Prevalence of hepatic steatosis and fibrosis in Turner syndrome: A prospective case-control study.

BACKGROUND AND AIMS: Abnormal liver chemistries are common in Turner syndrome (TS). Guidelines suggest that TS patients undergo annual screening of liver enzymes, but the role of non-invasive screening for steatosis and fibrosis is not clearly defined. We compared the prevalence of hepatic steatosis and fibrosis among TS patients to healthy controls using ultrasound with shear-wave elastography (SWE) and assessed for risk factors associated with steatosis and fibrosis in TS. METHODS: Prospective case-control study of TS versus control patients from 2019 to 2021. All patients underwent abdominal ultrasound with doppler and SWE to assess hepatic fibrosis and steatosis. Risk factors were compared between TS and controls, as well as within the TS group. RESULTS: A total of 55 TS and 50 control patients were included. Mean age was 23.6 years vs. 24.6 years in the control group (p = .75). TS patients had significantly more steatosis (65% vs. 12%, stage 1 vs. 0, p < .0001) and fibrosis (39% vs. 2%, average Metavir F2 vs. F0, p < .00001) than controls. These findings remained significant after adjusting for body mass index (BMI) (p < .01). GGT is more sensitive than AST or ALT in identifying these changes. CONCLUSION: TS is associated with an increased prevalence of hepatic steatosis and fibrosis compared to healthy controls. Our findings suggest that serum GGT and ultrasound with SWE may help identify TS patients with liver disease. Early risk factor mitigation including timely oestrogen replacement, weight control, normalization of lipids and promoting multidisciplinary collaboration should be encouraged.

A Prospective Multimodal Education Intervention for Providers Does Not Increase Hepatic Encephalopathy Treatment Rates.

BACKGROUND: Over 50% of hospitalizations from hepatic encephalopathy (HE) are preventable, but patients often do not receive medical treatment. AIMS: To use a multimodal education intervention (MMEI) to increase HE treatment rates and to evaluate (1) trends in HE treatment, (2) predictors of receiving treatment, and (3) the impact of treatment on hospitalization outcomes. METHODS: Prospective single-center cohort study of patients hospitalized with HE from April 1, 2020-September 30, 2022. The first 15 months were a control ("pre-MMEI"), the subsequent 15 months (MMEI) included three phases: (1) prior authorization resources, (2) electronic order set, and (3) in-person provider education. Treatment included receiving any drug (lactulose or rifaximin), or combination therapy. Treatment rates pre- vs. post-MMEI were compared using logistic regression. RESULTS: 471 patients were included. There were lower odds of receiving any drug post-MMEI (p = 0.03). There was no difference in receiving combination therapy pre- or post-MMEI (p = 0.32). Predictors of receiving any drug included alcohol-related or cryptogenic cirrhosis (p's < 0.001), and the presence of ascites (p = 0.005) and/or portal hypertension (p = 0.003). The only significant predictor of not receiving any drug treatment was having autoimmune cirrhosis (p < 0.001). Patients seen by internal medicine (p = 0.01) or who were intoxicated (p = 0.02) were less likely to receive rifaximin. Any treatment was associated with higher 30-day liver disease-specific readmission (p < 0.001). CONCLUSION: This MMEI did not increase HE treatment rates, suggesting that alternative strategies are needed to identify and address barriers to treatment.

Racial and Gender Disparities Among Obese Patients With Pancreatic Cancer: A Trend Analysis in the United States.

BACKGROUND: Pancreatic cancer (PC) is the third leading cause of cancer death. Obesity can increase the risk of PC by up to 50%. Studies have shown racial and gender disparities in PC, however, there is a paucity of such information in obese PC patients. AIM: The aim of this study was to: (1) evaluate the incidence and prevalence of obesity among PC patients in the United States over the last 15 years, and (2) determine if variation exists in the demographic of obese PC patients over the last 15 years. It is hoped that this information could be used to assist in primary prevention and early detection of PC. METHODS: A population-based retrospective analysis in IBM Explorys, a pooled, national, deidentified database of 63 million patients from 300 hospitals in the United States. Patient populations were identified using SNOMED and ICD codes. Cochrane-Armitage testing was performed to analyze trends in obesity among PC. Subgroup analysis for gender, age, race, and mortality rate were assessed. RESULTS: The percentage of obese patients with PC increased over the 15-year period (2.5% to 8.5%, P <0.0001). Rates of obesity among PC patients increased among females ( P =0.0004), individuals under age 65 years ( P =0.0002), and all races, but especially for African Americans ( P =0.0007) and those in minority groups. CONCLUSION: Awareness of disparities in PC and applying targeted care to those at increased risk are essential to improve future outcomes, including increased health care access and recruitment in research studies for minority groups.

Mortality Increased Among Hospitalized Patients with Cirrhosis Before and Following Different Waves of the COVID-19 Pandemic.

BACKGROUND: The Coronavirus disease 2019 (COVID-19) pandemic disrupted patient care and worsened the morbidity and mortality of some chronic diseases. The impact of the COVID-19 pandemic on hospitalizations and outcomes in patients with cirrhosis both before and during different time periods of the pandemic has not been evaluated. AIMS: Describe characteristics of hospitalized patients with cirrhosis and evaluate inpatient mortality and 30-day readmission before and after the start of the COVID-19 pandemic. METHODS: Retrospective single-center cohort study of all hospitalized patients with cirrhosis from 2018 to 2022. Time periods within the COVID-19 pandemic were defined using reference data from the World Health Organization and Centers for Disease Control. Adjusted odds ratios from logistic regression were used to assess differences between periods. RESULTS: 33,926 unique hospitalizations were identified. Most patients were over age 60 years across all time periods of the pandemic. More Hispanic patients were hospitalized during COVID-19 than before COVID-19. Medicare and Medicaid are utilized less frequently during COVID-19 than before COVID-19. After controlling for age and gender, inpatient mortality was significantly higher during all COVID-19 periods except Omicron compared to before COVID-19. The odds of experiencing a 30-day readmission were 1.2 times higher in the pre-vaccination period compared to the pre-COVID-19 period. CONCLUSION: Inpatient mortality among patients with cirrhosis has increased during the COVID-19 pandemic compared to before COVID-19. Although COVID-19 infection may have had a small direct pathologic effect on the natural history of cirrhotic liver disease, it is more likely that other factors are impacting this population.

Illicit Drug Use and Endoscopy: When Do We Say No?

BACKGROUND: Illicit drug use (IDU) is often encountered in patients undergoing elective ambulatory surgical procedures such as endoscopy. Given the variety of systemic effects of these drugs, sedation and anesthetics are believed to increase the risk of cardiopulmonary complications during procedures. Procedural cancelations are common, regardless of the drug type, recency of use, and total dosage consumed. There is a lack of institutional and society recommendations regarding the optimal approach to performing outpatient endoscopy on patients with IDU. AIM: To review the literature for current recommendations regarding the optimal management of outpatient elective endoscopic procedures in patients with IDU. Secondary aim is to provide guidance for clinicians who encounter IDU in endoscopic practice. METHODS: Systematic review of PubMed, CINAHL, Embase, and Google Scholar for articles presenting data on outcomes of elective procedures in patients using illicit drugs. RESULTS: There are no clinically relevant differences in periprocedural complications or mortality in cannabis users compared to non-users. Endoscopy in patients with remote cocaine use was also found to have similar outcomes to recent use. CONCLUSIONS: Canceling endoscopic procedures in patients with recent IDU without consideration of the type of drug, dosage, and chronicity may lead to unnecessary delays in care and increased patient morbidity. Healthcare systems would benefit from additional guidelines for evaluating the patient with recent illicit drug use for acute intoxication and consider proceeding with procedures in the non-toxic population.

Stop Blaming the Weatherman! A Retrospective Study of Endoscopy Show Rates at a Midwest Urban Safety-Net Hospital.

BACKGROUND: Weather patterns are well-known to affect human health and behavior and are often arbitrarily blamed for high no-show rates (NSRs). The NSR for outpatient gastrointestinal procedures ranges from 4% to 41% depending on the population and procedure performed. Identifying potential causes will allow for the optimization of endoscopy resource utilization. AIM: The aim of this study was to evaluate the effects of a day of the year and weather conditions have on NSRs for outpatient endoscopic procedures at a safety-net hospital in Cleveland, Ohio, United States. METHODS: A 12-month, retrospective cohort study of the NSR for outpatient endoscopic procedures was performed using local weather data from January 1, 2017 to December 31, 2017. Data was assessed by analysis of variance/t test, and the χ test was used to analyze weather impact on NSR. RESULTS: A total of 7935 patients had an average overall NSR of 11.8%. Average NSR for esophagogastroduodenoscopies (EGDs) were 9.9%, colonoscopies 12.3%, and advanced endoscopy procedures 11.1%. The NSR was highest in April (15.3%, P=0.01) and lowest in September (9.0%, P=0.04). There is a greater likelihood of procedural no-show for colonoscopies compared with EGDs when mean temperatures were at or below freezing (P=0.02) and with snowfall (P=0.03). NSR were also high for EGDs on federal holidays (25%, P=0.03) and colonoscopies on days following federal holidays (25.3%, P<0.01). Day of the week, wind speed, presence of precipitation, wind chill, the temperature change from the prior day, and temperature (high, low, and mean) had no significant impact on NSR. CONCLUSIONS: Our study demonstrates that scheduling adjustments on federal holidays, days when temperatures are below freezing, and snowfall may improve department resource utilization. These data, along with other variables that affect NSR for endoscopic procedures, should be taken into consideration when attempting to optimize scheduling and available resources in a safety-net hospital.

Clinician dashboard views and improvement in preventative health outcome measures: a retrospective analysis.

BACKGROUND: Measuring and reporting outcome data is fundamental for health care systems to drive improvement. Our electronic health record built a dashboard that allows each primary care provider (PCP) to view real-time population health quality data of their patient panel and use that information to identify care gaps. We hypothesized that the number of dashboard views would be positively associated with clinical quality improvement. METHODS: We performed a retrospective analysis of change in quality scores compared to number of dashboard views for each PCP over a five-month period (2017-18). Using the manager dashboard, we recorded the number of views for each provider. The quality scores analyzed were: colorectal cancer (CRC) screening rates and diabetic patients with an A1c greater than 9% or no A1c in the past year. RESULTS: Data from 120 PCPs were included. The number of dashboard views by each PCP ranged from 0 to 222. Thirty-one PCPs (25.8%) did not view their dashboard. We found no significant correlation between views and change in quality scores (correlation coefficient = 0.06, 95% CI [- 0.13, 0.25] and - 0.05, 95% CI [- 0.25, 0.14] for CRC and diabetes, respectively). CONCLUSION: Clinical dashboards provide feedback to PCPs and are likely to become more available as healthcare systems continue to focus on improving population health. However, dashboards on their own may not be sufficient to impact clinical quality improvement. Dashboard viewership did not appear to impact clinician performance on quality metrics.

Evaluating online patient education materials for liver cirrhosis.

BACKGROUND & AIMS: Liver cirrhosis affects 4.5 million adults in the United States (US). As more patients educate themselves online, we evaluated the accessibility, quality, understandability, accuracy, readability, and comprehensiveness (AQUA-RC) of online patient education materials for cirrhosis. METHODS: Cross-sectional analysis using Google® and YouTube® on a cleared internet browser from 12 cities across the US. The authors independently reviewed the top 25 search results from each platform using search terms "liver cirrhosis" and "cirrhosis". Accessibility was evaluated from twelve cities in six regions across the US. We evaluated resource quality using the DISCERN score, understandability using the PEMAT score, readability using the Flesch-Kinkaid score, and accuracy/comprehensiveness using a list of author-generated criteria. AQUA-RC was compared between 1) academic websites (AW) vs. non-academic websites (NAW), and 2) websites vs. YouTube® videos. RESULTS: 28 websites and 25 videos were included. Accessibility was equal across all regions. Websites had higher average quality scores than videos, although this was not statistically significant (p = 0.84). Websites were more understandable than videos (p < 0.00001). Both websites and videos were 100% accurate. Readability for websites was higher than recommended standards. Websites were more comprehensive than videos (p = 0.02). CONCLUSION: Online patient education materials for cirrhosis in the US are equally accessible, but readability and understandability are too complex. Websites are of greater quality, accuracy, and comprehensiveness than YouTube videos, which are often narrowly focused and targeted at the medical community rather than patients. Further efforts should be made to improve online patient education and expand content across platforms.

Outcomes and factors associated with cryptococcal disease among cirrhotics: A study of the national inpatient sample 2005 to 2014.

BACKGROUND: Cryptococcal disease (CD) confers a higher mortality in cirrhotic patients compared to non-cirrhotic patients. Factor association for CD in cirrhotic patients is poorly understood. Our aim was to determine the incidence, demographic, and comorbidities associated with CD among cirrhotic patients in the United States (US). METHOD: Retrospective analysis of admissions of cirrhotic patients, with or without CD, using the National Inpatient Sample (NIS) database from 2005 to 2014. The number of admissions were reported in raw and weighted frequencies. The trends of CD among cirrhotic patients and overall CD were evaluated. Rao-Scott chi-square, t-tests, and multivariate logistic regressions were performed to evaluate variables and CD among cirrhotic patients. RESULTS: There were 886,962 admissions for cirrhosis, and 164 of these with CD. By adjusted odds ratio (AOR), CD was more often associated with cirrhosis in Southern (2.95; 95 % CI 1.24, 7.02) and Western regions (4.45; 95 % CI 1.91, 10.37), Hispanic patients (1.80; 95 % CI 1.01, 3.20), and patients with chronic kidney disease (CKD) (3.13; 95 % CI 2.09, 4.69). Of note, CD in cirrhotic patients was associated with higher inpatient mortality (AOR of 3.89, 95 % CI 2.53, 5.99), longer length of stay (9.87 vs. 4.88 days), and a higher total charge ($76,880 vs. $ 37,227) when compared to cirrhotic patients without CD. DISCUSSION: Patients with cirrhosis admitted with CD have a high inpatient mortality. The geographical location and CKD were important factors associated with CD among cirrhotic patients. Autoimmune liver diseases and immunosuppression did not appear to increase the risk of CD.

A Brief Intervention on Alcohol Use Disorder Is Associated With Treatment Access for Inpatients With Alcohol-Associated Liver Disease.

BACKGROUND: Alcohol-associated liver disease (ALD) is the most common indication for liver transplantation in the United States. Alcohol use disorder (AUD) treatment is recommended in all patients with ALD and AUD, but it remains underutilized. AIMS: To identify predictors of AUD treatment and to assess 30-day readmission, return to drinking, and 1-year transplant-free survival. METHODS: Retrospective single-center cohort study of consecutive patients hospitalized with ALD and AUD between 2018 and 2020. Patients who died or were lost to follow-up at 90 days after hospitalization were excluded. AUD treatment was defined as receiving medication or participating in residential, outpatient, or support groups within 90 days of discharge. RESULTS: One hundred nine patients were included. Mean age was 51.7 years, and 63% were male. Fifty-six (51%) patients received AUD treatment, and 23 (21%) patients received more than one treatment. Predictors of AUD treatment were younger age (OR, 1.07 [95% CI, 1.04-1.12]; P < 0.001), gastroenterology/hepatology consult (AOR, 8.54 [95% CI, 2.55-39.50]; P = 0.0002), addiction psychiatry consult (AOR, 2.77 [95% CI, 1.16-6.84]; P = 0.02), and a brief AUD intervention (AOR, 18.19 [95% CI, 3.36-339.07]; P = 0.0001). Cirrhosis decompensation, MELD-Na score, and insurance status were not associated with treatment. Thirty-one patients (28.4%) were readmitted, and 29 (26.6%) remained abstinent 30 days from discharge. Patients who received treatment had improved transplant-free survival (HR, 0.44, P = 0.04). CONCLUSION: A brief intervention on AUD had the strongest association with receiving AUD treatment in our cohort. Further efforts to incorporate brief interventions when offering AUD treatment to patients with ALD may be beneficial.

You can't handle the truth! Comparing serum phosphatidylethanol to self-reported alcohol intake in chronic liver disease patients.

BACKGROUND: Serum phosphatidylethanol (PEth) testing has emerged as a promising biomarker for assessing recent alcohol consumption, surpassing the limitations of self-reported data. Limited clinical data exists comparing PEth levels and patients' reported alcohol intake. AIMS: Compare PEth testing results with self-reported alcohol intake and assesses variables associated with underreporting. METHODS: Single-center retrospective cohort of patients with a diagnosis of chronic liver disease and serum PEth. A patient's first positive PEth (>/=10 ng/mL) and self-reported alcohol consumption was used. PEth results were categorized as mild (10-20), moderate (20-200), or heavy (>200). Severity measures between self-report and PEth were assessed using Bhapkar's test and Bonferroni-adjusted McNemar's tests. Demographic data was analyzed using Chi-Square tests. RESULTS: 279 patients were included. 94 (33.7%) patients had consistency with self-report, and 185 patients had inconsistencies in their report (66.3%, p < 0.001). Of 279 patients, 161 (57.7%) underreported their alcohol consumption, and 55 (19.7%) heavy PEth patients underreported alcohol consumption as light. 58% of alcohol-related and 56.4% of non-alcohol-related cirrhotic patients underreported their alcohol use. CONCLUSION: In our cohort, only one third of self-reported alcohol consumption was consistent with the PEth level. Notably, 57.7% underreported alcohol intake. Our study reinforces the clinical importance of PEth testing as an objective clinical measure.

Chronic Inflammatory Demyelinating Polyneuropathy After Therapy With Infliximab Biosimilar.

Tumor necrosis factor-α inhibitors are monoclonal antibodies that are commonly used in the treatment of inflammatory bowel disease. A rare side effect of these biological agents is chronic inflammatory demyelinating polyneuropathy, which is a debilitating disease characterized by weakness, sensory dysfunction, and diminished or absent reflexes. We present the first reported case of chronic inflammatory demyelinating polyneuropathy after treatment with the tumor necrosis factor-α inhibitor biosimilar, infliximab-dyyp (Inflectra).

Lactated Ringer's or Normal Saline for Initial Resuscitation in Patients Hospitalized With Acute Pancreatitis: A Retrospective Database Analysis.

OBJECTIVES: Fluid resuscitation is required in acute pancreatitis (AP) to prevent hypovolemia and organ hypoperfusion. Lactated Ringer's (LR) is a buffered crystalloid with possible advantages in AP versus normal saline (NS). We aim to assess outcomes in patients hospitalized with AP based on fluid used for resuscitation. METHODS: In this retrospective analysis, we identified hospital admissions to Veterans Affairs facilities for AP from 2011 to 2017 and grouped by initial resuscitation fluid: LR versus NS. Outcomes included major complications and mortality at 30 and 365 days. Multivariable models were used to adjust for confounding variables. RESULTS: A total of 20,049 admissions were included in the study, of which 10% received LR as initial fluid. After adjustment for all available confounders, resuscitation with LR was associated with lower 1-year mortality compared with NS (adjusted odds ratio, 0.61 [95% confidence interval, 0.50-0.76]). Major complication and early mortality were similar between groups. CONCLUSIONS: In this study, we demonstrate an association between use of LR as initial resuscitation fluid and reduced 1-year mortality in a large retrospective sample of veterans hospitalized with AP. These results support the use of LR for resuscitation for most patients hospitalized with AP.

Peristalsis in an unusual place-The diagnostic utility of point-of-care ultrasound: A case report.

Complications related to inguinal hernias are commonly encountered in medicine. Clinical presentation can vary, and although diagnosis can often be made during physical examination, point-of-care ultrasound (POCUS) can be useful in cases where the diagnosis is unclear. Our case underscores to clinicians the utility of POCUS in diagnosing inguinal hernias.

Current status of liver transplantation for cholangiocarcinoma.

Cholangiocarcinoma (CCA) is the second most common liver cancer with a median survival of 12-24 mo without treatment. It is further classified based on its location into intrahepatic CCA (iCCA), perihilar CCA (pCCA), and distal CCA. Surgical resection is the mainstay of treatment, but up to 70% of these tumors are inoperable at the time of diagnosis. CCA was previously an absolute contraindication for liver transplantation (LT) due to poor outcomes primary due to early recurrent disease. However, improvement in patient selection criteria and neoadjuvant treatment protocols have improved outcomes for inoperable pCCA patients with recent studies reporting LT may improve survival in iCCA. Future advances in the treatment of CCA should include refining patient selection criteria and organ allocation for all subtypes of CCA, determining effective immunotherapies and the evolving role of personalized medicine in patients ineligible for surgical resection or LT. Our article reviews the current status of LT in CCA, along with future directions in managing patients with CCA.

Clinical efficacy, timing, and outcomes of ERCP for management of bile duct leaks: a nationwide cohort study.

Background and study aims Endoscopic retrograde cholangiopancreatography (ERCP) can safely and effectively manage postsurgical or traumatic bile duct leaks (BDLs). Standardized guidelines are lacking regarding effective management of BDLs. Our aim was to evaluate the efficacy, clinical outcomes, and complications of different ERCP techniques and intervention timing using a nationwide database. Patients and methods We performed a retrospective analysis of the IBM Explorys database (1999-2019), a pooled, national, de-identified clinical database of over 64 million unique patients across the United States. ERCP timing after BDL was classified as emergent (< 1 day), urgent (1-3 days) or expectant (> 3 days). ERCP technique was classified into sphincterotomy, stent or combination therapy. ERCP complications were defined as pancreatitis, duodenal perforation, duodenal hemorrhage, and ascending cholangitis within 7 days of the procedure. Results Expectant ERCP had a decreased risk of adverse events (AEs) compared to emergent and urgent ERCP ( P  = 0.004). Rehospitalization rates also were lower in expectant ERCP ( P  < 0.001). Patients with COPD were more likely to have an AE if the ERCP was performed emergently compared to expectantly ( P  = 0.002). Combination therapy had a lower rate of ERCP failure compared to placement of a biliary stent ( P  = 0.02). There was no statistically significant difference in rates of ERCP failure between biliary stent and sphincterotomy ( P  = 0.06) or sphincterotomy and combination therapy ( P  = 0.74). Conclusion Our study suggests that ERCP does not need to be performed emergently or urgently for management of BDLs. Combination therapy is superior to stenting or sphincterotomy; however, future prospective studies are needed to validate these findings.

Erratum: Clinical efficacy, timing, and outcomes of ERCP for management of bile duct leaks: a nationwide cohort study.

[This corrects the article DOI: 10.1055/a-1322-2425.].