Chest Pain Risk Stratification in the Emergency Department: Current Perspectives.

Chest pain is the second leading cause of all emergency department (ED) visits in adults in the United States, with nearly 11 million encounters yearly. While identifying low-risk patients is crucial for early discharge, identifying high-risk patients in ED is vital in timely and appropriate acute coronary syndrome (ACS) management. Traditional methods such as physical examination, cardiac markers, or imaging tests cannot reliably confirm or rule out ACS; they cannot be singularly incorporated to risk stratify patients. Various clinical risk scores have been proposed to address this challenge for risk stratification in patients being evaluated for suspected ACS. The ideal risk score should demonstrate high sensitivity and specificity to accurately differentiate between patients with varying levels of risk, particularly in identifying those at high risk for major adverse cardiovascular events. Simultaneously, an ideal scoring system should also be able to compute information for other non-coronary etiologies of chest pain that require time-sensitive interventions and workups (eg, aortic dissection and pulmonary embolism). In this review, we have assembled major risk scores used for risk stratification in patients with acute chest pain in ED. We have abbreviated their salient features to assist readers in their clinical decision-making.

Case-control analysis of venous thromboembolism risk in non-alcoholic steatohepatitis diagnosed by transient elastography.

BACKGROUND: Nonalcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease worldwide. Studies have shown a strong association between non-alcoholic steatohepatitis (NASH) cirrhosis and portal vein thrombosis. Specifically, there is paucity of data on the association of NASH and venous thromboembolism (VTE), with one such study predicting a 2.5-fold increased risk for VTE compared to other liver diseases in hospitalized patients. The mechanism is believed to be a hepatocellular injury, which causes a chronic inflammatory state leading to the unregulated activation of procoagulant factors. There has been no prior analysis of the degree of steatosis and fibrosis (measured using transient elastography, commonly known as FibroScan) in NASH and its association with VTE. AIM: To examine the association between the degree of hepatic steatosis and fibrosis, quantified by transient elastography, and the incidence of VTE in patients with NASH. METHODS: In our case-control study, we included patients with a documented diagnosis of NASH. We excluded patients with inherited thrombophilia, hemoglobinopathy, malignancy, alcohol use disorder, autoimmune hepatitis, and primary biliary cirrhosis. The collected data included age, demographics, tobacco use, recreational drug use, medical history, and vibration controlled transient elastography scores. VTE-specific data included the location, type of anticoagulant, need for hospital stay, and history of VTE recurrence. Steatosis was categorized as S0-S1 (mild) and S2-S3 (moderate to severe) based on the controlled attenuation parameter score. Fibrosis was classified based on the kilopascal score and graded as F0-F1 (Metavir stage), F2, F3, and F4 (cirrhosis). χ2 and Mann-Whitney U tests were used for the qualitative and quantitative variable analyses, respectively. Furthermore, we performed a logistic regression using VTE as the dependent variable. RESULTS: A total of 415 patients were analyzed, and 386 met the inclusion criteria. 51 and 335 patients were included in the VTE and non-VTE groups, respectively. Patients with VTE had a mean age of 60.63 years compared to 55.22 years in the non-VTE group (P < 0.014). Patients with VTE had a higher body mass index (31.14 kg/m² vs 29.30 kg/m²) and a higher prevalence of diabetes mellitus (29.4% vs 13.1%). The history of NASH was significantly higher in the VTE group (45.1% vs 30.4%, P < 0.037). Furthermore, moderate-to-severe steatosis was significantly higher in the VTE group (66.7% vs 47.2%, P < 0.009). Similarly, the F2-F4 fibrosis grade had a prevalence of 58.8% in the VTE group compared to 38.5% in the non-VTE group (P < 0.006). On logistic regression, using VTE as a dependent variable, diabetes mellitus had an odds ratio (OR) =1.702 (P < 0.015), and F2-F4 fibrosis grade had an OR = 1.5 (P < 0.033). CONCLUSION: Our analysis shows that NASH is an independent risk factor for VTE, especially deep vein thrombosis. There was a statistically significant association between the incidence of VTE, moderate-to-severe steatosis, and fibrosis. All hospitalized patients should be considered for medical thromboprophylaxis, particularly those with NASH.

Influence of nonalcoholic fatty liver disease on inflammatory bowel disease hospitalizations in the United States.

Background: The reported prevalence of nonalcoholic fatty liver disease (NAFLD) in patients with inflammatory bowel disease (IBD) is 32%. We assessed the influence of NAFLD on IBD hospitalizations in the United States (US). Methods: We utilized the National Inpatient Sample database, from 2016-2019, to identify the total IBD hospitalizations in the US and we further subdivided them according to the presence or absence of NAFLD. Hospitalization characteristics, comorbidities and outcomes were compared. Statistical significance was set at P<0.05. Results: There were 1,272,260 IBD hospitalizations in the US, of which 5.04% involved NAFLD. For IBD hospitalizations with NAFLD, the mean age was 50-64 years, and the proportion of males was 46.97%. IBD hospitalizations with NAFLD had a lower proportion of African Americans (8.7% vs. 11.38%, P<0.001). Comorbidities such as hypertension (50.34% vs. 44.04%, P<0.001) and obesity (18.77% vs. 11.81%, P<0.001) were significantly higher in the NAFLD cohort. Overall, based on the Charlson Comorbidity Index, patients with NAFLD had a higher number of comorbidities (52.77% vs. 20.66%, P<0.001). Mortality was higher in the NAFLD compared to the non-NAFLD cohort (3.14% vs. 1.44%, P<0.001). Patients with NAFLD also incurred significantly higher hospital charges ($69,536 vs. $55,467, p<0.001) and had a longer mean length of stay (6.10 vs. 5.27 days, P<0.001) compared to the cohort without NAFLD. Complications and inpatient procedure requirements were also higher in the NAFLD cohort. Conclusion: Our study revealed greater mortality, morbidity, and healthcare resource utilization in patients with IBD who were hospitalized with a concomitant diagnosis of NAFLD.

Virtual patient education for hypertension: The truth about behavioral change.

Anti-hypertensive education is an important public health intervention to decrease the mortality and burden of the disease. Using digital technologies for education as a part of preventive measures for hypertension is a cost-effective approach and helps low-income communities and vulnerable populations overcome barriers to healthcare access. The coronavirus disease 19 pandemic further highlighted the need of new health interventions to address health inequalities. Virtual education is helpful to improve awareness, knowledge, and attitude toward hypertension. However, given the complexity of behavioral change, educational approaches do not always provide a change in behavior. Some of the obstacles in online hypertensive education could be time limitations, not being tailored to individual needs and not including the different elements of behavioral models to enhance behavior change. Studies regarding virtual education should be encouraged and involve lifestyle modifications emphasizing the importance of Dietary Approaches to Stop Hypertension diet, salt restriction, and exercise and should be used adjunct to in-person visits for the management of hypertension. Additionally, to stratify patients according to hypertension type (essential or secondary) would be useful to create specific educational materials. Virtual hypertension education is promising to increase awareness regarding risk factors and most importantly motivate patients to be more compliant with management helping to decrease hypertension related complications and hospitalizations.

New scoring system for acute chest pain risk stratification: Is it worth SVEAT-ing it?

The emergency room is a very potent environment in the hospital. With the growing demands of the population, improved accessibility to health resources, and the onslaught of the triple pandemic, it is extremely crucial to triage patients at presentation. In the spectrum of complaints, chest pain is the commonest. Despite it being a daily ailment, chest pain brings concern to every physician at first. Chest pain could span from acute coronary syndrome, pulmonary embolism, and aortic dissection (all potentially fatal) to reflux, zoster, or musculoskeletal causes that do not need rapid interventions. We often employ scoring systems such as GRACE/PURSUIT/TIMI to assist in clinical decision-making. Over the years, the HEART score became a popular and effective tool for predicting the risk of 30-d major adverse cardiovascular events. Recently, a new scoring system called SVEAT was developed and compared to the HEART score. We have attempted to summarize how these scoring systems differ and their generalizability. With an increasing number of scoring systems being introduced, one must also prevent anchorage bias; i.e., tools such as these are only diagnosis-specific and not organ-specific, and other emergent differential diagnoses must also be kept in mind before discharging the patient home without additional workup.

Hyperglycemia in COVID-19 infection without diabetes mellitus: Association with inflammatory markers.

BACKGROUND: New onset hyperglycemia is common in patients with severe coronavirus disease 2019 (COVID-19) infection. Cytokine storm due to COVID-19 infection is an essential etiology for new-onset hyperglycemia, but factors like direct severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-induced pancreatic ß-cell failure have also been postulated to play a role. AIM: We plan to investigate further the mechanisms underlying SARS-CoV-2 infection-induced hyperglycemia, particularly the rationale of the cytokine-induced hyperglycemia hypothesis, by evaluating the association between inflammatory markers and new onset hyperglycemia in non-diabetic patients with COVID-19 infection. METHODS: We conducted a retrospective case-control study on adults without diabetes mellitus hospitalized for COVID-19 infection. The serum levels of glucose and inflammatory markers at presentation before initiation of corticosteroid were collected. Hyperglycemia was defined as glucose levels ≥ 140 mg/dL. C-Reactive protein (CRP) ≥ 100 mg/L, ferritin ≥ 530 ng/mL, lactate dehydrogenase (LDH) ≥ 590 U/L, and D-dimer ≥ 0.5 mg/L were considered elevated. We used the χ 2 test for categorical variables and the Mann-Whitney U test for continuous variables and calculated the logistic regression for hyperglycemia. RESULTS: Of the 520 patients screened, 248 met the inclusion criteria. Baseline demographics were equally distributed between patients with hyperglycemia and those who were normoglycemic. Serum inflammatory markers in patients with or without new-onset hyperglycemia were elevated as follows: CRP (58.1% vs 65.6%, P = 0.29), ferritin (48.4% vs 34.9%, P = 0.14), D-dimer (37.1% vs 37.1%, P = 0.76) and LDH (19.4% vs 11.8%, P = 0.02). Logistic regression analysis showed LDH odds ratio (OR) = 1.623 (P = 0.256). We observed significantly higher mortality (24.2% vs 9.1%, P = 0.001; OR = 2.528, P = 0.024) and length of stay (8.89 vs 6.69, P = 0.026) in patients with hyperglycemia. CONCLUSION: Our study showed no association between CRP, ferritin, LDH, D-dimer levels, and new-onset hyperglycemia in non-diabetic patients with COVID-19 infection. It also shows an increased mortality risk and length of stay in patients with hyperglycemia. With new-onset hyperglycemia being closely associated with poor prognostic indices, it becomes pivotal to understand the underlying pathophysiological mechanisms behind the SARS-CoV-2 infection-induced hyperglycemia. We conclude that the stress hyperglycemia hypothesis is not the only mechanism of SARS-CoV-2 infection-induced hyperglycemia but rather a multicausal pathogenesis leading to hyperglycemia that requires further research and understanding. This would help us improve not only the clinical outcomes of COVID-19 disease and inpatient hyperglycemia management but also understand the long-term effects of SARS-CoV-2 infection and further management.

Influence of non-alcoholic fatty liver disease on non-variceal upper gastrointestinal bleeding: A nationwide analysis.

BACKGROUND: Non-alcoholic fatty liver disease (NAFLD) is the leading cause of liver disease globally with an estimated prevalence of 25%, with the clinical and economic burden expected to continue to increase. In the United States, non-variceal upper gastrointestinal bleeding (NVUGIB) has an estimated incidence of 61-78 cases per 100000 people with a mortality rate of 2%-15% based on co-morbidity burden. AIM: To identify the outcomes of NVUGIB in NAFLD hospitalizations in the United States. METHODS: We utilized the National Inpatient Sample from 2016-2019 to identify all NVUGIB hospitalizations in the United States. This population was divided based on the presence and absence of NAFLD. Hospitalization characteristics, outcomes and complications were compared. RESULTS: The total number of hospitalizations for NVUGIB was 799785, of which 6% were found to have NAFLD. NAFLD and GIB was, on average, more common in younger patients, females, and Hispanics than GIB without NAFLD. Interestingly, GIB was less common amongst blacks with NAFLD. Multivariate logistic regression analysis was conducted, controlling for the multiple covariates. The primary outcome of interest, mortality, was found to be significantly higher in patients with NAFLD and GIB [adjusted odds ratio (aOR) = 1.018 (1.013-1.022)]. Secondary outcomes of interest, shock [aOR = 1.015 (1.008-1.022)], acute respiratory failure [aOR = 1.01 (1.005-1.015)] and acute liver failure [aOR = 1.016 (1.013-1.019)] were all more likely to occur in this cohort. Patients with NAFLD were also more likely to incur higher total hospital charges (THC) [$2148 ($1677-$2618)]; however, were less likely to have a longer length of stay [0.27 d (0.17-0.38)]. Interestingly, in our study, the patients with NAFLD were less likely to suffer from acute myocardial infarction [aOR = 0.992 (0.989-0.995)]. Patients with NAFLD were not more likely to suffer acute kidney injury, sepsis, blood transfusion, intubation, or dialysis. CONCLUSION: NVUGIB in NAFLD hospitalizations had higher inpatient mortality, THC, and complications such as shock, acute respiratory failure, and acute liver failure compared to those without NAFLD.

Detection of colorectal adenomas using artificial intelligence models in patients with chronic hepatitis C.

BACKGROUND: Hepatitis C virus is known for its oncogenic potential, especially in hepatocellular carcinoma and non-Hodgkin lymphoma. Several studies have shown that chronic hepatitis C (CHC) has an increased risk of the development of colorectal cancer (CRC). AIM: To analyze this positive relationship and develop an artificial intelligence (AI)-based tool using machine learning (ML) algorithms to stratify these patient populations into risk groups for CRC/adenoma detection. METHODS: To develop the AI automated calculator, we applied ML to train models to predict the probability and the number of adenomas detected on colonoscopy. Data sets were split into 70:30 ratios for training and internal validation. The Scikit-learn standard scaler was used to scale values of continuous variables. Colonoscopy findings were used as the gold standard and deep learning architecture was used to train six ML models for prediction. A Flask (customizable Python framework) application programming interface (API) was used to deploy the trained ML model with the highest accuracy as a web application. Finally, Heroku was used for the deployment of the web-based API to https://adenomadetection.herokuapp.com. RESULTS: Of 415 patients, 206 had colonoscopy results. On internal validation, the Bernoulli naive Bayes model predicted the probability of adenoma detection with the highest accuracy of 56%, precision of 55%, recall of 55%, and F1 measure of 54%. Support vector regressor predicted the number of adenomas with the least mean absolute error of 0.905. CONCLUSION: Our AI-based tool can help providers stratify patients with CHC for early referral for screening colonoscopy. Along with providing a numerical percentage, the calculator can also comment on the number of adenomatous polyps a gastroenterologist can expect, prompting a higher adenoma detection rate.

Use of inflammatory markers as predictor for mechanical ventilation in COVID-19 patients with stages IIIb-V chronic kidney disease?

BACKGROUND: Studies have shown elevated C-reactive protein (CRP) to predict mechanical ventilation (MV) in patients with coronavirus disease 2019 (COVID-19). Its utility is unknown in patients with chronic kidney disease (CKD), who have elevated baseline CRP levels due to chronic inflammation and reduced renal clearance. AIM: To assess whether an association exists between elevated inflammatory markers and MV rate in patients with stages IIIb-V CKD and COVID-19. METHODS: We conducted a retrospective cohort study on patients with COVID-19 and stages IIIb-V CKD. The primary outcome was the rate of invasive MV, the rate of noninvasive MV, and the rate of no MV. Statistical analyses used unpaired t-test for continuous variables and chi-square analysis for categorical variables. Cutoffs for variables were CRP: 100 mg/L, ferritin: 530 ng/mL, D-dimer: 0.5 mg/L, and lactate dehydrogenase (LDH): 590 U/L. RESULTS: 290 were screened, and 118 met the inclusion criteria. CRP, D-dimer, and ferritin were significantly different among the three groups. On univariate analysis for invasive MV (IMV), CRP had an odds ratio (OR)-5.44; ferritin, OR-2.8; LDH, OR-7.7; D-dimer, OR-3.9, (P < 0.05). The admission CRP level had an area under curve-receiver operator characteristic (AUROC): 0.747 for the IMV group (sensitivity-80.8%, specificity-50%) and 0.663 for the non-IMV (NIMV) group (area under the curve, sensitivity-69.2%, specificity-53%). CONCLUSION: Our results demonstrate a positive correlation between CRP, ferritin, and D-dimer levels and MV and NIMV rates in CKD patients. The AUROC demonstrates a good sensitivity for CRP levels in detecting the need for MV in patients with stages IIIb-V CKD. This may be because of the greater magnitude of increased inflammation due to COVID-19 itself compared with increased inflammation and reduced clearance due to CKD alone.

Assessment of Predictive Factors of Hepatic Steatosis Diagnosed by Vibration Controlled Transient Elastography (VCTE) in Chronic Hepatitis C Virus-Infected Patients.

This retrospective, cross-sectional study aimed to evaluate the predictive factors of moderate/severe hepatic steatosis diagnosed by vibration-controlled transient elastography (VCTE). It included 158 adult patients with suspected nonalcoholic fatty liver disease (NAFLD) evaluated by VCTE in an outpatient setting of a community-based teaching hospital. Patients with significant alcohol consumption, oral contraceptive use, hepatitis B disease, autoimmune hepatitis, and primary biliary cirrhosis were excluded. Steatosis was categorized as S0-S1 (mild) and S2-S3 (moderate/severe) based on the controlled attenuation parameter (CAP) score. Results demonstrated the mean values of BMI (p = 0.001), kiloPascals [kPa] (fibrosis) raw score (p = 0.009), obesity (p = 0.001), diabetes mellitus [DM] (p = 0.014), and comorbidities status [chronic hepatitis C(HCV), DM, obesity, HCV+DM] (p = 0.028) were significantly different between the two arms of the study viz. S0-S1 (mild) and S2-S3 (moderate/severe). A multinomial logistic regression analysis of the comorbidities associated with hepatic steatosis revealed a good level of prediction (R2-0.584) for hepatic steatosis. Of all the variables analyzed, obesity was the most impactful vavriable. Furthermore, the -2 log-likelihood of the regressed model in patients with HCV and hepatic steatosis did not show a significant correlation when adjusted for obesity. Obesity had a significant independent association with steatosis (chi-square value = 52, df = 12). Interestingly, DM independently predicted a weak association with steatosis (chi-square value = 0.825, df = 3). In conclusion, our study demonstrates that hepatic steatosis is independently associated with metabolic parameters like obesity and DM. Management of these risk factors in patients with HCV may be vital to reducing the risk of steatosis and progression to fibrosis.

A Case-Control Study of Distinguishing Between Stroke Mimics and True Strokes.

This study was conducted with the primary aim to distinguish patients with a true stroke versus a stroke mimic based on clinical features and imaging. We conducted a retrospective case-control study on 116 adult patients who received alteplase (tPA) to treat acute stroke at our hospital. We further analyzed 79 patients with a normal computed tomography angiography (CTA). Based on their magnetic resonance imaging (MRI) of the brain, they were divided into cases (stroke mimics) and controls (true strokes). Data were collected retrospectively by reviewing individual medical charts on the electronic medical record (EMR), including age, gender, history of stroke, seizure, hypertension, diabetes, atrial fibrillation, hyperlipidemia, presenting NIH Stroke Scale/Score, hemorrhagic conversion, history of migraine, history of depression, sidedness of symptoms and aphasia. Data were categorized to separate those who were later diagnosed to be stroke mimics by being-postictal, encephalopathic, in acute migraine, suffered post-stroke recrudescence (PSR) due to metabolic insult, or had conversion disorder when symptoms could not be attributed to any medical condition or mental illness. Of the 79 study subjects, 48 (60%) were stroke mimics. The mean age of the cohort was 68.67 years, and 46.8% of the study subjects were females. Based on the multivariate logistic regression analysis, factors associated with being a stroke mimic were older age, history of migraine, and a history of prior stroke. In conclusion, increased attention to history and clinical examination as the first step can aid in the proper diagnosis of strokes versus stroke mimics. Identifying stroke mimics early could help expedite hospital workup and prevent inadvertent investigations, reducing hospital occupancy during the ongoing COVID-19 pandemic. We could potentially avoid the administration of tPA to such patients, reducing both the cost and adverse effects of it. Every stroke can cause neurological deficits, but every deficit need not be a stroke.

Retrospective analysis of aspirin's role in the severity of COVID-19 pneumonia.

BACKGROUND: Since December 2019, an outbreak of pneumonia caused by severe acute respiratory syndrome - coronavirus-2 (SARS-CoV-2) has led to a life-threatening ongoing pandemic worldwide. A retrospective study by Chow et al showed aspirin use was associated with decreased intensive care unit (ICU) admissions in hospitalized coronavirus disease 2019 (COVID-19) patients. Recently, the RECOVERY TRIAL showed no associated reductions in the 28-d mortality or the progression to mechanical ventilation of such patients. With these conflicting findings, our study was aimed at evaluating the impact of daily aspirin intake on the outcome of COVID-19 patients. AIM: To study was aimed at evaluating the impact of daily aspirin intake on the outcome of COVID-19 patients. METHODS: This retrospective cohort study was conducted on 125 COVID-19 positive patients. Subgroup analysis to evaluate the association of demographics and comorbidities was undertaken. The impact of chronic aspirin use was assessed on the survival outcomes, need for mechanical ventilation, and progression to ICU. Variables were evaluated using the chi-square test and multinomial logistic regression analysis. RESULTS: 125 patients were studied, 30.40% were on daily aspirin, and 69.60% were not. Cross-tabulation of the clinical parameters showed that hypertension (P = 0.004), hyperlipidemia (0.016), and diabetes mellitus (P = 0.022) were significantly associated with aspirin intake. Regression analysis for progression to the ICU, need for mechanical ventilation and survival outcomes against daily aspirin intake showed no statistical significance. CONCLUSION: Our study suggests that daily aspirin intake has no protective impact on COVID-19 illness-associated survival outcomes, mechanical ventilation, or progression to ICU level of care.

Glycogen hepatopathy in type-1 diabetes mellitus: A case report.

BACKGROUND: It has been studied that fluctuating glucose levels may superimpose glycated hemoglobin in determining the risk for diabetes mellitus (DM) complications. While non-alcoholic steatohepatitis (NASH) remains a predominant cause of elevated transaminases in Type 2 DM due to a strong underplay of metabolic syndrome, Type 1 DM can contrastingly affect the liver in a direct, benign, and reversible manner, causing Glycogen hepatopathy (GH) - with a good prognosis. CASE SUMMARY: A 50-year-old female with history of poorly controlled type 1 DM, status post cholecystectomy several years ago, and obesity presented with nausea, vomiting, and abdominal pain. Her vitals at the time of admission were stable. On physical examination, she had diffuse abdominal tenderness. Her finger-stick glucose was 612 mg/dL with elevated ketones and low bicarbonate. Her labs revealed abnormal liver studies: AST 1460 U/L, ALP: 682 U/L, ALP: 569 U/L, total bilirubin: 0.3mg/dL, normal total protein, albumin, and prothrombin time/ international normalized ratio (PT/INR). A magnetic resonance cholangiopancreatography (MRCP) demonstrated mild intra and extra-hepatic biliary ductal dilation without evidence of choledocholithiasis. She subsequently underwent a diagnostic ERCP which showed a moderately dilated CBD, for which a stent was placed. Studies for viral hepatitis, Wilson's Disease, alpha-1-antitrypsin, and iron panel came back normal. Due to waxing and waning transaminases during the hospital course, a liver biopsy was eventually done, revealing slightly enlarged hepatocytes that were PAS-positive, suggestive of glycogenic hepatopathy. With treatment of hyperglycemia and ensuing strict glycemic control, her transaminases improved, and she was discharged. CONCLUSION: With a negative hepatocellular and cholestatic work-up, our patient likely had GH, a close differential for NASH but a poorly recognized entity. GH, first described in 1930 as a component of Mauriac syndrome, is believed to be due to glucose and insulin levels fluctuation. Dual echo magnetic resonance imaging sequencing and computed tomography scans of the liver are helpful to differentiate GH from NASH. Still, liver biopsy remains the gold standard for diagnosis. Biopsy predominantly shows intra-cellular glycogen deposition, with minimal or no steatosis or inflammation. As GH is reversible with good glycemic control, it should be one of the differentials in patients with brittle diabetes and elevated transaminases. GH, however, can cause a dramatic elevation in transaminases (50-1600 IU/L) alongside hepatomegaly and abdominal pain that would raise concern for acute liver injury leading to exhaustive work-up, as was in our patient above. Fluctuation in transaminases is predominantly seen during hyperglycemic episodes, and proper glycemic control is the mainstay of the treatment.

COVID-19 and Outcomes in Patients With Inflammatory Bowel Disease: Systematic Review and Meta-Analysis.

BACKGROUND: Our understanding of coronavirus disease 2019 (COVID-19) and its implications for patients with inflammatory bowel diseases (IBD) is rapidly evolving. We performed a systematic review and meta-analysis to investigate the epidemiology, clinical characteristics, and outcomes in IBD patients with COVID-19. METHODS: We searched PubMed, EMBASE, Cochrane Central, Clinicaltrials.gov, Web of Science, MedRxiv, and Google Scholar from inception through October 2020. We included studies with IBD patients and confirmed COVID-19. Data were collected on the prevalence, patient characteristics, pre-infection treatments for IBD, comorbidities, hospitalization, intensive care unit (ICU), admission, and death. RESULTS: Twenty-three studies with 51,643 IBD patients and 1449 with COVID-19 met our inclusion criteria. In 14 studies (n = 50,706) that included IBD patients with and without COVID-19, the prevalence of infection was 1.01% (95% confidence interval [CI], 0.92-1.10). Of IBD patients with COVID-19, 52.7% had Crohn's disease, 42.2% had ulcerative colitis, and 5.1% had indeterminate colitis. Nine studies (n = 687) reported outcomes according to IBD therapy received. Compared with patients on corticosteroids, those on antitumor necrosis factor (anti-TNF) therapy had a lower risk of hospitalization (risk ratio [RR], 0.24; 95% CI, 0.16-0.35; P < .01; I2 = 0%) and ICU admission (RR, 0.10; 95% CI, 0.03-0.37; P < .01) but not death (RR, 0.16; 95% CI, 0.02-1.71; P = .13; I2 = 39%). Compared with patients on mesalamine, those on antitumor necrosis factor therapy had a lower risk of hospitalizations (RR, 0.37; 95% CI, 0.25-0.54), ICU admissions (RR, 0.20; 95% CI, 0.07-0.58), and death (0.21; 95% CI, 0.04-1.00). Comparing patients on immunomodulators vs mesalamine or anti-TNF therapy, there was no difference in these outcomes. CONCLUSIONS: The prevalence of COVID-19 in IBD patients was low. Use of corticosteroids or mesalamine was significantly associated with worse outcomes, whereas use of anti-TNFs was associated with more favorable outcomes. Further investigation clarifying the mechanisms of these disparate observations could help identify risk and adverse outcome-mitigating strategies for patients with IBD.