly to the rise in inpatient hospitalization for secondary diagnosis of AH (0.48% in 2002 to 0.67% in 2010). Most of the AH-related hospitalization were males. Hepatic encephalopathy was found to be the most common admitting diagnosis for individuals hospitalized with secondary diagnosis of AH (8.9% in 2002 and 8.6% in 2010). There was a significant decrease in inpatient mortality for primary diagnosis of AH from 10.07% (in 2002) to 5.76% (in 2010) (absolute risk reduction: 4.3%). Average cost of hospitalization related to primary diagnosis of AH was $27,124 and $46,264 in 2002 and 2010, respectively. After adjusting for inflation, the additional cost of each hospitalization seemed to increase by 40.7% in 2010 compared with 2002 (additional cost per hospitalization $11,044 in 2010 compared with 2002). Federal (Medicare) or state (Medicaid) supported health insurance program are the main primary expected payers for these AH hospitalizations (∼25% to 29%). Despite increase in cost per hospitalization, length of stay for hospitalization due to primary diagnosis of AH was not observed to decrease substantially over time (6.7 d in 2002 to 6.1 d in 2010). CONCLUSIONS: AH-related hospitalization continued to increase during the study period, despite the decrease in the in-hospital mortality rate. Substantial increases in health care cost and utilization among hospitalized AH patients were observed.

The association between metabolic syndrome and hepatocellular carcinoma: systemic review and meta-analysis.

BACKGROUND: The metabolic syndrome (MetS) and/or its individual components have been linked to the development of cancer. Recent studies have suggested a similar link to hepatocellular carcinoma (HCC). The aim of this study was to evaluate the direction and magnitude of the association between the MetS and HCC. METHODS: Two reviewers independently conducted a systemic search to identify the available evidence from databases from January 1980 to June 2012. Search terms included "Metabolic syndrome," "insulin resistance syndrome," "metabolic abnormalities" combined with "hepatocellular carcinoma," and "liver cancer." No language restriction was applied to the search. Only studies reporting an effect measure for the association between MetS and HCC were eligible for inclusion. Publication bias was assessed using the Begg and Egger tests, with a visual inspection of funnel plot. All analyses were performed using Comprehensive Meta-analysis version 2 software. RESULTS: Four studies (3 cohort and 1 case control) with a total of 829,651 participants were included in the analysis. The age range of participants was between 30 and 84 years. The combined analysis showed an overall 81% increased risk of HCC in cases with MetS (relative risk, 1.81; 95% confidence interval, 1.37-2.41). After excluding the single case-control study from analysis, the overall risk ratio remained statistically significant (relative risk, 1.49; 95% confidence interval, 1.27-1.74). Funnel plot inspection, Begg and Egger tests showed no evidence of publication bias for combined analysis. CONCLUSIONS: Though studies are scarce, currently available epidemiologic data are suggestive of significantly higher risk of HCC among patients with MetS.

Past exposure to hepatitis B: a risk factor for increase in mortality?

BACKGROUND: Chronic hepatitis B has been shown to increase mortality, but association of past exposure to hepatitis B and mortality has not been studied well. The aim of this study was to evaluate the risk of overall and liver-related mortality in individuals with past exposure to hepatitis B. METHODS: The National Health and Nutrition Examination Survey III (NHANES III) and its related public linked mortality files were used for this study. The participants with presence of anti-HBc ± anti-HBs, in absence of hepatitis B surface antigen were considered to have previous exposure to hepatitis B. The overall mortality from past exposure to hepatitis B was assessed in participants without any chronic liver diseases (CLD) and in participants with chronic hepatitis C, alcoholic liver disease (ALD), and nonalcoholic fatty liver disease. The Cox proportional regression analysis was used to calculate adjusted hazard ratios. RESULTS: A total of 15,650 individuals were included in the analyses. Past exposure to hepatitis B was an independent predictor of increase in overall mortality in individuals without CLD [adjusted hazard ratio (aHR)=1.29; 95% confidence interval (CI), 1.06-1.56; P=0.012] and those with ALD (aHR=2.25; 95% CI, 1.20-4.23; P=0.013). It was also an independent predictor of liver-related mortality in ALD cohort (aHR=7.75; 95% CI, 2.56-23.48; P<0.001). Past exposure to hepatitis B did not correlate with a significant increase in overall or liver-related mortality in chronic hepatitis C or nonalcoholic fatty liver disease cohorts. CONCLUSION: Past exposure to hepatitis B is associated with significant increase in overall mortality among individuals with ALD and those without CLD.

Association between metabolic syndrome and its individual components with viral hepatitis B.

BACKGROUND: The association between hepatitis B and metabolic syndrome (MetS) has not been well described. Overall epidemiologic evidences for this association have suggested conflicting results. The aim this study was to determine the association between hepatitis B infection and MetS using large U.S. population database, the Third National Health and Nutrition Examination Survey. METHODS: Individuals aged ≥18 years were included in this study. MetS was defined according to the Third Report of the National Cholesterol Education Program Adult Treatment Panel guideline. The chronic hepatitis B was defined as the presence of hepatitis B surface antigen. The presence of hepatitis B core antibody with/without surface antibody, in the absence of surface antigen, was considered as past exposure to hepatitis B. To represent national estimates, weighted frequencies for chronic hepatitis B and past exposure to hepatitis B are reported. Multivariate logistic regression analysis accounting for age, gender, race, smoking and alcohol status was conducted to identify the independent predictor(s) of MetS. RESULTS: This study cohort consisted of total population of 593,594 with chronic hepatitis B and 7,280,620 with past exposure to hepatitis B. Prevalence of MetS among included study cohort was 25.7%. Inverse association was observed between MetS and chronic hepatitis B (adjusted odds ratio, 0.32; 95% confidence interval, 0.12-0.84). Among individual components of MetS, waist circumference was inversely associated with chronic hepatitis B (adjusted odds ratio, 0.31; 95% confidence interval, 0.14-0.71). No significant association was noted between past exposure to hepatitis B and MetS or its individual components. CONCLUSIONS: In this study, the authors noted significant inverse association between MetS and chronic hepatitis B.

Profound jaundice in a patient with acute hepatitis C.

A 52-year-old African-American woman with overall good health and medical history of asthma and depression presented with right lower quadrant abdominal pain, vomiting and icterus for 3 weeks. Her physical examination was remarkable for only sclera icterus and mild tenderness on palpation in the right lower quadrant. Investigations revealed marked hyperbilirubinemia and transaminitis, with other serological and radiological studies unremarkable and a hepatitis A, B and C panel negative 3 weeks before presentation. Repeat hepatitis panel showing hepatitis C antibody positive with viral load 20 739 524 IU/mL. Liver biopsy supported the diagnosis of acute hepatitis C infection.

The association between metabolic syndrome and colorectal neoplasm: systemic review and meta-analysis.

BACKGROUND: There has been constant speculation about the association between metabolic syndrome (MetS) and colorectal neoplasia (CN); however, the published results are conflicting. The aims of this study are to conduct a systematic search, and assess the literature to determine the available evidence on the association between these two conditions. METHODS: Meta-analysis was conducted based on relevant studies identified through a systematic literature review from PubMed, OvidSP, and Cochrane database during January 1980 to July 2011. A combined analysis was performed, followed by a subgroup analyses stratified by the study design, type of colorectal lesions, and sex. Publication bias was assessed using the Begg and Egger tests and visual inspection of funnel plot. RESULTS: Eighteen studies were included in the final analysis. Overall, MetS was associated with 34% increase in the risk of CN [summary relative risk (RR), 1.34; 95% confidence interval (CI), 1.24-1.44]. The association between MetS and CN was found to be statistically significant in separate analysis for both case-control studies (summary RR, 1.58; 95% CI, 1.44-1.73) and cohort studies (summary RR, 1.21; 95% CI, 1.13-1.29). The association remained significant when analyses were restricted by type of colorectal lesions (colorectal cancer: RR, 1.30; 95% CI, 1.18-1.43; colorectal adenoma: RR, 1.37; 95% CI, 1.26-1.49). Further subgroup analysis by sex showed significant association between MetS and CN in both male and female population. CONCLUSIONS: Our meta-analysis showed significant association between presence of MetS and CN. These results may help in identifying high-risk individuals at early stage, who might benefit from targeted colorectal cancer screening intervention.

Racial disparities in gastrointestinal cancers-related mortality in the U.S. population.

BACKGROUND: Racial difference in cancer-related mortality has been described in epidemiological studies and evidence points towards higher mortalities in the minorities. To determine the magnitude of racial disparities and sex differences in GI cancer-related mortalities in the US population, we analyzed the data using the third National Health and Nutrition Examination Survey (NHANES III) and related mortality data files. METHODS: NHANES III and its related public linked mortality files were used for this study. Our study cohort included subjects who were ≥18 years and were part of the longitudinal mortality follow-up database. The overall GI cancers related mortality was calculated using combined mortality from malignant neoplasm of esophagus, stomach, colon, liver and pancreas. The evaluation of independent predictors of overall GI cancer-related mortality and of each individual GI cancer was carried out using the Cox proportional hazards model. RESULTS: A total of 13,221 individuals were included in the analyses with the average person year follow-up of 13.9 years. During the follow-up period, 4,146 subjects died. Of these, 199 were from GI-related cancers. Non-Hispanic black (NHB) had significantly higher overall GI-cancer related mortality compared to non-Hispanic white (NHW, adjusted hazard ratio, aHR: 2.31, 95% CI 1.57-3.38, p < 0.001). Subgroup analyses by sex demonstrated higher mortality from gastric, colorectal and primary liver cancer related mortality in NHB men compared to NHW men. Esophageal and pancreatic cancer mortalities were higher in NHB women compared to NHW women. CONCLUSION: Overall GI cancer-related mortality is significantly higher among NHB compared to NHW in the U.S. population.