Efficacy and adverse effects of insulin versus plasmapheresis in patients with hypertriglyceridemia-3-induced acute pancreatitis: a systematic review and meta-analysis.

Background: Hypertriglyceridemia is a common cause of acute pancreatitis (AP). This literature review compared the effectiveness and adverse events of insulin therapy, with or without heparin, and plasmapheresis, in reducing triglyceride levels in patients with hypertriglyceridemia-induced AP. Methods: Systematic reviews, meta-analyses, evidence syntheses, editorials, commentaries, protocols, abstracts, theses and preprints were excluded. Review Manager was used to conduct the meta-analysis. The literature search yielded 2765 articles, but only 5 were included in the systematic review and meta-analysis and the total number of participants in the review was 269. Results: From this study's analysis, insulin ± heparin was more successful in reducing triglyceride levels than plasmapheresis (standardized mean difference -0.37, 95% confidence interval [CI] 0.99 to 0.25; P=0.25). Insulin ± heparin therapy had a lower mortality rate than plasmapheresis (risk ratio [RR] 0.70, 95%CI 0.25-1.95). Hypotension, hypoglycemia, and acute renal failure were less common in the plasmapheresis therapy group than in insulin ± heparin therapy (RR 1.13, 95%CI 0.46-2.81, RR 3.90, 95%CI 0.45-33.78, and RR 0.48, 95%CI 0.02-13.98 for hypotension, hypoglycemia, and acute renal failure, respectively). Conclusions: This study found no significant difference in mortality between insulin ± heparin therapy and plasmapheresis used for the reduction in triglyceride levels. It is notable that no substantial differences were observed in the most common side-effects encountered during these therapies, thus indicating non-inferiority.

Impact of COVID vaccine and comorbidities in patients receiving casirivimab-imdevimab monoclonal antibody during SARS-CoV-2 B.1.617.2 (Delta) surge: A real-world study.

BACKGROUND: Several randomized trials and real-world studies depicted the role of monoclonal antibody infusion in reducing hospitalization, and halting progression from asymptomatic to symptomatic COVID pneumonia, viral titer, and death. No data exists to show outcomes of patients who received casirivimab-imdevimab infusion based on their vaccination status and underlying comorbidities. This study aims to provide outcomes of casirivimab-imdevimab treatment during the SARS-CoV-2 B1.617.2 (Delta) surge among fully vaccinated and not fully vaccinated individuals. METHODS: COVID-19-positive patients who received casirivimab-imdevimab infusion during the Delta surge were analyzed to compare their underlying comorbidities and the rate of 28-days all-cause and COVID-related ED visits or hospitalization, among fully vaccinated and not fully vaccinated individuals. RESULTS: A total of 3,586 patients received casirivimab-imdevimab infusion. COVID-related hospitalizations were directly related to the number of comorbidities (OR:1.745, 95 % CI:1.469-2.074). Vaccinated patients with ≥3 comorbidities had lower rates of 28-day COVID-related ED visits or hospitalization (p = 0.044) and those with ≥4 comorbidities had lower rates of 28-day All-cause ED visits or hospitalization (p = 0.029). Hypertension (OR:2.418, 95 %CI:1.341-4.360), immunocompromised state (OR:5.250, 95 %CI: 1.912-14.417), age ≥ 65 (OR:4.045, 95 %CI:2.224-7.358) increased the probability of hospitalization due to COVID and being fully vaccinated lowered the likelihood of hospitalization (OR: 0.472, 95 %CI: 0.239-0.933). Vaccinated patients had a lower length of COVID-related hospitalization (2 days vs 4.5 days, p < 0.001). CONCLUSION: COVID vaccination status and comorbidities are significant predictors of outcomes after casirivimab-imdevimab treatment. Despite having higher comorbidities, patients who were fully vaccinated at the time of casirivimab-imdevimab infusion had a lower length of hospitalization and reduced 28-day COVID ED visits or hospitalizations. Future trials should also compare outcomes based on the patient's vaccination status.

Diabetes associated with higher health care utilization and poor outcomes after COPD-related hospitalizations.

OBJECTIVES: Readmissions after hospitalizations for acute exacerbation of chronic obstructive pulmonary disease (COPD) have a high socioeconomic burden. Comorbidities such as diabetes increase the risk for hospital readmissions, but the impact of diabetes on hospital outcomes remains unknown. The aim of this study was to evaluate the effect of complicated or uncomplicated diabetes on outcomes and health care costs related to admissions and readmissions in patients 35 years and older with an index admission for COPD. STUDY DESIGN: This was a retrospective longitudinal data analysis. We analyzed data from the Healthcare Cost and Utilization Project (HCUP) Nationwide Readmissions Database. METHODS: We analyzed the 2012-2015 HCUP Nationwide Readmissions Database and used multivariable weighted regression analyses to adjust for confounding factors. Individuals with any chronic pulmonary disease other than COPD were excluded. RESULTS: Of 1,728,931 patients hospitalized for COPD, 522,020 (30.2%) had a diagnosis of diabetes. Risk of all-cause 30-day readmission was higher among patients with complicated diabetes (adjusted odds ratio [OR], 1.15; 95% CI, 1.11-1.18) and uncomplicated diabetes (adjusted OR, 1.10; 95% CI, 1.08-1.12) compared with patients without diabetes. Diabetes was associated with longer length of stay, higher rates of hospital complications during index hospitalizations and 30-day readmissions, and a higher health care cost. Although diabetes was not associated with higher hospital mortality, routine hospital discharges were less common and the need for home health care upon discharge was higher among those with diabetes. CONCLUSIONS: Patients hospitalized for COPD and coexisting diabetes have worse clinical outcomes and higher 30-day readmissions compared with patients hospitalized for COPD without diabetes. Optimizing medical therapies and targeted interventions for both diseases is needed to alleviate disease burden to individuals and to society.

Right Ventricle Dilation Detected on Point-of-Care Ultrasound Is a Predictor of Poor Outcomes in Critically Ill Patients With COVID-19.

BACKGROUND: During the COVID-19 pandemic, the need for judicious use of diagnostic tests and to limit personnel exposure has led to increased use and dependence on point-of-care ultrasound (POCUS) examinations. We reviewed POCUS findings in patients admitted to the intensive care unit (ICU) for acute respiratory failure with COVID-19 and correlated the findings to severity of illness and 30-day outcomes. METHODS: Patients admitted to the ICU in March and April 2020 were reviewed for inclusion (acute hypoxemic respiratory failure secondary to COVID-19 pneumonia; documentation of POCUS findings). RESULTS: Forty-three patients met inclusion criteria. B lines and pleural thickening were associated with a lower PaO2/FiO2 by 71 (P = .005; adjusted R 2 = 0.24). Right ventricle (RV) dilation was more common in patients with 30-day mortality (P = .02) and was a predictor of mortality when adjusted for hypertension, diabetes mellitus, and age (odds ratio, 12.0; P = .048). All patients with RV dilation had bilateral B lines with pleural irregularities. CONCLUSIONS: Although lung ultrasound abnormalities are prevalent in patients with severe disease, RV involvement seems to be predictive of outcomes. Further studies are needed to discern the etiology and pathophysiology of RV dilation in COVID-19.

Three metachronous primary lung cancers in a chronic smoker: A case report and review of the literature.

RATIONALE: Lung cancer is a leading cause of cancer-related deaths. Smoking is major risk factor for initial and subsequent lung cancer especially in active smokers. Treatment of subsequent lung cancer depends on whether it is synchronous or metachronous. We report a rare case of triple metachronous lung cancer and review of literature of patients with triple metachronous cancers. This will be the second case reported of triple metachronous lung cancer. PATIENT CONCERNS: A 60-year-old male, active smoker with diabetes mellitus, chronic obstructive pulmonary disease (COPD) and peripheral arterial disease presented with cough and hemoptysis. Initial computed tomography (CT) scan showed right upper lobe spiculated mass. DIAGNOSIS: He underwent transthoracic needle biopsy for right upper lobe mass, showing primary lung adenocarcinoma (ADC)-Stage-IIIA. He continued to smoke and 9-years later had new left upper lobe spiculated nodule, which on surgical resection showed squamous cell carcinoma (SCC)-Stage-IA1. Despite counselling on smoking cessation, he was unable to quit. Six months later, he presented with shortness of breath and CT chest showing right hilar adenopathy in right upper and lower lobes. He underwent transbronchial biopsies of lesion which showed small cell lung carcinoma (SCLC). INTERVENTIONS: His initial lung ADC-Stage-IIIA, was treated with chemotherapy, weekly thoracic radiation and additional chemotherapy cycles. Nine years later, his left upper lobe mass showing SCC-Stage-IA1 was deemed curative after apical resection and he was kept on surveillance. Six months later, after diagnosis of SCLC in right upper and lower lobe, patient was not a candidate for systemic chemotherapy due to poor performance status and opted for hospice care. OUTCOMES: His initial lung ADC-Stage-IIIA showed complete radiological response with chemotherapy and radiation. Subsequent SCC-Stage-IA1 was deemed curative after resection. Due to his poor performance status, he was not a candidate for chemotherapy for SCLC and patient opted for hospice care. LESSONS: Smoking is a major risk factor for developing lung cancer and with continued smoking, patients are at higher risk for developing subsequent primary lung cancers. We recommend, patients with lung cancer must quit smoking, and those who do not, should remain on long-term surveillance.

Systematic Review of Safety and Cost-Effectiveness of Venous Thromboembolism Prophylaxis Strategies in Patients Undergoing Craniotomy for Brain Tumor.

BACKGROUND: Studies have evaluated various strategies to prevent venous thromboembolism (VTE) in neuro-oncology patients, without consensus. OBJECTIVE: To perform a systematic review with cost-effectiveness analysis (CEA) of various prophylaxis strategies in tumor patients undergoing craniotomy to determine the safest and most cost-effective prophylaxis regimen. METHODS: A literature search was conducted for VTE prophylaxis in brain tumor patients. Articles reporting the type of surgery, choice of VTE prophylaxis, and outcomes were included. Safety of prophylaxis strategies was determined by measuring rates of VTE and intracranial hemorrhage. Cost estimates were collected based on institutional data and existing literature. CEA was performed at 30 d after craniotomy, comparing the following strategies: mechanical prophylaxis (MP), low molecular weight heparin with MP (MP+LMWH), and unfractionated heparin with MP (MP+UFH) to prevent symptomatic VTE. All costs were reported in 2016 US dollars. RESULTS: A total of 34 studies were reviewed (8 studies evaluated LMWH, 12 for MP, and 7 for UFH individually or in combination; 4 studies used LMWH and UFH preoperatively). Overall probability of VTE was 1.49% (95% confidence interval (CI) 0.42-3.72) for MP+UFH, 2.72% [95% CI 1.23-5.15] for MP+LMWH, and 2.59% (95% CI 1.31-4.58) for MP, which were not statistically significant. Compared to a control of MP alone, the number needed to treat for MP+UFH is 91 and 769 for MP+LMWH. The risk of intracranial hemorrhage was 0.26% (95% CI 0.01-1.34) for MP, 0.74% (95% CI 0.09-2.61) for MP+UFH, and 2.72% (95% CI 1.23-5.15) for MP+LMWH, which were also not statistically significant. Compared to MP, the number needed to harm for MP+UFH was 208 and for MP+LMWH was 41. Fifteen studies were included in the final CEA. The estimated cost of treatment was $127.47 for MP, $142.20 for MP+UFH, and $169.40 for MP+LMWH. The average cost per quality-adjusted life-year for different strategies was $284.14 for MP+UFH, $338.39 for MP, and $722.87 for MP+LMWH. CONCLUSION: Although MP+LMWH is frequently considered the optimal prophylaxis for VTE risk reduction, our model suggests that MP+UFH is the safest and most cost-effective measure to balance VTE and hemorrhage risks in brain tumor patients at lower risk of hemorrhage. MP+LMWH may be more effective for patients at higher risk of VTE.

Career prospects and professional landscape after advanced endoscopy fellowship training: a survey assessing graduates from 2009 to 2013.

BACKGROUND AND AIMS: The advanced endoscopy (AE) fellowship is a popular career track for graduating gastroenterology fellows. The number of fellows completing AE fellowships and the number of programs offering this training have increased in the past 5 years. Despite this, we suspect that the number of AE attending (staff physician) positions have decreased (relative to the number of fellows graduating), raising concerns regarding AE job market saturation. Our aim was to survey practicing gastroenterology physicians who completed an AE fellowship within the past 5 years regarding their current professional status. METHODS: A 16-question survey was distributed using Research Electronic Data Capture by e-mail to practicing gastroenterologists who completed an AE fellowship between 2009 and 2013. The survey questions elicited information regarding demographics, professional status, and additional information. RESULTS: A total of 96 invitations were distributed via e-mail. Forty-one of 96 respondents (43%) replied to the survey. Approximately half of the respondents were employed in an academic practice, with the remainder in private practice (56% and 44%, respectively). Nearly half (46%) of the respondents found it "difficult" to find an AE position after training. Thirty-nine percent of private-practice endoscopists were performing > 200 ERCPs/year, whereas 65% were doing so in academic settings (P = .09). Fifty-six percent of respondents were in small practices (0 to 1 partner), with a significantly smaller group size in private versus academic practice (72% versus 43%, P = .021). Seventy-eight percent of respondents believed the AE job market was saturated; most responded that the AE job market was saturated in both academic and private practice (44%), whereas 34% believed the job market was saturated in academics only. Most respondents (73%) who were training AE fellows found it difficult to place them in AE attending positions. Respondents from academic practice found it significantly more difficult to balance work and personal life compared with those in private practice (87% versus 33%, respectively; P = .0004). CONCLUSION: This index survey highlights the trends related to the current state of the post-AE fellowship professional landscape. Further evaluation and discussion are needed to address these evolving issues in professional practice in the field of gastroenterology.

64-detector CT angiography within 24 hours after carotid endarterectomy and correlation with postoperative stroke.

OBJECT: Carotid endarterectomy (CEA) carries a small but not insignificant risk of stroke/transient ischemic attack (TIA), most frequently observed within 24 hours of surgery, which can lead to the need for urgent vascular imaging in the immediate postoperative period. However, distinguishing expected versus pathological postoperative changes may not be straightforward on imaging studies of the carotid artery early after CEA. The authors aimed to describe routine versus pathological anatomical findings on CTA performed within 24 hours of CEA, and to evaluate associations between these CTA findings and postoperative stroke/TIA. METHODS: The authors reviewed 113 consecutive adult patients who underwent postoperative CTA within 24 hours of CEA at a single academic institution. Presence and location of arterial "flaps," luminal "step-off," intraluminal thrombus and hematoma were documented from postoperative CTA scans. Medical records were reviewed to determine the incidence of new postoperative neurological findings. RESULTS: Postoperative CTA findings included common carotid artery (CCA) step-off (63.7%), one or more intraarterial flaps (27.4%), hematoma at the surgical site (15.9%), and new intraluminal thrombus (7.1%). Flaps were seen in the external carotid artery (ECA), internal carotid artery (ICA), and CCA in 18.6%, 9.7%, and 6.2% of patients, respectively. New postoperative neurological findings were present in 7.1% of patients undergoing CTA. Flaps (especially ICA/CCA) and/or intraluminal thrombi were more frequently seen in patients undergoing CTA for new postoperative stroke/TIA (85.7%) versus patients undergoing CTA for routine postoperative imaging (14.3%, p = 0.002). CONCLUSIONS: CTA within 24 hours of CEA demonstrates characteristic anatomical findings. CCA step-offs and ECA flaps are relatively common and clinically insignificant, whereas ICA/CCA flaps and thrombi are less frequently seen and are associated with postoperative stroke/TIA.

Does prolonged length of stay in the emergency department affect outcome for stroke patients?

INTRODUCTION: Conflicting data exist regarding the association between the length of stay (LOS) of critically ill patients in the emergency department (ED) and their subsequent outcome. However, such patients are an overall heterogeneous group, and we therefore sought to study the association between EDLOS and outcomes in a specific subgroup of critically ill patients, namely those with acute ischemic stroke/transient ischemic attack (AIS/TIA). METHODS: This was a retrospective review of adult patients with a discharge diagnosis of AIS/TIA presenting to an ED between July 2009 and February 2010. We collected demographics, EDLOS, arrival stroke severity (National Institutes of Health Stroke Scale - NIHSS), intravenous tissue plasminogen activator (IV tPA) use, functional outcome at discharge, discharge destination and hospital-LOS. We analyzed relationship between EDLOS, outcomes and discharge destination after controlling for confounders. RESULTS: 190 patients were included in the cohort. Median EDLOS was 332 minutes (Inter-Quartile Range -IQR: 250.3-557.8). There was a significant inverse linear association between EDLOS and hospital-LOS (p=0.049). Patients who received IV tPA had a shorter median EDLOS (238 minutes, IQR: 194-299) than patients who did not (median: 387 minutes, IQR: 285-588 minutes; p<0.0001). There was no significant association between EDLOS and poor outcome (p=0.40), discharge destination (p=0.20), or death (p=0.44). This remained true even after controlling for IV tPA use, NIHSS and hospital-LOS; and did not change even when analysis was restricted to AIS patients alone. CONCLUSION: There was no significant association between prolonged EDLOS and outcome for AIS/TIA patients at our institution. We therefore suggest that EDLOS alone is an insufficient indicator of stroke care in the ED, and that the ED can provide appropriate acute care for AIS/TIA patients. [West J Emerg Med. 2014;15(3):267-275.].

Sphingosine kinase 1 deficiency exacerbates LPS-induced neuroinflammation.

The pathogenesis of inflammation in the central nervous system (CNS), which contributes to numerous neurodegenerative diseases and results in encephalopathy and neuroinflammation, is poorly understood. Sphingolipid metabolism plays a crucial role in maintaining cellular processes in the CNS, and thus mediates the various pathological consequences of inflammation. For a better understanding of the role of sphingosine kinase activation during neuroinflammation, we developed a bacterial lipopolysaccharide (LPS)-induced brain injury model. The onset of the inflammatory response was observed beginning 4 hours after intracerebral injection of LPS into the lateral ventricles of the brain. A comparison of established neuroinflammatory parameters such as white matter rarefactions, development of cytotoxic edema, astrogliosis, loss of oligodendrocytes, and major cytokines levels in wild type and knockout mice suggested that the neuroinflammatory response in SphK1-/- mice was significantly upregulated. At 6 hours after intracerebroventricular injection of LPS in SphK1-/- mice, the immunoreactivity of the microglia markers and astrocyte marker glial fibrillary acidic protein (GFAP) were significantly increased, while the oligodendrocyte marker O4 was decreased compared to WT mice. Furthermore, western blotting data showed increased levels of GFAP. These results suggest that SphK1 activation is involved in the regulation of LPS induced brain injury. RESEARCH HIGHLIGHTS: • Lipopolysaccharide (LPS) intracerebral injection induces severe neuroinflammation. • Sphingosine kinase 1 deletion worsens the effect of the LPS. • Overexpression of SphK1 might be a potential new treatment approach to neuroinflammation.

Uric Acid as a potential biomarker of pulmonary arterial hypertension in patients with sickle cell disease.

Serum uric acid (UA) is emerging as a strong and independent marker for pulmonary arterial hypertension (PAH). PAH is well recognized as a life threatening complication of sickle cell disease (SCD). However, the association between UA and PAH in SCD is unknown. We reviewed electronic medical records (EMR) of 559 consecutive adult SCD patients from Kings County Hospital Center (KCHC) between January 2005 and February 2010. Patients (n = 96) with measurement of UA in close temporal proximity to the transthoracic echocardiography (TTE) were identified. PAH was defined as pulmonary artery systolic pressure (PASP) ≥30 mm Hg. Patients (n = 16) with other risk factors which may cause PAH and chronic renal insufficiency were excluded. In 18 patients, TTE could not measure PASP. Finally, 62 patients were selected. Statistical analysis was performed using Student t tests, Pearson correlation coefficient and multivariate regression analysis. Out of 62 patients, 30 had PAH. Patients with PAH had a higher UA level (8.67 ± 4.8 vs. 5.35 ± 2.1, P = 0.001). We found strong positive correlation between the UA level and PASP (r = 0.71; P < 0.0001). This correlation was independent of diuretic use. UA could be a potential marker for PAH in SCD. However, its' prognostic and pathophysiologic role in SCD patients with PAH needs to be further investigated.