ABSTRACT
This is an important topic and an interesting paper to work through. Serum ammonia is important for the diagnosis and management of urea cycle disorders and acute liver failure. Based on the premise that serum ammonia levels are unreliable for the diagnosis of hepatic encephalopathy (HE) and not associated with the severity of HE in individuals with cirrhosis Aby and colleagues looked at serum ammonia ordering in adult patients presenting to a large mid-western healthcare system – 20 338 tests (8536 patients) over 5 years. 53% of the cohort had chronic liver disease, 8 patients had a Urea Cycle Disorder, 69 patients had Acute Liver Failure and 148 were on Sodium Valproate. Of the 20 338 tests, 1138 (6.5%) were ordered for a definitive, appropriate indication, while the remainder were felt to have been ordered inappropriately. There was no change in the proportions over time. This data has significant financial implications with hence the title – serum ammonia use: unnecessary, frequent and costly with the need to educate clinicians regarding appropriate ammonia testing - in essence when to do and when not to do – we don’t, for example, want to miss a urea cycle disorder. There is an excellent accompanying commentary Testing for ammonia: do as I say, not as we do which includes a nice table on when to test in the hospital setting (See page 275).
ABSTRACT
OBJECTIVE: Our aim was to explore the risk of infection with all classes of inflammatory bowel disease (IBD) medications and the impact of these medications on the disease course in a nationwide cohort of patients with IBD. DESIGN: This was a retrospective national cohort study of patients with IBD in the Veterans Affairs Healthcare System. We categorised IBD medication use immediately prior to the COVID-19 pandemic and used survival analysis methods to study associations with SARS-CoV-2 infection, as well as a combined secondary outcome of COVID-19 hospitalisation or COVID-19-related mortality. RESULTS: The analytical cohort of 30 911 patients was primarily male (90.9%), white (78.6%) and with ulcerative colitis (58.8%). Over a median follow-up of 10.7 months, 649 patients (2.1%) were diagnosed with SARS-CoV-2 infection and 149 (0.5%) met the combined secondary outcome. In adjusted models, vedolizumab (VDZ) use was significantly associated with infection relative to mesalazine alone (HR 1.70, 95% CI 1.16 to 2.48, p=0.006). Patients on no IBD medications had increased risk of the combined secondary outcome relative to mesalazine alone (sub-HR 1.64, 95% CI 1.12 to 2.42, p=0.01), however, no other IBD medication categories were significantly associated with this outcome, relative to mesalazine alone (each p>0.05). Corticosteroid use was independently associated with both SARS-CoV-2 infection (HR 1.60, 95% CI 1.23 to 2.09, p=0.001) and the combined secondary outcome (sub-HR 1.90, 95% CI 1.14 to 3.17, p=0.01). CONCLUSION: VDZ and corticosteroid were associated with an increased risk of SARS-CoV-2 infection. Except for corticosteroids no medications including mesalazine were associated with an increased risk of severe COVID-19.