National Trends and Predictors of Opioid Administration in Patients Presenting With Abdominal Pain to the Emergency Department (2010-2018).

Given the current opioid crisis, in this study, we assess the national trend and factors associated with opioid administration for patients presenting to the emergency department with abdominal pain. This is a retrospective cross-sectional study conducted using the National Hospital Ambulatory Medical Care Survey from 2010 to 2018. Weighted multiple logistic regression was applied to assess the independent factors associated with opioid administration in the emergency department. Trends of opioid administration were evaluated using the linear trend analysis. There were an estimated total of 100,925,982 emergency department visits for abdominal pain. Overall, opioid was administered in 16.8% of visits. Age less than 25 years was associated with lower odds of receiving opioids. Patients living in the Northeast had the lower odds of receiving opioids (odds ratio [OR] = 0.82, p = .006) than patients living in the Midwest. Patients in the West had the highest odds of receiving opioids (OR = 1.16, p = .01). Non-Hispanic White patients had higher odds of opioid administration (OR = 1.29, p < .001). Trend analysis demonstrated a statistically significant reduction in opioid administration. From 2010 to 2018, opioid administration has approximately decreased in half. Living in the West and the non-Hispanic White racial group were the significant factors associated with a higher risk of opioid administration.

Disparities in Emergency Department Waiting Times for Acute Gastrointestinal Bleeding: Results From the National Hospital Ambulatory Medical Care Survey, 2009-2018.

OBJECTIVE: The primary aim of this study was to assess waiting time (WT) across different racial groups to determine whether racial disparities exist in patients presenting with gastrointestinal bleeding (GIB) to the United States emergency departments (EDs). METHODS: Using the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2009 to 2018, we compared WT of patients with GIB across different racial/ethnic groups, including nonhispanic white (NHW), African American (AA), Hispanic White (HW), and Nonhispanic other. Multinomial logistic regression was applied to adjust the outcomes for possible confounders. We also assessed the trend of the WT over the study interval and compared the WT between the first (2009) and last year (2018) of the study interval. RESULTS: There were an estimated 7.8 million ED visits for GIB between 2009 and 2018. Mean WT ranged from 48 minutes in NHW to 68 minutes in AA. After adjusting for gender, age, geographic regions, payment type, type of GI bleeding, and triage status, multinomial logistic regression showed significantly higher waiting time for AA patients than NHW (OR 1.01, P =0.03). The overall trend showed a significant decrease in the mean WT ( P value<0.001). In 2009, AA waited 69 minutes longer than NHW ( P value<0.001), while in 2018, this gap was erased with no statistically significant difference ( P value=0.26). CONCLUSION: Racial disparities among patients presenting with GIB are present in the United States EDs. African Americans waited longer for their first visits. Over time, ED wait time has decreased, leading to a decline in the observed racial disparity.

Hepatitis E in immunocompromised individuals.

Hepatitis E virus (HEV) originally identified as a cause of acute icteric hepatitis in developing countries has grown to be a cause of zoonotic viral hepatitis in developed countries such as the United States. While there are eight identified genotypes to date, genotype 1 (HEV1), HEV2, HEV3, HEV4 are the most common to infect humans. HEV1 and HEV2 are most common in developing countries including Latina America, Africa and Asia, and are commonly transmitted through contaminated water supplies leading to regional outbreaks. In contrast HEV3 and HEV4 circulate freely in many mammalian animals and can lead to occasional transmission to humans through fecal contamination or consumption of undercooked meat. The incidence and prevalence of HEV in the United States is undetermined given the absence of FDA approved serological assays and the lack of commercially available testing. In majority of cases, HEV infection is a self-limiting hepatitis requiring only symptomatic treatment. However, this is not the case in immunocompromised individuals, including those that have undergone solid organ or stem cell transplantation. In this subset of patients, chronic infection can be life threatening as hepatic insult can lead to inflammation and fibrosis with subsequent cirrhosis and death. The need for re-transplantation as a result of post-transplant hepatitis is of great concern. In addition, there have been many reported incidents of extrahepatic manifestations, for which the exact mechanisms remain to be elucidated. The cornerstone of treatment in immunocompromised solid organ transplant recipients is reduction of immunosuppressive therapies, while attempting to minimize the risk of organ rejection. Subsequent treatment options include ribavirin, and pegylated interferon alpha in those who have demonstrated ribavirin resistance. Further investigation assessing safety and efficacy of anti-viral therapy is imperative given the rising global health burden. Given this concern, vaccination has been approved in China with other investigations underway throughout the world. In this review we introduce the epidemiology, diagnosis, clinical manifestations, and treatment of HEV, with emphasis on immunocompromised individuals in the United States.

Zenker's peroral endoscopic myotomy, or flexible or rigid septotomy for Zenker's diverticulum: a multicenter retrospective comparison.

BACKGROUND: Treatment of Zenker's diverticulum has evolved from open surgery to endoscopic techniques, including flexible and rigid endoscopic septotomy, and more recently, peroral endoscopic myotomy (Z-POEM). This study compared the effectiveness of flexible and rigid endoscopic septotomy with that of Z-POEM. METHODS: Consecutive patients who underwent endoscopic septotomy (flexible/rigid) or Z-POEM for Zenker's diverticulum between 1/2016 and 9/2019 were included. Primary outcomes were clinical success (decrease in Dakkak and Bennett dysphagia score to ≤ 1), clinical failure, and clinical recurrence. Secondary outcomes included technical success and rate/severity of adverse events. RESULTS: 245 patients (110 females, mean age 72.63 years, standard deviation [SD] 12.37 years) from 12 centers were included. Z-POEM was the most common management modality (n = 119), followed by flexible (n = 86) and rigid (n = 40) endoscopic septotomy. Clinical success was 92.7 % for Z-POEM, 89.2 % for rigid septotomy, and 86.7 % for flexible septotomy (P = 0.26). Symptoms recurred in 24 patients (15 Z-POEM during a mean follow-up of 282.04 [SD 300.48] days, 6 flexible, 3 rigid [P = 0.47]). Adverse events occurred in 30.0 % rigid septotomy patients, 16.8 % Z-POEM patients, and 2.3 % flexible septotomy patients (P < 0.05). CONCLUSIONS: There was no difference in outcomes between the three treatment approaches for symptomatic Zenker's diverticulum. Rigid endoscopic septotomy was associated with the highest rate of complications, while flexible endoscopic septotomy appeared to be the safest. Recurrence following Z-POEM was similar to flexible and rigid endoscopic septotomy. Prospective studies with long-term follow-up are required.

Peroral endoscopic myotomy (POEM) vs pneumatic dilation (PD) in treatment of achalasia: A meta-analysis of studies with ≥ 12-month follow-up.

Background and study aims Peroral endoscopic myotomy (POEM) is increasingly being used as the preferred treatment option for achalasia. The aim of this systematic review and meta-analysis was to compare the efficacy and safety of POEM versus pneumatic balloon dilation (PD). Methods We performed a comprehensive review of studies that reported clinical outcomes of POEM and PD for the treatment of achalasia. Measured outcomes included clinical success (improvement of symptoms based on a validated scale including an Eckardt score ≤ 3), adverse events, and post-treatment gastroesophageal reflux disease (GERD). Results Sixty-six studies (6268 patients) were included in the final analysis, of which 29 studies (2919 patients) reported on POEM and 33 studies (3050 patients) reported on PD and 4 studies (299 patients) compared POEM versus PD. Clinical success with POEM was superior to PD at 12, 24, and 36 months (92.9 %, vs 76.9 % P  = 0.001; 90.6 % vs 74.8 %, P  = 0.004; 88.4 % vs 72.2 %, P  = 0.006, respectively). POEM was superior to PD in type I, II and III achalasia (92.7 % vs 61 %, P  = 0.01; 92.3 % vs 80.3 %, P  = 0.01; 92.3 %v 41.9 %, P  = 0.01 respectively) Pooled OR of clinical success at 12 and 24 months were significantly higher with POEM (8.97; P  = 0.001 & 5.64; P  = 0.006). Pooled OR of GERD was significantly higher with POEM (by symptoms: 2.95, P  = 0.02 and by endoscopic findings: 6.98, P  = 0.001). Rates of esophageal perforation (0.3 % vs 0.6 %, P  = 0.8) and significant bleeding (0.4 % vs 0.7 %, P  = 0.56) were comparable between POEM and PD groups. Conclusions POEM is more efficacious than PD in the treatment of patients with achalasia during short-term and long-term follow-up, albeit with higher risk of abnormal esophageal acid exposure.

Computational Fluid Dynamics (CFD)-Based Optimization of Injection Process during Endoscopic Mucosal Therapy.

Creation of a submucosal plane to separate the lesion from the deeper muscle layer in gastrointestinal tract is an integral and essential part of endoscopic resection therapies such as endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). Thereby, an optimized submucosal injection technique is required to ensure a successful process. In this study, the computational fluid dynamics (CFD) technique is employed as a foundational step towards the development of a framework that can provide useful directions to optimize the injection process. Three different lifting agents, including Glycerol, Eleview®, and ORISE® gel have been used for this study. The role of different injection angles, injection dynamics, and effect of temperature are studied to understand the lifting characteristic of each agent. The study shows that Eleview® provides the highest lifting effect, including the initial injection period. To evaluate the impact of the injection process, two cases are simulated, termed static injection and dynamic injection. Under static injection, the injection angle is investigated from lower to higher angles of injection. In the dynamic injection, two cases are modulated, where a continuous change of injection angle from lower to higher degrees (denoted as clockwise) and vice-versa in the anti-clockwise direction are investigated. Increased lifting characteristics are observed at decreasing/lower angle of injection. Further, the correlation between temperature of the lifting agents and their lifting characteristics is investigated.

EUS-guided 22-gauge fine needle biopsy versus single-incision with needle knife for the diagnosis of upper gastrointestinal subepithelial lesions: a randomized controlled trial.

Background and study aims EUS-FNA has suboptimal accuracy in diagnosing gastrointestinal subepithelial tumors (SETs). EUS-guided 22-gauge fine needle biopsy (EUS-FNB) and single-incision with needle knife (SINK) were proposed to increase accuracy of diagnosis. This study aimed to prospectively compare the diagnostic accuracy and safety of EUS-FNB with SINK in patients with upper gastrointestinal SETs. Patients and methods All adult patients referred for EUS evaluation of upper gastrointestinal SETs ≥ 15 mm in size were eligible for inclusion. Patients were randomized to undergo EUS-FNB or SINK. Lesions were sampled with a 22-gauge reverse beveled core needle in the EUS-FNB group and by a conventional needle-knife sphincterotome and biopsy forceps in the SINK group. Patients were blinded to the technique used. The primary outcome was diagnostic accuracy. Secondary outcomes included adverse events, histological yield and procedure duration. Study enrollment was terminated early due to poor recruitment. Results A total of 56 patients (31 male (55.37 %); mean age, 67.41 ±â€Š12.70 years) were randomized to either EUS-FNB (n = 26) or SINK (n = 30). Technical success was 96.15 % and 96.66 %, respectively. The majority of lesions were gastrointestinal stromal tumors (51.78 %). No significant difference was found between EUS-FNB and SINK in terms of diagnostic accuracy for a malignant or benign disease (76 % vs. 89.28 %, respectively; P  = 0.278). The rate of adverse events (none severe) was also comparable (7.69 % vs. 10 %, respectively; P =  1.0) including two abdominal pain episodes in the EUS-FNB group compared to two delayed bleeding (one requiring hospitalization and radiologic embolization) and 1 abdominal pain in the SINK group. Conclusion EUS-FNB and SINK are equally effective techniques for upper gastrointestinal SETs sampling. SINK can be associated with mild to moderate delayed bleeding.

Unilateral versus bilateral endoscopic stenting in patients with unresectable malignant hilar obstruction: a systematic review and meta-analysis.

Background and study aims Endoscopic stent placement is used for palliative management of unresectable malignant hilar obstruction, which could be achieved by either unilateral or bilateral stent insertion. Materials and methods A literature search was performed to identify studies that reported outcomes of metallic biliary stent placement in patients with malignant hilar obstruction. Weighted pooled rates (WPR) along with 95 % confidence intervals (95 %CI) were calculated to determine and compare outcomes including technical and functional success, early and late adverse events, post procedure cholangitis, and stent occlusion between two groups. Results A total of 21 studies with 1292 patients were included. WPR of technical success was significantly higher in the unilateral group (97 %, 95 %CI: 93 -98 %) vs. bilateral group (89 %, 95 %CI: 84 -92 %) ( P  = 0.0.003). WPR for functional success in the unilateral and bilateral groups were 96 % (95 %CI: 91 -98 %) and 94 % (95 %CI: 91 -97 %), respectively ( P  = 0.48). The rate of early and late complications was comparable between the two groups. Conclusion In patients with unresectable malignant hilar obstruction, unilateral and bilateral metallic stenting techniques are comparable in terms of efficacy and safety.

Outcome, complication and follow-up of patients with esophageal foreign body impaction: an academic institute's 15 years of experience.

Esophageal foreign body impaction (EFBI) is a gastrointestinal emergency, mostly requiring endoscopic management. The aim of this study is to evaluate the epidemiology, adverse events, and outcomes of patients following the episode of EFBI. All esophagogastroduodenoscopy (EGD) reports of admitted patients for EFBI at the University of Kansas Medical Center between 2003 and 2018 were retrospectively reviewed. Of 204 patients, who met the inclusion criteria, 60% were male and the mean age was 54.7 ± 17.7 years. The encounter was the first episode of EFBI in 76% of cases. EGD in less than 24 hours of patients' admission was required in 79% of cases. The distal esophagus was the most common site of impaction (44%). Push and pull techniques were used in 38 and 35.2% of cases, respectively, while 11% were managed by a combination of both techniques. Structural causes were the most common etiologic findings including benign strictures and stenosis in 21.5% of patients, followed by Schatzki's ring (7.8%) and hiatal hernia (6.9%). Of all cases, 45% did follow-up in up to 1 year, and biopsy was done in 34% of cases. Out of 43 patients who had endoscopic findings suspicious for eosinophilic esophagitis (EoE), the diagnosis was confirmed by pathology in 37. The rate of recurrence EFBI was significantly higher in patients with EoE (P < 0.001). EFBI-related esophageal adverse events (AEs) occurred in 4.9% of cases. Cardiovascular and pulmonary AEs occurred in 1.5 and 2.9%, respectively. Logistic regression did not find any predictor for AEs occurrence. EFBI managed very well with endoscopic treatments. Despite the emerging data about the safety of the push technique, there are still concerns regarding its adverse events especially the risk of perforations. Our study shows no significant difference in adverse events between different types of techniques.

Endoscopic ultrasound-guided drainage of pancreatic walled-off necrosis using 20-mm versus 15-mm lumen-apposing metal stents: an international, multicenter, case-matched study.

BACKGROUNDS: Endoscopic ultrasound (EUS)-guided placement of lumen-apposing metal stents (LAMSs) has gained popularity for the treatment of pancreatic walled-off necrosis (WON). We compared the 20-mm and 15-mm LAMSs for the treatment of symptomatic WON in terms of clinical success and adverse events. METHODS: We conducted a retrospective, case-matched study of 306 adults at 22 tertiary centers from 04/2014 to 10/2018. A total of 102 patients with symptomatic WON who underwent drainage with 20-mm LAMS (cases) and 204 patients who underwent drainage with 15-mm LAMS (controls) were matched by age, sex, and drainage approach. Conditional logistic regression analysis was performed to compare clinical success (resolution of WON on follow-up imaging without reintervention) and adverse events (according to American Society for Gastrointestinal Endoscopy criteria). RESULTS: Clinical success was achieved in 92.2 % of patients with 20-mm LAMS and 91.7 % of patients with 15-mm LAMS (odds ratio 0.92; P = 0.91). Patients with 20-mm LAMS underwent fewer direct endoscopic necrosectomy (DEN) sessions (mean 1.3 vs. 2.1; P < 0.001), despite having larger WON collections (transverse axis 118.2 vs. 101.9 mm, P = 0.003; anteroposterior axis 95.9 vs. 80.1 mm, P = 0.01). There was no difference in overall adverse events (21.6 % vs. 15.2 %; P = 0.72) and bleeding events (4.9 % vs. 3.4 %; P = 0.54) between the 20-mm and 15-mm LAMS groups, respectively. CONCLUSIONS: The 20-mm LAMS showed comparable clinical success and safety profile to the 15-mm LAMS, with the need for fewer DEN sessions for WON resolution.

Efficacy and feasibility of G-POEM in management of patients with refractory gastroparesis: a systematic review and meta-analysis.

Background and aim Clinical management of patients with gastroparesis is challenging. Prior pyloric targeted procedures are either invasive or have questionable long-term efficacy. Gastric per-oral endoscopic myotomy (G-POEM) has been recently introduced as a minimally invasive approach. In this review, we performed a meta-analysis to evaluate the feasibility and efficacy of this technique in the management of patients with refractory gastroparesis. Methods PubMed, Embase, and Scopus databases were searched to identify relevant studies published through May 2018. Weighted pool rates (WPR) of the clinical resolution were calculated. Pooled values of Gastroparesis Cardinal Symptom Index (GCSI) before and after the procedure were compared. Pooled difference in means comparing gastric emptying before and after the procedure was calculated. Fixed or random effect model was used according to the level of heterogeneity. Results Seven studies with 196 patients were included in the meta-analysis. The mean value of procedure duration was 69.7 (95 % confidence interval [95 % CI]: 39 - 99 minutes) and average estimate of hospital stay was 1.96 (95 % CI: 1.22 - 2.95) days. The WPR for clinical success was 82 % (95 % CI: 74 % - 87 %, I 2  = 0). Compared with pre-procedure GCSI values, mean values of GCSI were reduced significantly at 5 days (-1.57 (95 % CI:-2.2,-0.9), I 2  = 80 %) ( P  < 0.001). Mean values of gastric emptying were significantly decreased 2 - 3 months after the procedure (-22.3 (95 %CI: -32.9, - 11.6), I 2  = 67 %) ( P  < 0.05). Conclusion Due to the high rate of clinical success and low rate of adverse events, G-POEM should be considered in management of refractory gastroparesis.

Comparison of bandage contact lens removal on the fourth versus seventh postoperative day after photorefractive keratectomy: A randomized clinical trial.

PURPOSE: To compare the outcomes of bandage contact lens (BCL) removal on the fourth versus seventh post-operative day following photorefractive keratectomy (PRK). METHODS: This study recruited eyes of patients who underwent PRK surgery. The patients were randomly assigned to 2 groups. In Group 1 BCL was removed on the 4th postoperative day, while in Group 2, BCL was removed on the 7th postoperative day. After BCL removal, patients were asked to express their pain score and eye discomfort. At one and three months follow-up examinations, visual acuity scale was assessed. Slit-lamp examination was performed in all visits to evaluate complications. RESULTS: 260 eyes of 130 patients underwent PRK. The age and sex ratio were not significantly different between the two groups. One month after the surgery, the logMAR uncorrected distance visual acuity (UDVA) and corrected distance visual acuity (CDVA) were significantly lower in Group 2 (P value = 0.016, 0.001 respectively), however, the UDVA and CDVA were not significantly different after 3 months (P > 0.05). In Group 1, filamentary keratitis (FK) was observed in 10 (7.6%) eyes, 6 (4.61%) eyes were diagnosed with recurrent corneal erosion (RCE) and corneal haze was detected in 3 (2.3%) eyes. However, in Group 2, RCE was observed in 4 (2.3%) and FK was noted in 4 (3.07%) eyes. No haze was seen in Group 2. The difference in rate of complications was statistically significant (14.6% and 6.1% in Groups 1 and 2, respectively, P = 0.02). Pain and eye discomfort scores were not significantly different (P > 0.05). There was no major complications including infectious keratitis in either groups. CONCLUSION: Following PRK surgery, BCL removal on the seventh postoperative day yields faster visual rehabilitation and lower rate of postoperative complications with no increase in eye pain, discomfort or infection.

Comparison of intravenous lidocaine versus morphine in alleviating pain in patients with critical limb ischaemia.

BACKGROUND: Numerous drugs have been proposed to alleviate ischaemic limb pain, but none have been successful in relieving ischaemic pain thoroughly and rapidly. OBJECTIVE: To compare the effectiveness of intravenous lidocaine and intravenous morphine in decreasing pain in patients with critical limb ischaemia. METHODS: A randomised double-blind controlled trial was performed in 63 patients with critical limb ischaemia recruited from the emergency department between October 2012 and December 2013; 23 patients were excluded and the remainder were randomly divided into two groups of 20 patients. Patients in the lidocaine group received lidocaine infusion (2 mg/kg) while patients in the morphine group received morphine (0.1 mg/kg). Patients' visual analogue pain scores (VAS), from 0 to 10, were reported before and 15 and 30 min after the infusion. RESULTS: Before the infusion the mean±SD VAS score was 7.50±1.93 in the lidocaine group and 7.65±1.92 in the morphine group. At 15 min the mean±SD VAS score in the lidocaine group was lower than in the morphine group (5.75±1.77 vs 7.00±1.83; mean difference 1.25, 95% CI 0.095 to 2.405) and, at 30 min, the mean±SD VAS score in the lidocaine group was again lower (4.25±1.48 vs 6.50±1.73; mean difference 2.25, 95% CI 1.218 to 3.282). CONCLUSIONS: Lidocaine may be helpful in decreasing ischaemic pain in patients with critical limb ischaemia. TRIAL REGISTRATION NUMBER: http://www.irct.irIRCT201210148872N2.