The Use of Glucagon-like Peptide-1 Receptor Agonists in Patients with Type 2 Diabetes Mellitus Does Not Increase the Risk of Pancreatic Cancer: A U.S.-Based Cohort Study.

BACKGROUND: GLP-1 RAs are widely used for T2DM treatment due to their cardiorenal and metabolic benefits. This study examines the risk of pancreatic cancer with GLP-1 RA use in patients with T2DM. METHODS: We analyzed TriNetX's deidentified research database using the U.S. Collaborative Network comprising 62 healthcare organizations across the U.S.A. Patients with T2DM were split into two cohorts: one receiving GLP-1 RAs, and one not receiving GLP-1 RAs. We excluded patients with known risk factors for pancreatic cancer, including pancreatic cysts, a personal or family history of BRCA1, BRCA2, CDKN2A, KRAS, MEN1, MLH1, MSH2, NOTCH1, PALB2, PMS2, and PRSS1S genes, family history of pancreatic cancer, and VHL syndrome. Using a 1:1 propensity score-matching model based on baseline characteristics and comorbidities, we created comparable cohorts. We then compared the rate of pancreatic cancer between the two cohorts at a 7-year interval. RESULTS: Out of 7,146,015 identified patients with T2DM, 10.3% were on a GLP-1 RA and 89.7% were not. Post-PSM, 721,110 patients were in each group. Patients on GLP-1 RAs had a 0.1% risk compared to a 0.2% risk of pancreatic cancer in the 7-year timeframe. CONCLUSION: The use of GLP-1 RAs in patients with type 2 diabetes mellitus (T2DM) does not appear to substantially elevate the risk of pancreatic cancer; in fact, it may potentially exert a protective effect.

Safety of DOACs in patients with Child-Pugh Class C cirrhosis and atrial fibrillation.

Background: Anticoagulation (AC) is used for stroke prevention in atrial fibrillation (AF). Direct Oral Anticoagulants (DOACs) are safe in patients with AF without cirrhosis, they are hardly studied in patients with advanced cirrhosis. Our study evaluates the safety and outcomes of DOACs in patients with Child-Pugh class C cirrhosis (CPC). Methods: We queried TriNetX Database. Patients with CPC and AF were divided into three cohorts: patients on DOACs, no AC, and warfarin. Three study arms were created using a 1:1 propensity score matching system (PSM). Results: Totally 16 029 patients met the inclusion criteria. Of those, 20.2% (n = 3235) were on DOACs, 47.1% (n = 7552) were not on AC, and 32.7% (n = 5242) were on warfarin. First arm comparing AC versus no AC, a statistically significant benefit was identified in 3-year mortality risk (47% vs 71%, P < 0.0001) and transplant status (17% vs 5%, p < 0.0001) with AC. However, no significant difference was identified regarding intracranial hemorrhage and GI bleeding risk. Second arm comparing patients on DOACs versus no AC, we identified mortality benefit (40% vs 72%, P < 0.0001) and a higher transplant rate (9% vs 3.2%, P < 0.0001) with DOACs. Intracranial hemorrhage rates (6% vs 4%, P = 0.03) were higher in patients on DOACs. Third arm comparing patients on DOACs versus Warfarin, a statistically significant lower risk of intracranial hemorrhage (6.6% vs 8.7%, P = 0.004) and GI bleed (2% vs 2.4%, P < 0.0001) were identified in patients on DOACs. Conclusion: Anticoagulation is safe in patients with CPC with AF and may provide a mortality benefit. DOACs are a safer alternative to warfarin.

The Use of Pre-Endoscopic Metoclopramide Does Not Prevent the Need for Repeat Endoscopy: A U.S. Based Retrospective Cohort Study.

BACKGROUND: Peptic ulcer disease (PUD) can cause upper gastrointestinal bleeding (UGIB), often needing esophagogastroduodenoscopy (EGD). Second-look endoscopies verify resolution, but cost concerns prompt research on metoclopramide's efficacy compared to erythromycin. METHODS: We analyzed the Diamond Network of TriNetX Research database, dividing UGIB patients with PUD undergoing EGD into three groups: metoclopramide, erythromycin, and no medication. Using 1:1 propensity score matching, we compared repeat EGD, post-EGD transfusion, and mortality within one month in two study arms. RESULTS: Out of 97,040 patients, 11.5% received metoclopramide, 3.9% received erythromycin, and 84.6% received no medication. Comparing metoclopramide to no medication showed no significant difference in repeat EGD (10.1% vs. 9.7%, p = 0.34), transfusion (0.78% vs. 0.86%, p = 0.5), or mortality (1.08% vs. 1.08%, p = 0.95). However, metoclopramide had a higher repeat EGD rate compared to erythromycin (9.4% vs. 7.5%, p = 0.003), with no significant difference in transfusion or mortality. CONCLUSIONS: The need to repeat EGD was not decreased with pre-EGD use of metoclopramide. If a prokinetic agent is to be used prior to EGD, erythromycin shows superior reduction in the need of repeat EGD as compared to metoclopramide.

Use of proton pump inhibitors improves outcomes in mild acute pancreatitis: A nationwide cohort study.

Previous studies showed a potential anti-inflammatory effect of proton pump inhibitors (PPI) as well as possible inhibition of pancreatic secretion. This presents the question of their possible use in acute pancreatitis (AP). Current clinical evidence does not address the role of PPI and the present review for possible therapeutic use and safety is lacking. Therefore, our study aims to address the role of PPI in the management of AP and their association with the different outcomes of AP. We queried the Diamond Network through TriNetX-Research Network. This network included 92 healthcare organizations. Patients with mild AP with Bedside Index of Severity in Acute Pancreatitis (BISAP) score of Zero regardless of etiology were divided into 2 cohorts; 1st cohort included patients on PPI, and 2nd cohort included patients not on any PPI. Patients with BISAP score equal to or more than 1 or on PPI prior to the study date were excluded. Two well-matched cohorts were created using 1:1 propensity-scored matching model between cohorts. We compared the incidence of intensive care unit admission, mortality, and other associated complications. A total of 431,571 patients met the inclusion criteria. Of those, 32.9% (n = 142,062) were on PPI, and 67% (n = 289,509) were not on any PPI. After propensity matching, the sample included 115,630 patients on PPI vs 115,630 patients not on PPI. The PPI group had a lower rate of mortality (3.7% vs 4.4%, P < .001), a lower rate of intensive care unit admission (3.9% vs 5.5%, P < .001), a lower rate of necrotizing pancreatitis (1.1% vs 1.9%, P < .001), a lower rate of Hospital-Acquired Pneumonia (3.6% vs 4.9%, P < .001), a lower rate of respiratory failure (2.8% vs 4.2%, P < .001), and a lower rate of acute kidney injury (6.9% vs 10.1%, P < .001). There was no statistical difference in the rate of Clostridium difficile infection between the 2 cohorts (0.9% vs 0.8%, P = .5). The use of PPI in mild AP with a BISAP-score of zero is associated with reduced pancreatitis-related complications and improved mortality. Prospective studies are needed to confirm these findings.

SARS-CoV-2 Infection Is an Independent Risk Factor for Decompensation in Cirrhosis Patients.

BACKGROUND: SARS-CoV-2 causes varied gastrointestinal symptoms. Cirrhosis patients face higher mortality rates from it, especially those with decompensated cirrhosis. This study examines SARS-CoV-2's impact on decompensation in previously compensated cirrhotic patients. METHODS: We analyzed the Global Collaborative Network, comprising 98 healthcare organizations across sixteen countries, using TriNetX's deidentified research database. Compensated cirrhosis patients were split into two groups: one with SARS-CoV-2-positive patients and another testing negative. Using a 1:1 propensity score matching model based on baseline characteristics and comorbidities, we created comparable cohorts. We then assessed decompensation, mortality, and GI bleed at 1 and 3 months. RESULTS: Out of 252,631 identified compensated cirrhosis patients, 27.3% (69,057) tested SARS-CoV-2-positive, while 72.6% (183,574) remained negative. Post PSM, 61,963 patients were in each group. SARS-CoV-2-positive patients showed significantly higher decompensation rates (4.4% vs. 1.9% at 1 month; 6% vs. 2.6% overall). Rates of complications, like ascites, SBP, HE, and HRS, increased notably. Mortality (2.5% vs. 1.7% at 1 month; 3.6% vs. 2.7% at 3 months) and GI bleed (1.3% vs. 0.9% at 1 month; 1.9% vs. 1.2% at 3 months) were also elevated in SARS-CoV-2 patients. CONCLUSIONS: SARS-CoV-2 increases decompensation over 2-fold in compensated cirrhosis patients and raises mortality and increases rates of complications at 1 and 3 months.

Biliary Cyst: An Unusual Cause of Cholestasis Post Cholecystectomy.

Biliary cysts are relatively uncommon and they can be congenital or acquired and can have various presentations such as cholelithiasis, cholangitis, jaundice, and pancreatitis. Biliary cysts are associated with a high risk of biliary cancers and such risk increases with age. Identification of biliary cysts warrants an aggressive approach to lower cancer risk. Surgical management has a high success rate and it lowers morbidity, mortality, and cancer risk. We present a 40-year-old female who had a cholecystectomy in 2016. She presented with obstructive jaundice and was found to have a class I biliary cyst. She underwent endoscopic retrograde cholangiopancreatography with stenting which led to complete resolution of her symptoms. Later, she underwent elective Roux-en-Y hepaticojejunostomy with cyst resection three months later. She underwent a successful recovery.

Daptomycin-Induced Acute Liver Failure: A Rare Case Report.

Acute liver failure (ALF) is characterized by severe liver injury, encephalopathy, and impaired coagulation/synthetic function. Drug-induced liver injury (DILI) can rarely, in a dose-dependent manner, lead to ALF. This article presents a rare case of daptomycin-induced acute liver failure in a patient with no prior liver disease. A 73-year-old male with multiple comorbidities including heart failure, diabetes, and chronic kidney disease received daptomycin treatment for diabetic left foot osteomyelitis. Five days after starting therapy, he developed weakness, jaundice, and drowsiness, leading to ICU admission. Physical examination and labs revealed hepatomegaly, elevated liver enzymes and abnormal ultrasound findings. Autoimmune and infectious causes were ruled out. Daptomycin was discontinued, and the patient's labs showed significant improvement within three days. One week after recovery from acute liver failure, he experienced cardiogenic shock due to worsening of his underlying heart failure and was transferred to the Cardiac ICU before ultimately being discharged to inpatient hospice care. To our best knowledge, this is the first reported case of daptomycin-induced acute liver failure, presenting with massive liver enzyme elevations, synthetic dysfunction, and encephalopathy. The Naranjo scale score suggests a probable causal relationship between daptomycin and liver injury. While a few cases of daptomycin-induced liver injury have been reported, there are no previous reports of acute liver failure. The rapid development of liver failure following daptomycin administration and subsequent recovery after discontinuation is noteworthy. However, various confounding factors and the mechanism of daptomycin-induced liver failure remain unclear. Further research is needed to identify predisposing factors and better understand this rare complication. While rare, this care also raises caution to follow liver function closely while prescribing daptomycin.

Acute Gallstone Pancreatitis in Pregnancy: A Multidisciplinary Approach.

A common cause of gastrointestinal-related hospitalizations in the United States of America is acute pancreatitis (AP), with an annual incidence of up to 80 cases per 100,000 people. The incidence of AP in pregnancy varies and is approximately 1 in 1000 to 1 in 10,000 births due to the prevalence of obesity and gallstone-related conditions. Deciding on the timing of surgical intervention in acute biliary pancreatitis during pregnancy remains challenging, and there are no consensus recommendations. Gallstone pancreatitis has a high recurrence rate of up to 50% during the first trimester. A 30-year-old G3P2 at 34 weeks of gestation presented to the emergency room (ER) with recurrent intermittent sudden severe epigastric and right upper quadrant abdominal pain radiating to the back. She had no history of alcohol consumption, and lipid studies were normal on presentation. A right upper quadrant ultrasound scan showed cholelithiasis without signs of acute cholecystitis and a common bile duct diameter of 0.5 cm. However, her serum lipase level was 824, compared to normal levels on her previous ER visits. Other significant labs included elevated alkaline phosphatase (ALP) of 125 and mild transaminitis, with alanine transaminase (ALT) and aspartate aminotransferase (AST) levels of 84 and 57, respectively. She was admitted on account of suspected gallstone pancreatitis and was treated supportively with IV fluids and adequate pain control with opioids. A subsequent magnetic resonance cholangiopancreatography (MRCP) revealed no obvious choledocholithiasis. After consultation with the obstetrics, gastroenterology, and general surgery teams, it was decided to defer cholecystectomy until after delivery. The patient was induced at 36 weeks of gestation, and she had an uneventful vaginal delivery. Two weeks later, she had an elective laparoscopic cholecystectomy with no complications.

Best care paradigm to optimize functionality after extra-articular distal humeral fractures in the young patient.

For younger patients with extra-articular distal humerus fractures closed management is plagued with high rates of malunion, suboptimal functional outcomes, extended immobilization with loss of early motion, a delay in return to work, and a general period of lost productivity. Surgical management offers an appealing alternative. Maintaining respect for the triceps musculature and minimizing iatrogenic injury to the radial nerve are primary concerns with operative treatment. Accordingly, use of a triceps-sparing approach and single column plating may be the optimal treatment paradigm in the young patient presenting with an extra-articular distal humerus fracture.

Perception Versus Reality in the Cost of Orthopedic Trauma Implants.

OBJECTIVE: Health care costs are increasing in medicine and in orthopedics. Device choice in orthopedic cases can impact the cost of the procedure and thus result in cost savings. This study aims to determine whether orthopedic attendings and residents accurately estimate device costs they are implanting in trauma cases and whether costs would influence their surgical device selection. DESIGN: Using nationally published average cost data for 13 implants, a survey was distributed at 6 US academic centers. Respondents were asked to select the correct cost from cost ranges. They also answered yes/no questions about their choices regarding published research outcomes for specific fractures. Residents' answers were compared with faculty answers using t tests for each cost estimate question, and chi-square tests for yes/no questions and frequencies. RESULTS: A total of 51 faculty members and 76 residents responded. Attending estimates were closer to the actual cost for most devices. The average total error in cost estimate for all 13 implants was $11,288.36 for residents (35.6% difference) and $10,208.33 for faculty members (32.2% difference). Significantly more faculty members estimated costs within 10% versus residents. When asked if the literature showed differences in outcome when using different implants to treat 4 common fractures, most answered these questions correctly. Further, 71.1% of residents said their choice of implant would change if costs affected physician reimbursements versus 58% for faculty members. CONCLUSIONS: Our data indicate orthopedic physicians are not aware of true implant costs and nearly half of attendings would not consider cost as a factor in deciding between equivalent implants, even if this affected their reimbursement. Most notably, participants showed a poor ability to closely estimate the cost of more expensive implants (actual device cost greater than $2000). Our results suggest that medical cost containment should be stressed to the next generation of surgeons.