Post-hospitalization Short Versus Long Steroid Taper Strategies in Patients With Acute Severe Ulcerative Colitis: A Comparison of Clinical Outcomes.

Background: Ulcerative colitis (UC) is a chronic inflammatory colon disease characterized by relapsing flares and remission episodes. However, the optimal steroid tapering strategy in patients hospitalized for acute severe UC (ASUC) remains relatively unknown. We aim to examine the clinical outcomes in patients hospitalized for ASUC regarding variable prednisone taper regimens upon discharge. Methods: We retrospectively reviewed all adult patients admitted to our facility with ASUC between 2000 and 2022. Patients were divided into 2 groups based on the duration of steroid taper on discharge (< 6 and > 6 weeks). Patients who had colectomy at index admission were excluded from the analysis. The primary outcome was rehospitalization for ASUC within 6 months of index admission. Secondary outcomes included the need for colectomy, worsening endoscopic disease extent and/or severity during the follow-up period (6 months), and a composite outcome as a surrogate of worsening disease (defined as a combination of all products above). Two-sample t-tests and Pearson's chi-square tests were used to compare the means of continuous and categorical variables, respectively. Multivariate logistic regression analysis was performed to identify independent predictors for rehospitalization with ASUC. Results: A total of 215 patients (short steroid taper = 91 and long steroid taper = 124) were analyzed. A higher number of patients in the long steroid taper group had a longer disease duration since diagnosis and moderate-severe endoscopic disease activity (63.8 vs. 25.6 months, p < 0.0001, 46.8% vs. 23.1%, P = ≤ .05, respectively). Both groups had similar disease extent, prior biologic therapy, and the need for inpatient rescue therapy. At the 6-month follow-up, rates of rehospitalization with a flare of UC were comparable between the 2 groups (68.3% vs. 68.5%, P = .723). On univariate and multivariate logistic regression, escalation of steroid dose within four weeks of discharge (aOR 6.09, 95% CI: 1.82-20.3, P  = .003) was noted to be the only independent predictor for rehospitalization with ASUC. Conclusions: This is the first study comparing clinical outcomes between post-discharge steroid tapering regimens in hospitalized patients for ASUC. Both examined steroid taper regimens upon discharge showed comparable clinical results. Hence, we suggest a short steroid taper as a standard post-hospitalization strategy in patients following ASUC encounters. It is likely to enhance patient tolerability and reduce steroid-related adverse effects without adversely affecting outcomes.

Gastric intestinal metaplasia and gastric cancer prevention: Watchful waiting.

Gastric intestinal metaplasia (GIM), a common histologic finding, is associated with increased risk of gastric cancer, and GIM associated with Helicobacter pylori infection is classified as an environmental metaplastic atrophic gastritis. Patients may be asymptomatic or present with various dyspeptic symptoms. Autoimmune metaplastic atrophic gastritis is a less common but important cause of chronic gastritis. The Correa cascade describes the evolution of precancerous mucosal changes that lead to development of GIM, with differentiation of 2 histologic types of GIM (complete and incomplete) and the consequences of each type. The risk of progression to malignancy is higher with incomplete GIM. It is also higher for those who immigrate from regions with a high incidence of H pylori infection to areas where the incidence is low. Guidelines regarding endoscopic management of GIM vary by geographic region.

Comparison between metabolic-associated fatty liver disease and nonalcoholic fatty liver disease: From nomenclature to clinical outcomes.

As a result of the obesity epidemic, Nonalcoholic fatty liver disease (NAFLD) and its complications have increased among millions of people. Consequently, a group of experts recommended changing the term NAFLD to an inclusive terminology more reflective of the underlying pathogenesis; metabolic-associated fatty liver disease (MAFLD). This new term of MAFLD has its own disease epidemiology and clinical outcomes prompting efforts in studying its differences from NAFLD. This article discusses the rationale behind the nomenclature change, the main differences, and its clinical implications.

Liver transplantation amidst the COVID-19 era: Our center's experience.

Coronavirus disease 2019 significantly impacted the liver transplant process worldwide. Consequently, it brought significant challenges and limitations to transplant policies and organ allocation forcing liver transplant centers to adjust their protocols to ensure maximum benefit and avoid harm to their patients. Our center, like many others, was obliged to adapt to the challenges. This paper provided an overview of the effects of coronavirus disease 2019 on liver transplantations and detailed our center's experience and efforts during this unprecedented pandemic to serve as a guide for future public health crises.

Outcomes of total pancreatectomy with islet autotransplantation: A systematic review and meta-analysis.

BACKGROUND: Despite the increased use of total pancreatectomy with islet autotransplantation (TPIAT), systematic evidence of its outcomes remains limited. AIM: To evaluate the outcomes of TPIAT. METHODS: We searched PubMed, EMBASE, and Cochrane databases from inception through March 2019 for studies on TPIAT outcomes. Data were extracted and analyzed using comprehensive meta-analysis software. The random-effects model was used for all variables. Heterogeneity was assessed using the I2 measure and Cochrane Q-statistic. Publication bias was assessed using Egger's test. RESULTS: Twenty-one studies published between 1980 and 2017 examining 1011 patients were included. Eighteen studies were of adults, while three studied pediatric populations. Narcotic independence was achieved in 53.5% [95% Confidence Interval (CI): 45-62, P < 0.05, I2 = 81%] of adults compared to 51.9% (95%CI: 17-85, P < 0.05, I2 = 84%) of children. Insulin-independence post-procedure was achieved in 31.8% (95%CI: 26-38, P < 0.05, I2 = 64%) of adults with considerable heterogeneity compared to 47.7% (95%CI: 20-77, P < 0.05, I2 = 82%) in children. Glycated hemoglobin (HbA1C) 12 mo post-surgery was reported in four studies with a pooled value of 6.76% (P = 0.27). Neither stratification by age of the studied population nor meta-regression analysis considering both the study publication date and the islet-cell-equivalent/kg weight explained the marked heterogeneity between studies. CONCLUSION: These results indicate acceptable success for TPIAT. Future studies should evaluate the discussed measures before and after surgery for comparison.

COVID-19 in liver transplant patients: Impact and considerations.

The coronavirus disease 2019 pandemic has significantly impacted liver tran splantation worldwide, leading to major effects on the transplant process, including the pretransplant, perioperative, and post-transplant periods. It is believed that patients with chronic liver disease, especially those with cirrhosis, have a higher risk of complications from coronavirus disease 2019 infection compared to the general population. However, evaluation of coronavirus disease 2019 effects on liver transplant patients has not uniformly demonstrated worse outcomes. Nonetheless, the pandemic created significant challenges and restrictions on transplant policies and organ allocation.

Statin Use Reduces the Risk of Hepatocellular Carcinoma: An Updated Meta-Analysis and Systematic Review.

Hepatocellular carcinoma (HCC) is the most common primary tumor of the liver resulting in approximately 800,000 deaths annually. A growing body of research investigating statin use and HCC risk has shown conflicting results. We aim to evaluate the current evidence of statin impact on HCC risk. We performed a comprehensive literature search in PubMed, PubMed Central, Embase, and ScienceDirect databases from inception through May 2019 to identify all studies that evaluated the association between statin use and HCC. We included studies that presented an odds ratio (OR) with a 95% confidence interval (CI) or presented data sufficient to calculate the OR with a 95% CI. Statistical analysis was performed using the Comprehensive Meta-Analysis (CMA), Version 3 software, and a Forrest plot was generated. We assessed for publication bias using conventional techniques. Twenty studies (three randomized controlled trials, six cohorts, and 11 case-controls) with 2,668,497 patients including 24,341 cases of HCC were included in the meta-analysis. Our findings indicate a significant risk reduction of HCC among all statin users with a pooled odds ratio of 0.573 (95% CI: 0.491-0.668, I2= 86.57%) compared to non-users. No publication bias was found using Egger's regression test or on visual inspection of the generated Funnel plot. The results indicate that statin use was associated with a 43% lower risk of HCC compared to statin non-users. Further prospective randomized research is needed to confirm the association.

Ischemic Colitis Is a Risk Factor for Clostridium difficile Infection.

INTRODUCTION:  Clostridium difficile infection (CDI) is an anaerobic infection that can carry detrimental outcomes for patients and is a growing burden to the US healthcare system. Various theories have been proposed for the etiopathogenesis of CDI, including antibiotic use, dysbiosis, and acid suppression. The role of ischemia in CDI has not been explored. We hypothesize that tissue ischemia is a risk factor for the development of CDI. The study aimed to assess whether ischemia was a risk factor for CDI using ischemic colitis as a target population. METHODS: We performed a case-control study using the National Inpatient Sample (NIS) database in 2013. The study group included all patients with ischemic colitis (ICD 9 Code: 557.0, 557.1, 557.9) and the control group included all patients with diverticulitis (ICD 9 Code: 562.11, 562.13). Univariable and multivariable analyses were performed to assess the risk factors associated with CDI (ICD 9 Code: 008.45). The case and control groups were compared using the chi-square test for analysis. Continuous variables were compared using t-tests and categorical variables were compared using Rao-Scott chi-square tests. In addition, multivariable logistic regression analysis was performed to assess the association between disease group and CDI while adjusting for confounders. Univariable analysis was performed to assess differences between subjects with ischemic colitis and those with diverticulitis; continuous variables were compared using t-tests and categorical variables were compared using Rao-Scott chi-square tests. All analyses were done using SAS (version 9.4, The SAS Institute, Cary, NC). RESULTS: We analyzed more than 30 million hospitalizations in 2013, with 120,490 being Ischemic colitis-related admissions and 309,940 being diverticulitis-related admissions. The rate of CDI was more in the ischemic colitis group than in the diverticulitis group (odds ratio [OR] = 1.39; 95% confidence interval [CI] [1.03-1.88], p=0.03). After adjusting for all variables, multivariate analysis showed CDI was associated with ischemic colitis (OR = 2.06; 95% CI 1.59-2.65, p<0.001). CONCLUSION: CDI was shown to be more prevalent in ischemic colitis than in diverticulitis control in this population-based study. As C. difficile is an anaerobe, we hypothesize that tissue hypoxia is a risk factor for its development. Further studies are needed to validate our findings.

Gastrointestinal Toxicities of Immune Checkpoint Inhibitors Are Associated With Enhanced Tumor Responsiveness and Improved Survival.

Background: Immune checkpoint inhibitors (ICIs) are increasingly used to treat advanced malignancies. However, they are associated with the development of multiple gastrointestinal immune-related adverse events (GI-irAEs). We aimed to evaluate the types and severity of GI-irAEs associated with ICI therapy, to identify potential risk factors for developing GI-irAEs and to determine the relationship of GI-irAEs development to tumor responsiveness and overall survival. Methods: All patients who received ICIs for advanced malignancies at our center were included. Medical records were reviewed, and data extraction included: baseline demographic characteristics, immunotherapy regimens, development of GI-irAEs, response to treatment, and overall survival. Overall survival was calculated from the date of treatment initiation and estimated by the Kaplan-Meier method. Results: Five hundred sixty-seven patients received ICI therapy for stage IV malignancies. Forty-one (7%) patients experienced at least one GI-irAE. Among those experiencing GI-irAEs, 23 (56%) developed hepatitis, 17 (42%) developed colitis, four (10%) developed pancreatitis, and two (5%) developed gastritis. Patients who developed GI-irAEs experienced a better response to ICI therapy compared to patients who did not develop GI-irAEs (41% vs. 27%, P = 0.003). The 2-year overall survival rate of stage IV cancer patients who developed GI-irAEs was 62% (95% confidence interval (CI): 49 - 79) and 36% for those who did not develop GI-irAEs (95% CI: 32 - 41) (P = 0.002). The median follow-up time of surviving patients was 28 months. Twelve (29%) of the patients receiving dual ICI therapy developed GI-irAEs. Conclusion: Hepatitis, colitis, and pancreatitis were the most commonly encountered GI-irAEs with ICI therapy. Development of these GI-irAEs was associated with superior tumor responsiveness and better overall survival.

The association between microscopic colitis and celiac disease: a systematic review and meta-analysis.

Background: Multiple studies suggested that celiac disease (CD) may be associated with microscopic colitis (MC); however, most were limited by a small sample size or the main scope of interest. We aimed to analyze previously published literature on this association to determine its extent and significance. Methods: A systematic review was conducted in PubMed, Embase, PubMed Central, Cochrane, and ScienceDirect databases from inception through January 2022. The PRISMA guideline was followed for data extraction. Effect estimates were extracted and combined using random effect, the generic inverse variance method of DerSimonian and Laird and pooled odds ratio (OR), and event rates (ER) were calculated. The Newcastle-Ottawa scale was used to evaluate the risk of bias. Forest plots were generated and publication bias assessed via conventional techniques. Results: Twenty-six studies with a total of 22,802 patients with MC were included in this analysis. CD was significantly associated with MC (odds ratio [OR] 8.276, 95% confidence interval [CI] 5.888-11.632; P<0.001). The ER for MC in CD patients was 6.2% (95%CI 4.1-9.2%; P<0.001), while the ER for CD in MC patients was 6.1% (95%CI 3.9-9.5%; P<0.001). CD was prevalent in both types of MC: 5.2% (95%CI 2.2-12.1%; P<0.001) in collagenous colitis and 6.3% (95%CI 3.4-11.5%; P<0.001) in lymphocytic colitis. We found no publication bias, according to funnel plots and Egger's regression asymmetry testing. Conclusions: Our meta-analysis confirms a statistically significant association between CD and MC, with a high prevalence of CD in both types of MC. Gastroenterologists should be wary of this association when evaluating patients with either disease, particularly patients with a suboptimal response to first-line therapy.

The Incidence of Endoscopic Retrograde Cholangiopancreatography-Related Complications in Patients With Liver Transplant: A Meta-Analysis and Systematic Review.

BACKGROUND: Existing literature on post-endoscopic retrograde cholangiopancreatography (ERCP) complications in patients with liver transplant remains scarce and largely inconsistent. We therefore aimed to systematically review and analyze the literature on complication rates associated with ERCP in patients with liver transplant. METHODS: We performed a comprehensive literature search in PubMed, PubMed Central, Embase, and ScienceDirect databases from inception through March 2020 to identify all the studies that evaluated post-ERCP complications in patients with liver transplant. Effect estimates from the individual studies were extracted and combined using the random effect, generic inverse variance method of DerSimonian and Laird, and a pooled odds ratio (OR) and event rates were calculated. Forest plots were generated, and publication bias was assessed for using conventional techniques. RESULTS: Fourteen studies with a total of 1,787 patients were analyzed. In total, 3,192 ERCPs were performed on these patients. The pooled all-complication rate was 5.2% (95% confidence interval (CI): 0.035 - 0.075). Procedural complications analyzed included post-ERCP pancreatitis 3.4% (95% CI: 0.025 - 0.047), bleeding 1.1% (95% CI: 0.006 - 0.020), infections 0.2% (95% CI: 0.025 - 0.047), and cholangitis 0.8% (95% CI: 0.004 - 0.020). No cases of periprocedural death were reported. The pooled OR for post-ERCP pancreatitis in patients with liver transplant compared to patients without liver transplant was 1.289 (95% CI: 0.455 - 3.653, P = 0.633, I2 = 72.88%). CONCLUSION: Post-ERCP complication rates in liver transplant patients are comparable to the general population and hence, peri-procedural evaluation and management may follow the current standards of care in this patient population.

Prevalence and Predictors of Gastrointestinal Dysmotility in Patients with Hypermobile Ehlers-Danlos Syndrome: A Tertiary Care Center Experience.

Introduction Ehlers-Danlos syndrome (EDS), specifically the hypermobility type (hEDS), is associated with a variety of gastrointestinal (GI) conditions. This study aims to evaluate the prevalence of and factors associated with gut dysmotility in patients with hEDS. Methods This is a retrospective study of hEDS patients conducted at the Cleveland Clinic's Center for Personalized Genetic Healthcare between January 2007 and December 2017. Demographics, GI motility testing, endoscopic, and imaging data were extracted from the patients' charts. Results A total of 218 patients with hEDS were identified. Among them, 136 (62.3%) patients had at least one GI symptom at the time of EDS diagnosis. Motility testing was performed and reported in 42 (19.2%) patients. Out of them, five (11.9%) had esophageal dysmotility, 18 (42.8%) had gastroparesis, five (11.9%) had small bowel/colon altered transit time, and four (9.5%) had global dysmotility. In univariable analysis, patients with postural orthostatic tachycardia syndrome (POTS) [odds ratio (OR): 8.88, 95% CI: 3.69-24.9, p<0.0001], fibromyalgia (OR: 4.43, 95% CI: 2.04-10.1, p=0.0002), history of irritable bowel syndrome (OR: 5.01, 95% CI: 2.31-11.2, p<0.0001), and gastroesophageal reflux disease (OR: 3.33, 95% CI: 1.55-7.44, p=0.002) were more likely to be diagnosed with GI dysmotility. On multivariable analysis, only POTS (OR: 5.74, 95% CI: 2.25-16.7, p=0.0005) was significantly associated with an increased likelihood of GI dysmotility. Conclusions This study suggests that GI symptoms are relatively common among patients with hEDS. Of the patients tested for dysmotility, 76.2% were found to have some form of dysmotility. POTS was found to be an independent predictive factor for GI dysmotility.

Improving Physician-patient and Physician-nurse Communication and Overall Satisfaction Rates: A Quality Improvement Project.

Introduction Communication between healthcare providers and patients is a key component associated with the quality of healthcare and patient satisfaction. Often, simple communication skills may be insufficient to sustain a successful provider-patient relationship. The aim of this project was to assess and improve patient and nurse satisfaction with physicians via improvement in physician-patient and physician-nurse communication to a level greater than 90%. Methods Initial surveys were given to the patients and nurses on admission to the regular nursing floor to assess current satisfaction rates. Afterward, visual handouts were given that provided details about the current medical team members and the role of each team member. which were updated daily along with the medical plan. Surveys were then handed out to the patients and their nurses at the time of discharge. All surveys were conducted anonymously. Results A total of 26 surveys (n = 13 patients, n = 13 nurses) were collected and analyzed for a preliminary assessment. Surveys concluded that 68.8% of patients were satisfied with the patient-provider communication; similarly, 74.4% of the nurses were satisfied with the nurse-provider communication. In the next six weeks, visual handouts were implemented. During this period, surveys involving a total of 40 patients and 40 nurses were collected. The results after the intervention revealed that 93.3% of patients were satisfied with the patient-provider communication, and 94.7% of nurses were satisfied with the nurse-provider communication. Post-intervention, the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) displayed an improvement in physician communication, reaching the expected goal of 84.4%. Conclusion Ineffective communication often goes undetected in many healthcare settings, causing serious effects on the health and safety of patients, and may ultimately jeopardize overall satisfaction. Literature has shown a positive correlation between patient satisfaction and improved clinical outcomes. Using visual aids and updating medical care plans on a daily basis are simple yet effective tools to improve communication. Written materials should be created in a patient-friendly manner to enhance communication, clarity, and understanding.

Hemochromatosis As an Unusual Cause of Pancreatitis in an African-American Female of Child-bearing Age.

Hemochromatosis is a disorder of iron overload whereby there is toxic deposition of iron in various tissues and organs of the body. It can either be hereditary or secondary to some other underlying cause. Patients with mutations in the HFE gene are often predisposed to developing this disorder. It has a wide range of clinical presentation, from non-specific symptoms such as fatigue to overt development of cirrhosis, diabetes and skin pigmentation. We present an unusual case of hemochromatosis where an African-American female of child-bearing age presented to the emergency room with complaints of epigastric pain. She was found to have mildly elevated lipase and liver enzymes. Imaging studies were suggestive of acute-on-chronic pancreatitis with iron deposition in the spleen, pancreas and bone marrow. Her ferritin and transferrin saturation levels were elevated. She was diagnosed with acute-on-chronic pancreatitis secondary to alcoholism and hemochromatosis and treated with phlebotomy with good outcome. This case is one of the few reported cases of hemochromatosis in African-Americans, and emphasizes that even females in child-bearing age group can develop this condition. Elevated ferritin and transferrin saturation levels should prompt evaluation for this disorder.

Another Fatality Due to Postpartum Group A Streptococcal Endometritis in the Modern Era.

Group A streptococcus (GAS) is a rare yet potentially lethal cause of postpartum endometritis. Atypical early presentation and the routine use of post-delivery analgesics which might mask the symptoms preclude timely diagnosis and appropriate management. The invasive disease usually follows a rapidly progressive course that has considerable morbidity and mortality. Streptococcal toxic shock syndrome (TSS) can complicate this condition leading to refractory septic shock and possible death. We hereby present a case of a 42-year-old female patient who developed GAS postpartum endometritis complicated by streptococcal TSS resulting in death despite enormous resuscitative efforts. We aim to increase awareness of this lethal condition highlighting the importance of early recognition and prompt management.

Hand-foot Syndrome Secondary to Low-dose Docetaxel in a Breast Cancer Patient.

Docetaxel-induced hand-foot syndrome (HFS) at low doses is a very rare side effect that usually occurs in a dose-dependent manner. HFS can be managed with conservative measures and may need chemotherapy discontinuation. In this report we present a case of HFS in a breast cancer patient after one dose of docetaxel.

Acute Reactive Acalculous Cholecystitis Secondary to Duodenal Ulcer Perforation.

Acute cholecystitis is the inflammation of the gallbladder, classically caused by gall stones obstructing the cystic duct. In contrast, acalculous cholecystitis is a gallbladder inflammation occurring in the absence of cholelithiasis with a reported prevalence of 10% of all cases of acute cholecystitis. Reactive acalculous cholecystitis is an extremely rare subset of this disease that results from an adjacent inflammatory or infectious intra-abdominal process that may lead to gallbladder stasis, ischemia, and subsequent wall inflammation. Many factors have been associated with acalculous cholecystitis, including (but not limited to) hemodynamic instability, altered immunity, and biliary tree anomalies. Lack of specific signs and symptoms of this particular entity often delays the diagnosis. Herein, we present a rare case of acute, reactive, acalculous cholecystitis secondary to a perforated duodenal ulcer found incidentally during laparoscopic cholecystectomy.

Anterograde Gastroduodenal Intussusception: A Rare but Lethal Complication of Percutaneous Endoscopic Gastrostomy Tube Placement.

Percutaneous endoscopic gastrostomy (PEG) tube placement is one of the methods of providing enteral nutrition support and is often used in critically ill patients. There are several complications of PEG tube placement, including intussusception. Jejunojejunal and retrograde jejunoduodenogastric intussusception are well-documented complications of PEG tube placement. Here we describe the case of a 25-year-old female who was diagnosed with anterograde gastroduodenal intussusception with the PEG tube acting as a lead point. Our case is unique as, to the best of our knowledge, there are no documented cases of PEG tube-related anterograde gastroduodenal intussusception. The reported patient was found to have extensive gastric pneumatosis and portal venous gas concerning for acute ischemia. Such cases warrant immediate surgical intervention. However, in our case, the patient's family opted for comfort care measures.

Exceptional association of hypocomplementemic urticarial vasculitis syndrome (HUVS) and symptomatic pulmonary histoplasmosis: a case-based literature review.

Hypocomplementemic urticarial vasculitis syndrome (HUVS) is a rare type III hypersensitivity disorder characterized by urticarial vasculitis and prolonged hypocomplementemia. Individuals with HUVS may also have joint involvement, pulmonary manifestations, ocular disease, kidney inflammation, or any other form of organ involvement. Hypocomplementemia, the presence of C1q antibody in the serum, and urticarial vasculitis are the keys to the diagnosis of HUVS. It has been reported to accompany certain infections such as hepatitis B, hepatitis C, infectious mononucleosis, and coxsackie group A. However, it has never been reported to be linked to histoplasmosis in the literature. To the best of our knowledge, we report the first case of HUVS presenting concurrently with pulmonary histoplasmosis.