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Background: Tofacitinib (tofa) is an oral Janus kinase inhibitor for the treatment of ulcerative colitis (UC). We compared 52 week real-world outcomes of tofa vs vedolizumab (vedo) for UC after anti-TNF failure. Method(s): In this retrospective cohort study, adults initiated tofa or vedo after failure of >=1 anti-TNF between 5/1/18 and 4/1/21 at a large U.S. medical center. Vedo patients were frequency matched to tofa patients 2:1 by age and sex. The primary outcome was steroid-free clinical remission at 12 and 52 (+/- 4) weeks (SFCR 12 and 52, simple clinical colitis activity index [SCCAI] <=2 or provider assessment and no use of oral/IV steroids for >=30 days). The secondary outcome was endoscopic response (ER) within 52 weeks (decrease in Mayo endoscopic subscore [MES] by >=1 point). Other outcomes within 52 weeks: Endoscopic remission (MES=0), biochemical response/remission (improvement by 25%/normalization of C-reactive protein), drug discontinuation for non-response (NR), improvement in arthralgia, UC hospitalization, and adverse events (AEs). Multivariable logistic regression was performed for primary/secondary outcomes adjusting for UC duration, number of prior anti-TNFs, steroid/immunomodulator use, albumin, Montreal disease extent >E1, MES = 3, and UC hospitalization within 12 months. Result(s): 136 vedo patients were matched to 68 tofa patients. Tofa patients had more anti-TNF exposures, higher CRP and SCCAI, and most had prior vedolizumab exposure (Table 1). 54% of tofa vs 46% of vedo patients achieved SFCR 12 and 59% vs 45% achieved SFCR 52. Within 52 weeks, 74% tofa vs 55% vedo had ER, 30% vs 27% had endoscopic remission, 55% vs 50% had improvement in arthralgia, 71% vs 59% had biochemical response, 46% vs 32% had biochemical remission, 5% vs 13% had UC hospitalization, 30% vs 29% discontinued treatment for NR, and 0% vs 2% discontinued treatment due to AEs (vedo group only: Perforated diverticulitis, nausea, and oral pain) (Figure 1). During available follow-up (not limited to 52 weeks), the most common AEs (reported among >1% of total cohort) included rash (0% tofa vs 4% vedo), C. difficileinfection (1% vs 2%), shingles (2% vs 1%), COVID-19 (1% vs 2%), other infection (2% vs 4%), and elevated liver enzymes (1% vs 2%) (Figure 2). After multivariable logistic regression, tofa was associated with a non-significantly higher odds of SFCR 12 (OR 1.66, 95% CI 0.77-3.62) and significantly higher odds of SFCR 52 (OR 2.15, 95% CI 1.01-4.61) and ER within 52 weeks (aOR 3.42, 95% CI 1.08- 10.80) vs vedo. Conclusion(s): Tofa was associated with higher odds of SFCR 52 and ER vs vedo for UC. AEs were consistent with known safety profiles. Due to limited sample sizes, larger cohort studies are needed.
ABSTRACT
Credit card fraud is a significant problem that is not going to go away. It is a growing problem and surged during the Covid-19 pandemic since more transactions are done without cash in hand now. Credit card frauds are complicated to distinguish as the characteristics of legitimate and fraudulent transactions are very similar. The performance evaluation of various Machine Learning (ML)-based credit card fraud recognition schemes are significantly pretentious due to data processing, including collecting variables and corresponding ML mechanism being used. One possible way to counter this problem is to apply ML algorithms such as Support Vector Machine (SVM), K nearest neighbor (KNN), Naive Bayes, and logistic regression. This research work aims to compare the ML as mentioned earlier models and its impact on credit card scam detection, especially in situations with imbalanced datasets. Moreover, we have proposed state of the art data balancing algorithm to solve data unbalancing problems in such situations. Our experiments show that the logistic regression has an accuracy of 99.91%, and naive bays have an accuracy of 97.65%. K nearest neighbor has an accuracy is 99.92%, support vector machine has an accuracy of 99.95%. The precision and accuracy comparison of our proposed approach shows that our model is state of the art. © 2021 IEEE.
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INTRODUCTION: Enterobacter species are important nosocomial pathogens. Enterobacter aerogenes is generally found in the human GI tract and does not cause disease in healthy people. We present a case of recurrent enterobacter bacteremia in a patient with hepatocellular carcinoma (HCC). CASE DESCRIPTION/METHODS: A 66 year old male with a history of hemochromatosis, HCC post chemoembolization, hepatitis C, portal vein thrombosis treated with Xarelto who presented with lower abdominal pain, vomiting, and poor oral intake for several weeks. His exam was significant for generalized abdominal tenderness. Vitals, cell counts were unremarkable and LFTs were mildly abnormal with ALP of 436 U/L. CRP was 203 mg/L. COVID-19 PCR negative. Blood cultures were 4/ 4 positive for Enterobacter aerogenes sensitive to ceftriaxone, cefepime, ertapenem and resistant to ampicillin/sulbactam and 1st and 2nd generation cephalosporins. He had been treated with ertapenem for 2 weeks for enterobacter bacteremia with unclear etiology, and the differential at this presentation included vascular infection such as thrombus or infective endocarditis. CT abdomen/ pelvis showed tumor thrombosis versus bland thrombus extending from the ablation field in into the inferior vena cava (IVC). Abdominal MRI confirmed 2.6 cm focus of signal intensity in right hepatic lobe contiguous with non occlusive IVC thrombus. TTE was negative for vegetations. Patient was discharged with 6 weeks of Ertapenem for suspicion of thrombophlebitis given the high grade recurrent bacteremia. DISCUSSION: To date there has been no major case reports or case series demonstrating a case of recurrent high grade enterobacter bacteremia with hepatocellular carcinoma. Spontaneous bacterial peritonitis caused by Enterobacter infections is more commonly associated with underlying HCC and upper gastrointestinal bleeding as compared to infection caused by E coli. For over the last two decades, there has been increasing suspicion about the induction of beta-lactam resistance in enterobacter infections mediated by chromosomally encoded amp-c beta lactamase following antibiotic exposure hence we opted to treat the patient with ertapenem for the 6 week duration. Our case demonstrates a patient with hepatocellular carcinoma with likely/presumed thrombophlebitis requiring prolonged antibiotic course.
ABSTRACT
INTRODUCTION: Although respiratory tract manifestations are most commonly reported symptoms in COVID-19, gastrointestinal system (esophagus, liver, gallbladder, pancreas and colon) is also affected by SARS-CoV-2, on the basis that they express angiotensin-converting enzyme 2 (ACE 2) receptor, the major receptor of SARS-CoV-2. We present a case of a patient with acute pancreatitis with COVID-19 infection that developed on day 6 of admission requiring a prolonged stay despite a normal respiratory status. CASE DESCRIPTION/METHODS: 68 year old male with a past medical history of hypertension, diabetes, CKD stage 3 who was a nursing home resident that tested positive for COVID-19 and was sent to ED for abnormal laboratory values. His admission labs were significant for Creatinine 6.6, BUN 77, CRP 158, Ferritin 920 and D-dimer 1.61. His creatinine improved to baseline with hydration. On day 6 of admission, he started complaining of nausea and vomiting. CT abdomen and pelvis and MRCP showed peripancreatic inflammatory changes consistent with acute pancreatitis. No biliary ductal dilatation or choledocholithiasis was seen. Lipase was 2035 along with an increase in WBC to 15.3 from 6.6. Abdominal exam was benign. His respiratory status was normal. He was managed with bowel rest and iv hydration. Gradually symptoms of nausea and vomiting improved. Diet was advanced gradually and the patient was discharged on day 19. DISCUSSION: The most common digestive symptoms reported in COVID-19 are lack of appetite, diarrhea, vomiting and abdominal pain. This was an example of a patient that had a delayed onset of GI symptoms including pancreatitis, while having normal respiratory function. Fluid hydration must be done judiciously in these patients, keeping in mind their respiratory status as it is suspected that these patients can be easily harmed by excessive fluid administration. (Figure Presented).