Pleasurable and problematic receptive anal intercourse and diseases of the colon, rectum and anus.

The ability to experience pleasurable sexual activity is important for human health. Receptive anal intercourse (RAI) is a common, though frequently stigmatized, pleasurable sexual activity. Little is known about how diseases of the colon, rectum, and anus and their treatments affect RAI. Engaging in RAI with gastrointestinal disease can be difficult due to the unpredictability of symptoms and treatment-related toxic effects. Patients might experience sphincter hypertonicity, gastrointestinal symptom-specific anxiety, altered pelvic blood flow from structural disorders, decreased sensation from cancer-directed therapies or body image issues from stoma creation. These can result in problematic RAI - encompassing anodyspareunia (painful RAI), arousal dysfunction, orgasm dysfunction and decreased sexual desire. Therapeutic strategies for problematic RAI in patients living with gastrointestinal diseases and/or treatment-related dysfunction include pelvic floor muscle strengthening and stretching, psychological interventions, and restorative devices. Providing health-care professionals with a framework to discuss pleasurable RAI and diagnose problematic RAI can help improve patient outcomes. Normalizing RAI, affirming pleasure from RAI and acknowledging that the gastrointestinal system is involved in sexual pleasure, sexual function and sexual health will help transform the scientific paradigm of sexual health to one that is more just and equitable.

Endoscopic advances in the management of gastric cancer and premalignant gastric conditions.

Gastric cancer is the fifth most common cancer and in 2018, it was the third most common cause of cancer-related deaths worldwide. Endoscopic advances continue to be made for the diagnosis and management of both early gastric cancer and premalignant gastric conditions. In this review, we discuss the epidemiology and risk factors of gastric cancer and emphasize the differences in early vs late-stage gastric cancer outcomes. We then discuss endoscopic advances in the diagnosis of early gastric cancer and premalignant gastric lesions. This includes the implementation of different imaging modalities such as narrow-band imaging, chromoendoscopy, confocal laser endomicroscopy, and other experimental techniques. We also discuss the use of endoscopic ultrasound in the diagnosis and staging of early gastric cancer. We then discuss the endoscopic advances made in the treatment of these conditions, including endoscopic mucosal resection, endoscopic submucosal dissection, and hybrid techniques such as laparoscopic endoscopic cooperative surgery. Finally, we comment on the current suggested recommendations for surveillance of both gastric cancer and its premalignant conditions.

Endoscopic stenting for malignant biliary obstruction is technically successful in patients with preexisting duodenal stents.

Background and study aims There are limited data on the success of endoscopic retrograde cholangiopancreatography (ERCP) in patients with malignant biliary and duodenal obstruction with a preexisting duodenal stent. The aim of this study was to evaluate patient and procedural outcomes of a cohort of patients with preexisting duodenal stents who underwent an attempt at ERCP for malignant biliary obstruction (MBO). Patients and methods This was a single-center retrospective study on consecutive patients with a preexisting duodenal stent who underwent attempted ERCP for MBO. Technical success was defined as successful cannulation of the common bile duct, with successful dilation and/or deployment of a biliary stent under fluoroscopy. Clinical success was defined as number of patients in the entire group who underwent ERCP successfully with resolution of symptoms. Results We identified 64 patients (73 % men, 74 % white, median age 62 years) with a preexisting duodenal stent who underwent 85 attempts at ERCP. ERCP was technically successful in 50 of 85 procedures (59 %). Overall ERCP was successful in 41 of 85 patients (48 %). ERCP was more likely to be successful in patients with Type 1 and 3 duodenal strictures than with Type 2 strictures (83 % and 92 % vs. 42 %, P  < 0.01), in patients with a preexisting sphincterotomy (79% vs. 20 %, P  = 0.01) or preexisting biliary stent (66 % vs. 34 %, P  = 0.04). Adverse events included bleeding (n = 3), post-procedure fever (n = 3) and abdominal pain (n = 1). Conclusions Although biliary stenting via ERCP is often technically challenging in patients with a prior duodenal stent, it is a safe and effective method of biliary drainage. ERCP should be attempted in patients with Type 1 and 3 duodenal strictures, a prior sphincterotomy or an indwelling biliary stent.

National trends of endoscopic retrograde cholangiopancreatography utilization and outcomes in decompensated cirrhosis.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) can be challenging in patients with decompensated cirrhosis (DC) due to increased risk of adverse events related to liver dysfunction. Limited data exist regarding its national utilization in patients with DC. We aim to determine the trends in utilization and outcomes of ERCP among patients with DC in US hospitalizations. METHODS: We identified hospitalizations undergoing ERCP (diagnostic and therapeutic) between 2000 and 2013 from the National Inpatient Sample (NIS) database and used validated ICD9-CM codes to identify DC hospitalizations. We utilized Cochrane-Armitage test to identify changes in trends and multivariable survey regression modeling for adjusted odds ratios (aOR) for adverse outcomes and mortality predictors. RESULTS: There were 43782 cases of ERCPs performed in DC patients during the study period. Absolute number of ERCPs performed in this population from 2000 to 2013 showed an upward trend; however, the proportion of DC patients undergoing ERCP remained stable. We noted significant decrease in utilization of diagnostic ERCP and an increase of therapeutic ERCPs (P < 0.01). There was a significant decrease in the mean length of stay for DC patients undergoing ERCP from 8.2 days in 2000 to 7.2 days in 2013 (P < 0.01) with an increase in the mean cost of hospitalization from $17053 to $19825 (P < 0.001). Mortality rates showed a downward trend from 2000 to 2013 from 13.6 to 9.6% (P < 0.01). Increasing age, Hispanic race, diagnosis of hypertension and diabetes mellitus, and private insurance were related to adverse discharges(P < 0.01). Increasing age, presence of hepatic encephalopathy, and sepsis were associated with higher mortality (P < 0.01). CONCLUSIONS: There is an increasing trend in therapeutic ERCP utilization in DC hospitalizations nationally. There is an overall decrease in mortality in DC hospitalizations undergoing ERCP. This improvement in mortality suggests improvement in both procedural technique and peri-procedural care as well as overall decreasing mortality in cirrhosis.

Direct Percutaneous Endoscopic Jejunostomy: Procedural and Nutrition Outcomes in a Large Patient Cohort.

BACKGROUND: Direct percutaneous endoscopic jejunostomy (DPEJ) is used for enteral nutrition (EN) in patients with postoperative anastomotic leaks after esophagectomy/gastrectomy and at high risk for aspiration. We characterized the indications, technical success, procedural/nutrition outcomes, and adverse events in a large cohort of patients undergoing DPEJ insertion. METHODS: Patients undergoing DPEJ insertion between January 2009 and March 2015 were identified from an institutional endoscopy database. Demographic, procedural, and nutrition outcome data were collected from electronic medical records. Regression analyses were used to identify predictors of adverse events and procedural success. RESULTS: A total of 452 patients underwent 480 attempts at DPEJ insertion. Indications included preoperative or postoperative weight loss (64%), postoperative upper gastrointestinal (UGI) anastomotic leak (13%), aspiration prevention (10%), and other (13%). Of attempted procedures, 398 (83%) were successful. Feeding was initiated in 389 (98%) of patients; a median of 1775 calories was delivered daily. Median body mass index (BMI) at baseline was 22.9 (11.4-44.7) and did not change over follow-up. Median change in BMI after DPEJ was similar in groups that received EN with palliative and curative intent. Adverse events following 480 attempted DPEJ insertions included 13 (3%) immediate and 74 (15%) delayed, 13 (3%) of which were serious. Patients with head and neck cancer had more adverse events than those with esophageal cancer (P = .020). CONCLUSION: DPEJ is a successful and safe procedure that effectively provides access for EN support in malnourished patients and patients with postoperative UGI cancer.

Epidemiology of pancreatic adenocarcinoma.

Pancreatic ductal adenocarcinoma is one of the most lethal cancers worldwide. The highest incidence rates her found are in North America and in Western Europe while lower rates in Asian Africa, with age standard incidence rates of 7.2 and 2.8 per 100,000 populations. Unfortunately the vast majority of individuals with pancreatic cancer present with symptoms, and once symptoms develop the chance for surgery is only about 20%. Additionally he incidence rate and mortality from pancreatic ductal adenocarcinoma in the United States shows a very close association suggesting that her earlier detection and treatment does little to change the outcome from this disease. Multiple of environmental and genetic risk factors have been implicated in the development of pancreatic ductal adenocarcinoma. We have reviewed those risk factors we believe are most important the development of this lethal disease. It is hoped that in the future, identification of biomarkers unique in the development of pancreatic ductal adenocarcinoma will be identified leading to earlier detection and a greater frequency of potential cure of this disease.

Predictors of Hospital Readmissions for Ulcerative Colitis in the United States: A National Database Study.

BACKGROUND: Early readmissions are important indicators of quality of care. Limited data exist describing hospital readmissions in ulcerative colitis (UC). The aim of this study was to describe unplanned, 30-day readmissions among adult UC patients and to assess readmission predictors. METHODS: We analyzed the 2013 United States National Readmission Database and identified UC admissions using administrative codes in patients from 18 to 80 years of age. Our primary outcome was a 30-day, unplanned readmission rate. We used chi-square tests, t tests, and Wilcoxon rank-sum tests for descriptive analyses and survey logistic regression to calculate adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for associations with readmissions adjusting for confounders. RESULTS: Among 26,094 hospitalizations with a primary UC diagnosis, there were 2757 (10.6%) 30-day, unplanned readmissions. The most common readmission diagnoses were reasons related to UC (58%), complications of surgical procedures/medical care (5.5%), Clostridium difficile (4.8%), and septicemia (4.3%). In multivariable analysis, length of stay ≥7 days (aOR 1.54, 95% CI, 1.24-1.90), not having an endoscopy (aOR 1.20, 95% CI, 1.04-1.38), and depression (aOR 1.40, 95% CI, 1.16-1.66) were significantly associated with readmission. 58.2% of readmissions had at least one of these factors. Patients were also less likely to be admitted if they were women or had self-pay payer status. Having a colectomy did not significantly increase readmissions (aOR 1.14, 95% CI, 0.86-1.52). CONCLUSIONS: On a national level, 1 in 10 hospitalizations for UC was followed by an unplanned readmission within 30 days. Not having an endoscopy on the index hospitalization and depression were independently associated with readmissions. Further studies should examine if strategies that address these predictors can decrease readmissions.

A Nationwide Analysis of Outcomes of Weekend Admissions for Intracerebral Hemorrhage Shows Disparities Based on Hospital Teaching Status.

BACKGROUND AND PURPOSE: With the "weekend effect" being well described, the Brain Attack Coalition released a set of "best practice" guidelines in 2005, with the goal to uniformly provide standard of care to patients with stroke. We attempted to define a "weekend effect" in outcomes among patients with intracranial hemorrhage (ICH) over the last decade, utilizing the Nationwide Inpatient Sample (NIS) data. We also attempted to analyze the trend of such an effect. MATERIALS AND METHODS: We determined the association of ICH weekend admissions with hospital outcomes including mortality, adverse discharge, length of stay, and cost compared to weekday admissions using multivariable logistic regression. We extracted our study cohort from the NIS, the largest all-payer data set in the United States. RESULTS: Of 485 329 ICH admissions from 2002 to 2011, 27.5% were weekend admissions. Overall, weekend admissions were associated with 11% higher odds of in-hospital mortality. When analyzed in 3-year groups, excess mortality of weekend admissions showed temporal decline. There was higher mortality with weekend admissions in nonteaching hospitals persisted (odds ratios 1.16, 1.13, and 1.09, respectively, for 3-year subgroups). Patients admitted during weekends were also 9% more likely to have an adverse discharge (odds ratio 1.09; 95% confidence interval: 1.07-1.11; P < .001) with no variation by hospital status. There was no effect of a weekend admission on either length of stay or cost of care. CONCLUSION: Nontraumatic ICH admissions on weekends have higher in-hospital mortality and adverse discharge. This demonstrates need for in-depth review for elucidating this discrepancy and stricter adherence to standard-of-care guidelines to ensure uniform care.

National trends of acute kidney injury requiring dialysis in decompensated cirrhosis hospitalizations in the United States.

BACKGROUND AND AIMS: Cirrhosis affects 5.5 million patients with estimated costs of US$4 billion. Previous studies about dialysis requiring acute kidney injury (AKI-D) in decompensated cirrhosis (DC) are from a single center/year. We aimed to describe national trends of incidence and impact of AKI-D in DC hospitalizations. METHODS: We extracted our cohort from the Nationwide Inpatient Sample (NIS) from 2006-2012. We identified hospitalizations with DC and AKI-D by validated ICD9 codes. We analyzed temporal changes in DC hospitalizations complicated by AKI-D and utilized multivariable logistic regression models to estimate AKI-D impact on hospital mortality. RESULTS: We identified a total of 3,655,700 adult DC hospitalizations from 2006 to 2012 of which 78,015 (2.1 %) had AKI-D. The proportion with AKI-D increased from 1.5 % in 2006 to 2.23 % in 2012; it was stable between 2009 and 2012 despite an increase in absolute numbers from 6773 to 13,930. The overall hospital mortality was significantly higher in hospitalizations with AKI-D versus those without (40.87 vs. 6.96 %; p < 0.001). In an adjusted multivariable analysis, adjusted odds ratio for mortality was 2.17 (95 % CI 2.06-2.28; p < 0.01) with AKI-D, which was stable from 2006 to 2012. Changes in demographics and increases in acute/chronic comorbidities and procedures explained temporal changes in AKI-D. CONCLUSIONS: Proportion of DC hospitalizations with AKI-D increased from 2006 to 2009, and although this was stable from 2009 to 2012, there was an increase in absolute cases. These results elucidate the burden of AKI-D on DC hospitalizations and excess associated mortality, as well as highlight the importance of prevention, early diagnosis and testing of novel interventions in this vulnerable population.

Association between probiotic and yogurt consumption and kidney disease: insights from NHANES.

BACKGROUND: Data from experimental animals suggest that probiotic supplements may retard CKD progression. However, the relationship between probiotic use, frequent yogurt consumption (as a natural probiotic source), and kidney parameters have not been evaluated in humans. FINDINGS: We utilized NHANES data, and analyzed the association of probiotic alone (1999-2012) and yogurt/probiotic (2003-2006) use with albuminuria and eGFR after adjustment for demographic and clinical parameters. Frequent yogurt consumption was defined as thrice or more weekly over the year prior to the interview. Frequent yogurt/probiotic consumers had lower adjusted odds of developing combined outcome (albuminuria and/or eGFR < 60 ml/min/1.73 m(2)) compared to infrequent consumers (OR = 0.76; 95 % CI = 0.61-0.94). When evaluated separately, frequent consumers had lower odds of albuminuria and nonsignificant trend towards decreased odds of low eGFR compared to infrequent consumers. In the probiotic cohort, probiotic consumers were found to have a lower adjusted odds of albuminuria compared to nonusers (OR = 0.59; 95 % CI = 0.37-0.94). CONCLUSION: Frequent yogurt and/or probiotics use is associated with decreased odds of proteinuric kidney disease. These hypothesis-generating results warrant further translational studies to further delineate the relationship between yogurt/probiotics with kidney dysfunction, as well as microbiome and dysbiosis as potential mediators.

A National Perspective of Do-Not-Resuscitate Order Utilization Predictors in Intracerebral Hemorrhage.

Nontraumatic intracerebral hemorrhage (ICH) is associated with substantial morbidity and mortality. Do-not-resuscitate (DNR) orders are linked to poorer outcomes in patients with ICH, possibly due to less active management. Demographic, regional, and social factors, not related to ICH severity, have not been adequately looked at as significant predictors of DNR utilization. We reviewed the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample (NIS) database in 2011 for adult ICH admissions and DNR status. We generated hierarchical 2-level multivariate regression models to estimate adjusted odds ratios. We analyzed 25 768 ICH hospitalizations, 18% of which (4620 hospitalizations) had DNR orders, corresponding to national estimates of 126 254 and 22 668, respectively. In multivariable regression, female gender, white or Hispanic/Latino ethnicity, no insurance coverage, and teaching hospitals were significantly associated with increased DNR utilization after adjusting for confounders. There was also significantly more interhospital variability in the lowest quartile of hospital volume. In conclusion, demographic factors and insurance status are significantly associated with increased DNR utilization, with more individual hospital variability in low-volume hospitals. The reasons for this are likely qualitative and linked to patient, provider, and hospital practices.

Incidence, Risk Factors, and Outcome Trends of Acute Kidney Injury in Elective Total Hip and Knee Arthroplasty.

Over the past decade, there has been a marked increase in the number of primary and revision total hip and knee arthroplasties performed in the United States. Acute kidney injury (AKI) is a common complication of these procedures; however, little is known about its epidemiology in the elective arthroplasty population. We conducted a study to determine the incidence, risk factors, and outcomes of AKI after elective joint arthroplasty. Drawing on the Nationwide Inpatient Sample database, we found that the proportion of hospitalizations complicated by AKI increased rapidly from 0.5% in 2002 to 1.8% to 1.9% in 2012. Multivariate analysis revealed that the key risk factors for AKI were chronic kidney disease and the postoperative events of sepsis, acute myocardial infarction, and blood transfusion. Moreover, codiagnosis with chronic kidney disease increased the risk for AKI associated with all 3 postoperative events. After adjusting for confounders, we found an association between AKI and a significantly increased risk for in-hospital mortality and discharge to long-term facilities. AKI serves as an important quality indicator in elective hip and knee surgeries. With elective arthroplasties expected to rise, carefully planned approach to interdisciplinary perioperative care is essential to reduce both the risk and consequences of AKI.

Systematic oral hydration with water is similar to parenteral hydration for prevention of contrast-induced nephropathy: an updated meta-analysis of randomised clinical data.

BACKGROUND: Contrast-induced nephropathy (CIN) is the third most common cause of hospital-acquired kidney injury and is related to increased long-term morbidity and mortality. Adequate intravenous (IV) hydration has been demonstrated to lessen its occurrence. Oral (PO) hydration with water is inexpensive and readily available but its role for CIN prevention is yet to be determined. METHODS: PubMed, EMBASE and the Cochrane Central register of controlled trials (CENTRAL) databases were searched until April 2015 and studies were selected using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. All randomised clinical trials with head-to-head comparison between PO and IV hydration were included. RESULTS: A total of 5 studies with 477 patients were included in the analysis, 255 of those receiving PO water. The incidence of CIN was statistically similar in the IV and PO arms (7.7% and 8.2%, respectively; relative risk 0.97; 95% CI 0.36 to 2.94; p=0.95). The incidence of CIN was statistically similar in the IV and PO arms in patients with chronic kidney disease and with normal renal function. Rise in creatinine at 48-72 h was lower in the PO hydration group compared with IV hydration (pooled standard mean difference 0.04; 95% CI 0.03 to 0.06; p<0.001; I(2)=62%). CONCLUSIONS: Our meta-analysis shows that systematic PO hydration with water is at least as effective as IV hydration with saline to prevent CIN. PO hydration is cheaper and more easily administered than IV hydration, thus making it more attractive and just as effective.

The burden of dialysis-requiring acute kidney injury among hospitalized adults with HIV infection: a nationwide inpatient sample analysis.

OBJECTIVE: The objective of this study was to describe the incidence of acute kidney injury (AKI) requiring renal replacement therapy ('dialysis-requiring AKI') and the impact on in-hospital mortality among hospitalized adults with HIV infection. DESIGN: A longitudinal analysis of a nationally representative administrative database. METHODS: We reviewed the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample Database, a large, nationally representative sample of inpatient hospital admissions, to identify all adult hospitalizations with an associated diagnosis of HIV infection from 2002 to 2010. We analysed temporal trends in the incidence of dialysis-requiring AKI and the associated odds of in-hospital mortality. We also explored potential reasons behind temporal changes. RESULTS: Among 183 0041 hospitalizations with an associated diagnosis of HIV infection, the proportion complicated by dialysis-requiring AKI increased from 0.7% in 2002 to 1.35% in 2010. This temporal rise was completely explained by changes in demographics and an increase in concurrent comorbidities and procedure utilization. The adjusted odds of in-hospital mortality associated with dialysis-requiring AKI also increased over the study period, from 1.45 [95% confidence interval (95% CI) 0.97-2.12] in 2002 to 2.64 (95% CI 2.04-3.42) in 2010. CONCLUSION: These data suggest that the incidence of dialysis-requiring AKI among hospitalized adults with HIV infection continues to increase, and that severe AKI remains a significant predictor of in-hospital mortality in this population. The increased incidence of dialysis-requiring AKI was largely explained by ageing of the HIV population and increasing prevalence of chronic non-AIDS comorbidities, suggesting that these trends will continue.

Spectrum of biliary complications following live donor liver transplantation.

Liver transplantation is the optimal treatment for many patients with advanced liver disease, including decompensated cirrhosis, hepatocellular carcinoma and acute liver failure. Organ shortage is the main determinant of death on the waiting list and hence living donor liver transplantation (LDLT) assumes importance. Biliary complications are the most common post operative morbidity after LDLT and occur due to anatomical and technical reasons. They include biliary leaks, strictures and cast formation and occur in the recipient as well as the donor. The types of biliary complications after LDLT along with their etiology, presenting features, diagnosis and endoscopic and surgical management are discussed.

Effect of Gender on the Response to Hepatitis C Treatment in an Inner-City Population.

INTRODUCTION: Hepatitis C virus (HCV) is the leading cause of cirrhosis, hepatocellular carcinoma, and liver transplantation in the United States. Response to treatment has improved with the addition of direct acting protease inhibitors. However, there are limited real-world data on the role of gender in achieving a sustained virologic response (SVR). METHODS: We conducted a cross-sectional study in 70 patients treated for HCV, genotype 1 infection with pegylated alpha interferon, ribavirin, and either telaprevir or boceprevir at our inner-city liver clinic. RESULTS: The SVR was significantly lower in women than in men (24% vs. 59%; p < .01). Statistical significance persisted after adjusting for age, race, genotype, prior treatment status, duration of therapy, and stage of fibrosis. The adjusted odds ratio for achieving SVR was significantly lower in women than in men (odds ratio [OR], 0.13; 95% CI, 0.03-0.58; p = .01). Relapse after completing treatment was more likely to occur in women (p = .02). Thirty-four patients (48%) did not complete therapy. Discontinuation because of loss to follow-up was more likely in women, whereas discontinuation owing to therapy limiting adverse drug events were more common in men. Discontinuation rates owing to failure of therapy were similar in men and women. CONCLUSIONS: There was a significant difference in SVR between men and women. Both biological and nonbiological factors, the latter including access to care, adherence to therapy, and attitudes of and toward health care providers all could play a role in contributing to the observed disparity between sexes in treatment response.

Trimetazidine Decreases Risk of Contrast-Induced Nephropathy in Patients With Chronic Kidney Disease: A Meta-Analysis of Randomized Controlled Trials.

OBJECTIVES: We sought to synthesize and analyze the available data from randomized controlled trials (RCTs) for trimetazidine (TMZ) in the prevention of contrast-induced nephropathy (CIN). BACKGROUND: Contrast-induced nephropathy after coronary angiography is associated with poor outcomes. Trimetazidine is an anti-ischemic drug that might reduce incidence of CIN, but current data are inconclusive. METHODS: We searched MEDLINE/PubMed, EMBASE, Scopus, Cochrane Library, Web of Science, and ScienceDirect electronic databases for RCTs comparing intravenous hydration with normal saline (NS) and/or N-acetyl cysteine (NAC) versus TMZ plus NS ± NAC for prevention of CIN. We used RevMan 5.2 for statistical analysis with the fixed effects model. RESULTS: Of the 808 studies, 3 RCTs met criteria with 290 patients in the TMZ plus NS ± NAC group and 292 patients in the NS ± NAC group. The mean age of patients was 59.5 years, and baseline serum creatinine ranged from 1.3 to 2 mg/dL. Trimetazidine significantly reduced the incidence of CIN by 11% (risk difference 0.11; 95% confidence interval, 0.16-0.06; P < .01). There was no significant heterogeneity between the studies (I(2) statistic = 0). The number needed to treat to prevent 1 episode of CIN was 9. CONCLUSIONS: The addition of TMZ to NS ± NAC significantly decreased the incidence of CIN in patients undergoing coronary angiography. In conclusion, TMZ could be considered as a potential tool for prevention of CIN in patients with renal dysfunction.