The Natural History of Asymptomatic Gallstones: A Longitudinal Study and Prediction Model.

BACKGROUND & AIMS: Despite the high prevalence of asymptomatic gallstones (AGs), there are limited data on their natural history. We aimed to determine the rate of symptom development in a contemporary population, determine factors associated with progression to symptomatic gallstones (SGs), and develop a clinical prediction model. METHODS: We used a retrospective cohort design. The time to first SG was shown using Kaplan-Meier curves. Multivariable competing risk (death) regression analysis was used to identify variables associated with SGs. A prediction model for the development of SGs after 10 years was generated and calibration curves were plotted. Participants were patients with AGs based on ultrasound or computed tomography from the general medical population. RESULTS: From 1996 to 2016, 22,257 patients (51% female) with AGs were identified; 14.5% developed SG with a median follow-up period of 4.6 years. The cumulative incidence was 10.1% (±0.22%) at 5 years, 21.5% (±0.39%) at 10 years, and 32.6% (±0.83%) at 15 years. In a multivariable model, the strongest predictors of developing SGs were female gender (hazard ratio [HR], 1.50; 95% CI, 1.39-1.61), younger age (HR per 5 years, 1.15; 95% CI, 1.14-1.16), multiple stones (HR, 2.42; 95% CI, 2.25-2.61), gallbladder polyps (HR, 2.55; 95% CI, 2.14-3.05), large stones (HR, 2.03; 95% CI, 1.80-2.29), and chronic hemolytic anemia (HR, 1.90; 95% CI, 1.33-2.72). The model showed good discrimination (C-statistic, 0.70) and calibration. CONCLUSIONS: In general medical patients with AGs, symptoms developed at approximately 2% per year. A predictive model with good calibration could be used to inform patients of their risk of SGs.

Peroral endoscopic myotomy is highly effective for achalasia patients with recurrent symptoms after pneumatic dilatation.

BACKGROUND: Previous interventions in achalasia such as pneumatic dilation (PD) might lead to difficulties with peroral endoscopic myotomy (POEM) along with sub-optimal outcomes. There are limited data in the literature on outcomes of POEM after PD, especially from the western hemisphere. Hence, we aimed to determine the safety and efficacy of POEM for recurrent symptoms after PD compared to treatment naïve achalasia patients. METHODS: Medical records of achalasia patients who underwent POEM at our institution between April 2014 and October 2019 were reviewed. Patients who had POEM for recurrent symptoms after prior PD were matched at 1:2 ratio with treatment naïve achalasia patients using propensity score matching. Patients who had prior Heller myotomy were excluded. Patient demographics, Eckardt scores, timed barium swallow (TBE), high-resolution esophageal manometry (HREM), and pH study findings were compared between the two groups, pre- and 2 months post-POEM. Treatment success was defined as reduction of Eckardt score to ≤ 3. RESULTS: A total of 39 patients (prior PD = 13; treatment naïve = 26) were included. Patient demographics, procedural, and peri-procedural outcomes were similar in both groups. Treatment success was similar in both groups, 100.0% in prior PD vs 91.7% in treatment naïve group (p = 0.53). On adjusted analysis, there was no significant difference in the pre-post-POEM improvement in Eckardt scores, TBE, and HREM parameters in the two groups. Gastroesophageal reflux disease rates were also similar in both groups. CONCLUSIONS: In achalasia with recurrent symptoms after PD, POEM is a safe and highly effective treatment modality. Prior PD does not seem to influence the outcomes or efficacy of POEM.

Comparative Effectiveness of Commercial Bowel Preparations in Ambulatory Patients Presenting for Screening or Surveillance Colonoscopy.

BACKGROUND: Inadequate bowel preparation (IBP) is associated with reduced adenoma detection. However, limited research has examined the impact of different commercial bowel preparations (CBPs) on IBP and adenoma detection. We aim to determine whether type of CBP used is associated with IBP or adenoma detection. METHODS: We retrospectively evaluated outpatient, screening or surveillance colonoscopies performed in the Cleveland Clinic health system between January 2011 and June 2017. IBP was defined by the Aronchick scale. Multilevel mixed-effects logistic regression was performed to assess the association between CBP type and IBP and adenoma detection. Fixed effects were defined as demographics, comorbidities, medication use, and colonoscopy factors. Random effect of individual endoscopist was considered. RESULTS: Of 153,639 colonoscopies, 75,874 records met inclusion criteria. Median age was 54; 50% were female; 17.7% had IBP, and adenoma detection rate was 32.6%. In adjusted analyses, compared to GoLYTELY, only NuLYTELY [OR 0.66 (95% CI 0.60, 0.72)] and SuPREP [OR 0.53 (95% CI 0.40, 0.69)] were associated with reduced IBP. Adenoma detection did not vary based on the type of bowel preparation used. CONCLUSIONS: Among patients referred for screening or surveillance colonoscopy, choice of CBP was not associated with adenoma detection. Decisions about CBP should be based on other factors, such as tolerability, cost, or safety.

Trends and risk factors for 30-day readmissions in patients with acute cholangitis: analysis from the national readmission database.

INTRODUCTION: Acute cholangitis (AC) can be associated with significant mortality and high risk of readmissions, if not managed promptly. We used national readmission database (NRD) to identify trends and risk factors associated with 30-day readmissions in patients with AC. METHODS: We conducted a retrospective cohort study of adult patients admitted with AC from 2010-2014 and Q1-Q3 of 2015 by extracting data from NRD. Initial admission with a primary diagnosis of acute cholangitis (ICD-9 code: 576.1) was considered as the index admission and any admission after index admission was considered a readmission regardless of the primary diagnosis. Multivariable regression analyses were performed to assess the association. RESULTS: From 52,906 AC index admissions, overall 30-day readmission rate was 21.48% without significant differences in the readmission rates across the study period. There was significant increase in the overall hospital charges for readmissions, while a significant reduction in the death rate was observed during the first readmission. Recurrent cholangitis (14%), septicemia (6.4%), and mechanical complication of bile duct prosthesis (3%) were the most common reasons for readmissions. The risk of readmission was significantly higher in patients with pancreatic neoplasm (OR 1.6, 95% CI 1.4-1.8), those who underwent percutaneous biliary procedures (OR 1.4, 95% CI 1.2-1.6), and who had an acute respiratory failure (OR 1.2, 95% CI 1.0-1.15). Other factors contributing to increased risk of readmissions included patients with Charleston comorbidity index > 3, diabetes, and length of stay > 3 days. Readmission risk was significantly lower in patients who underwent ERCP (OR 0.80, 95% CI 0.73-0.88) or cholecystectomy (OR 0.54, 95% CI 0.43-0.69). CONCLUSIONS: AC is associated with a high 30-day readmission rate of over 21%. Patients with malignant biliary obstruction, increased comorbidities, and those who undergo percutaneous drainage rather than ERCP seem to be at the highest risk.

Management of Urinary Tract Infections in Direct to Consumer Telemedicine.

BACKGROUND: Urinary tract infections (UTI) are a common reason for seeking care via direct to consumer (DTC) telemedicine, yet patterns of care, including antibiotic prescribing, have not been reported. OBJECTIVE: To describe management of UTI in a large nationwide DTC telemedicine platform. DESIGN: Cross-sectional observational study. PARTICIPANTS: Patients seeking care for or diagnosed with UTI via DTC telemedicine between July 2016 and July 2018. MAIN MEASURES: Patient measures included age, sex, geographic region, satisfaction with care, and patient-reported call reason. High-risk patients were defined as males, patients over 65 years, or those diagnosed with pyelonephritis. Physician measures included specialty and geographic region. Antibiotic prescription was assessed overall and by antibiotic type. Variation in antibiotic prescriptions was assessed by patient and physician factors, including geographic region of both parties. KEY RESULTS: Of the 20,600 patients diagnosed with a UTI during the study period, 96% were female. Most (84%) stated their call reason was a UTI. Overall, 94% of UTI patients received an antibiotic; 56% got nitrofurantoin, 29% got trimethoprim-sulfamethoxazole, and 10% got a quinolone. Receipt of an antibiotic was associated with higher satisfaction with care (p < 0.001). While nitrofurantoin was the most common antibiotic for all physician regions, antibiotic type varied by physician region. Of the 6% of the study population defined as high risk, 69% received an antibiotic: 72% of males, 91% of women over 65, and 21% of patients diagnosed with pyelonephritis. CONCLUSIONS: Management of UTI via DTC telemedicine appears to be appropriate for average-risk patients, and most are able to self-diagnose. Most patients received guideline-concordant care, but over half of high-risk patients received antibiotics. DTC telemedicine offers convenient, low-cost care that is generally appropriate. Efforts should be made to ensure high-risk patients get proper follow-up.

The Effect of Starting the Protein-Sparing Modified Fast on Weight Change over 5 years.

BACKGROUND: Ketogenic diets have been highlighted as a way to lose weight while experiencing reduced hunger. The protein-sparing modified fast (PSMF) induces ketosis but may be difficult to maintain. OBJECTIVE: To track weight loss for individuals initiating PSMF versus all other diets (e.g., balanced, high protein) for up to 5 years. DESIGN: Retrospective cohort study PARTICIPANTS: Adults who discussed the PSMF with a clinician between 2007 and 2014 INTERVENTION: Initiating the PSMF diet versus other diets MEASURES: The main outcome was percent weight change up to 5 years. Demographic and health data were collected using electronic health records. We fit regression models including age, sex, race, insurance, new medication prescriptions, and specialist visit to identify the effect of PSMF diet on percent weight change. We grouped patients by percent weight change at each year (≥ 5% loss, 4% loss to 4% gain, ≥ 5% gain) and used Pearson χ2 tests to compare proportions. RESULTS: Of 1,403 eligible patients, 879 (63%) started the PSMF. The PSMF group was slightly younger (52 vs. 54 years, p < 0.01) and had a higher body mass index (41.9 kg/m2 vs. 40.4 kg/m2, p < 0.001). In the adjusted analysis, the PSMF group averaged 3% more weight loss than the other group over the 5-year follow-up (95% CI - 3.5, - 2.0, p < 0.001). PSMF patients lost more weight initially, but by year 4, there was no difference between diets (1.6% versus 1.3%, PSMF versus other diets, p = 0.12). Patients starting the PSMF were more likely to experience ≥ 5% weight loss at 1 year (55% vs 20%, p < 0.001) and 3 years (33% vs. 23% p < 0.05), but not 5 years (34% vs 29%, p = 0.16, PSMF versus other diets, respectively). CONCLUSIONS: In clinical practice, the PSMF achieves rapid weight loss in the first 6 months, but only a small percentage of patients maintained significant weight loss long term.

Attitudes of High Versus Low Antibiotic Prescribers in the Management of Upper Respiratory Tract Infections: a Mixed Methods Study.

IMPORTANCE: Inappropriate antibiotic use for upper respiratory tract infections (URTIs) is an ongoing problem in primary care. There is extreme variation in the prescribing practices of individual physicians, which cannot be explained by clinical factors. OBJECTIVE: To identify factors associated with high and low prescriber status for management of URTIs in primary care practice. DESIGN AND PARTICIPANTS: Exploratory sequential mixed-methods design including interviews with primary care physicians in a large health system followed by a survey. Twenty-nine physicians participated in the qualitative interviews. Interviews were followed by a survey in which 109 physicians participated. MAIN MEASURES: Qualitative interviews were used to obtain perspectives of high and low prescribers on factors that influenced their decision making in the management of URTIs. A quantitative survey was created based on qualitative interviews and responses compared to actual prescribing rates. An assessment of self-prescribing pattern relative to their peers was also conducted. RESULTS: Qualitative interviews identified themes such as clinical factors (patient characteristics, symptom duration, and severity), nonclinical factors (physician-patient relationship, concern for patient satisfaction, preference and expectation, time pressure), desire to follow evidence-based medicine, and concern for adverse effects to influence prescribing. In the survey, reported concern regarding antibiotic side effects and the desire to practice evidence-based medicine were associated with lower prescribing rates whereas reported concern for patient satisfaction and patient demand were associated with high prescribing rates. High prescribers were generally unaware of their high prescribing status. CONCLUSIONS AND RELEVANCE: Physicians report that nonclinical factors frequently influence their decision to prescribe antibiotics for URTI. Physician concerns regarding antibiotic side effects and patient satisfaction are important factors in the decision-making process. Changes in the health system addressing both physicians and patients may be necessary to attain desired prescribing levels.

Obesity Does Not Impact Outcomes or Rates of Gastroesophageal Reflux After Peroral Endoscopic Myotomy in Achalasia.

BACKGROUND: Outcomes of laparoscopic Heller myotomy in obese patients with achalasia are suboptimal along with the increased risk of gastroesophageal reflux disease (GERD). The impact of obesity on treatment success and GERD after peroral endoscopic myotomy (POEM) are not well known. Hence, our study aims were to compare the clinical outcomes and rates of GERD after POEM in nonobese versus obese patients with achalasia. METHODS: Chart review of all achalasia patients who underwent POEM at our institution between April 2014 and June 2018. Patients with timed barium esophagram (TBE) and high-resolution esophageal manometry (HREM) before POEM along with post-POEM TBE, HREM, and esophageal pH study were included. Patients were categorized into 2 groups, nonobese (body mass index <30 kg/m) and obese (body mass index ≥30 kg/m). Patient demographics, TBE, HREM, pH study findings, and Eckardt scores were compared between the 2 groups. RESULTS: A total of 89 patients (46 nonobese; 43 obese) met the study criteria. There were no significant differences in age, gender, achalasia subtype, operative time, length of stay and complication rates between the 2 groups. Treatment success (Eckardt score ≤3) was similar in both groups (97.7% nonobese vs. 92.7% obese, P=0.35). Abnormal DeMeester scores on pH study (>14.72) were similar in nonobese and obese patients (58.7% vs. 46.5%, P=0.25). Symptomatic GERD was also similar in both groups (17.8% in nonobese vs. 20% in obese, P=0.79). CONCLUSIONS: POEM is an equally safe and effective treatment option for both nonobese and obese patients with achalasia in the short-term. Interestingly, POEM does not lead to higher rates of GERD in obese compared with nonobese patients.

National trends in healthcare outcomes and utilization of endoscopic and surgical interventions in patients hospitalized with esophageal foreign body and food impaction.

The incidence and number of emergency room visits for esophageal foreign body and food impaction (EFB) are on the rise. However, its impact on the rate of inpatient admissions, utilization of endoscopic and surgical interventions, and healthcare outcomes is poorly understood. We conducted a study to analyze these outcomes using the national inpatient sample (NIS) database. Data on all adult patients (≥18 years) admitted with EFB was extracted from the NIS database from 1998 to 2013. The temporal trends in discharge rates as well as in length of stay (LOS), hospital charges, and in-hospital mortality rates were assessed by linear and polynomial regression. Average age, gender, and race of inpatients with EFB were not significantly different between 1998 and 2013. The rate of EFB admissions increased significantly from 1998 to 2005 followed by a decline thereafter (p = 0.01). LOS and hospital charges significantly increased by 0.02 days/year (p = 0.015) and $1,547/year (p < 0.001), respectively. There was a trend towards less utilization of overall esophagogastroduodenoscopy (EGD) over the last decade with significant lower use of EGD within 24 hours in 2013 as compared to 1998 (p = 0.026). The rates of surgical intervention and inpatient mortality did not change significantly over the study period. The rate of inpatient admissions for EFB is on the decline in recent years, suggesting the modern-day practice of cost-effective medicine. Hospitalization costs for EFB have increased, whereas rates of surgical intervention and inpatient mortality have not changed significantly over the study period.

Population-Based Trends in Prevalence of Nonalcoholic Fatty Liver Disease in US Adults With Type 2 Diabetes.

Type 2 diabetes (T2D) affects more than 9% of U.S. adults.1 Nonalcoholic fatty liver disease (NAFLD) has been recognized as a common co-morbidity in T2D. However, most previous epidemiologic studies have been subject to ascertainment and selection bias or had small sample sizes. No recent studies have examined trends of the burden of NAFLD in diabetic patients. Using noninvasive scores and the National Health and Nutrition Examination Survey (NHANES), we aimed to estimate the population-based trends in prevalence of NAFLD-associated comorbidities in U.S. adults with T2D.

Peroral Endoscopic Myotomy Is Effective for Patients With Achalasia and Normal Lower-Esophageal Sphincter Relaxation Pressures.

Increased lower esophageal sphincter integrated relaxation pressure (LES-IRP) is a cardinal feature of achalasia. However, some patients with characteristic features of achalasia have normal LES-IRP.1,2 The efficacy of peroral endoscopic myotomy (POEM) in achalasia patients with normal LES-IRP is not well known. Hence, we aimed to compare POEM outcomes in achalasia patients with normal (<15 mm Hg) and increased (≥15 mm Hg) LES-IRP.

Peroral endoscopic myotomy leads to higher rates of abnormal esophageal acid exposure than laparoscopic Heller myotomy in achalasia.

BACKGROUND AND AIMS: Peroral endoscopic myotomy (POEM) may be associated with higher rates of gastroesophageal reflux disease (GERD) than laparoscopic Heller's myotomy with fundoplication (LHM), since POEM is not combined with a fundoplication. However, peri-esophageal anti-reflux barriers are preserved in POEM, which might prevent GERD. Hence, we sought to compare the objective esophageal pH study findings in achalasia patients after POEM and LHM. METHODS: Achalasia patients undergoing POEM from 2014 to 2015 at our institution were matched 1:3 with LHM patients using propensity score matching. Demographics, prior interventions, pre-treatment and 2-month post-treatment timed barium esophagram (TBE), high-resolution esophageal manometry (HREM) and 24-h esophageal pH study findings were compared between the two groups. RESULTS: Thirty-one patients in the POEM group and 88 patients in the LHM group were included. Larger proportion of POEM patients had prior interventions for achalasia as compared to LHM patients (overall: 71% vs. 44.3%; p = 0.012). Esophageal acid exposure was significantly higher in POEM as compared to LHM patients (abnormal total acid exposure: 48.4% vs. 13.6%; p < 0.001, abnormal DeMeester score 54.8% vs. 17.4%; p = 0.005 respectively). In sub-group analysis, similar results were noted on 24-h pH study after exclusion of the POEM patients with prior LHM and corresponding matches. There was no significant difference in the rate of GERD symptoms between POEM and LHM. There was no significant correlation between the post-treatment basal lower esophageal sphincter pressure and integrated relaxation pressure with abnormal acid exposure in either POEM or LHM. CONCLUSIONS: In patients with achalasia, POEM leads to significantly higher rates of abnormal esophageal acid exposure, without an increase in the rate of GERD symptoms, when compared to LHM with fundoplication. Interestingly, prior LHM has no impact on post-POEM pH study findings. Potential of increased esophageal acid exposure and possible consequences should be discussed with all patients prior to POEM. Further studies are needed to determine the long-term effects of increased acid exposure after POEM.

Erratum: Use of a Novel Submucosal Tunneling and Endoscopic Resection (STER) Technique for the Removal of an Esophageal Leiomyoma.

This corrects the article DOI: 10.1038/ajg.2017.168.

Temporal trends in utilization and outcomes of endoscopic retrograde cholangiopancreatography in acute cholangitis due to choledocholithiasis from 1998 to 2012.

BACKGROUND AND AIMS: Expeditious endoscopic retrograde cholangiopancreatography (ERCP) in acute cholangitis with biliary decompression is associated with better outcomes. In this study, we evaluated the temporal trends of ERCP utilization and healthcare outcomes among patients hospitalized with acute cholangitis due to choledocholithiasis (CDC) from 1998 to 2012. METHODS: We identified patients with a combined diagnosis of cholangitis and choledocholithiasis from the national inpatient sample database. The temporal trends of ERCP usage and outcomes were analyzed. Based on timing of the procedure, we arbitrarily divided ERCPs into urgent (<24 h), early(24-48 h), and delayed ERCP(>48 h) groups. In addition, trends in length of stay (LOS), hospital charges, and in-hospital mortality rates were evaluated. RESULTS: In-patient admissions for CDC increased by 105.7%. Overall ERCP rate also increased significantly from 66.5 ± 2.3% in 1998 to 80.3 ± 0.93% in 2012, particularly after 2006-2007. There was a significant increase in proportion of urgent and early ERCPs. In the early ERCP group, there was a significant decrease in LOS (6.4 ± 0.43 days in 1998 to 5.8 ± 0.24 days in 2012) and mortality rate (2.4 ± 1.4% in 1998 to 0.33 ± 0.33% in 2012). Hospital charges increased in all ERCP groups, but most significantly in delayed ERCP group ($20,448 ± 1611 in 1998 to $90,566 ± 6122 in 2012). CONCLUSION: In-patient admissions for CDC and ERCP rates have increased significantly, particularly evident after 2006-2007. This may be attributed to increasing incidence of gallstones and wider implementation of Tokyo guidelines for the management of acute cholangitis. In-hospital morality and LOS reduced significantly in early ERCP group, whereas hospital charges increased most significantly in delayed ERCP group.