Duloxetine as an Analgesic in Patients Who Do Not Have Central Sensitivity Undergoing Single-Setting, Bilateral Total Knee Arthroplasty: A Prospective, Double-Blinded, Randomized, Placebo-Controlled Trial.

BACKGROUND: Pain control and patient satisfaction after total knee arthroplasty (TKA) have room for improvement. While studies have reported better analgesic outcomes with antidepressants like duloxetine in patients who do not have central sensitivity (CS), we undertook this trial to determine the short and midterm analgesic role of low-dose duloxetine in patients who do not have CS. METHODS: This prospective, double-blinded, randomized, placebo-controlled trial was conducted in 106 patients undergoing single-setting, bilateral TKA under spinal anesthesia. There were 2 matched groups, with one given 20 mg of duloxetine and the other given a placebo (similar in appearance and weight) from preoperative day 2 to postoperative day 28. Follow-ups were scheduled at 48-hours, 1-week, 2-weeks, 4-weeks, and 3-months. Pain was measured using a visual analogue scale at rest and visual analogue scale at mobilization (mVAS). Secondary measures included additional non-steroidal anti-inflammatory drug consumption, patient satisfaction, and safety profile. RESULTS: The visual analogue scale at rest in the duloxetine group was better in the first 48 hours (6.38 ± 1.32 versus 7.02 ± 0.99; P = .017), 1-week (4.76 ± 1.24 versus 5.89 ± 1.06; P < .001), and 2-weeks (3.34 ± 1.19 versus 4.26 ± 1.02; P < .001) follow-up. The mVAS remained significantly higher in the duloxetine group in the first 48 hours (7.23 ± 1.12 versus 8.21 ± 0.69; P < .001), 1-week (5.83 ± 1.11 versus 6.82 ± 0.92; P < .001), and 2 weeks (3.70 ± 0.89 versus 4.60 ± 1.03; P < .001) follow-up. Both outcomes became comparable from 4-week follow-up onward. Patient satisfaction (8.44 ± 1.68 versus 7.17 ± 1.04; P < .001) and additional non-steroidal anti-inflammatory drug consumption (2,770 ± 533.05 versus 3,566.04 ± 464.54; P < .001) were better in the duloxetine group, with a comparable safety profile. CONCLUSIONS: In patients who did not have CS, persistent pain after bilateral TKA can be managed safely and successfully by a daily dose of 20 mg Duloxetine, improving patient satisfaction and analgesic consumption in the acute postoperative phase.

The Incidence of Rectal Neuroendocrine Tumors Is Increasing in Younger Adults in the US, 2001-2020.

Prior non-comparative data showed increasing incidence of rectal neuroendocrine tumors (RNET) in the US. We aimed to evaluate age-specific RNET incidence rates and time-trends in demographic- and tumor-specific populations. The RNET age-adjusted incidence rates were calculated from the United States Cancer Statistics (USCS) database between 2001 and 2020. The population was stratified by age into older (≥55 years) and younger adults (<55 years), as well as by sex and race. The tumors were categorized by their stage at diagnosis into early and late. The annual percentage change (APC) and average APC (AAPC) were estimated using joinpoint regression and Monte Carlo permutation analysis. Pairwise comparison assessed for parallelism and coincidence. There were 59,846 patients diagnosed with RNET between 2001 and 2020 (50.3% women). Overall, the RNET incidence rates during this period were increasing in younger but not older adults (AAPC = 3.12 vs. -1.10; AAPC difference = 4.22, p < 0.001), with non-identical non-parallel data (p-values < 0.001). While similar results were seen in men, a greater age-specific difference was noted in women (AAPC = 3.31 vs. -1.10; AAPC difference = 4.41, p = 0.003). The difference between younger and older adults was seen in non-Hispanic White (AAPC-difference = 4.89; p < 0.001) and non-Hispanic Black (AAPC-difference = 3.33; p = 0.03) patients, and, in most years, among Hispanic and Non-Hispanic Asian/Pacific Islander patients, and it was mostly driven by early-stage tumors (AAPC-difference = 3.93; p < 0.001). The nationwide data show a significantly increasing RNET incidence in younger adults, most notably in younger women and in early-stage tumors, seen in various races. Future studies should evaluate RNET risk factors and outcomes in demographic-specific populations.

Delayed Recovery of Idiopathic Common Peroneal Nerve Palsy After Total Knee Arthroplasty: A Rare Case Report.

Introduction: Common peroneal nerve palsy (CPNP) is a rare complication post total knee arthroplasty (TKA). Even though it is diagnosed acutely, the recovery potential is just over 50%. The average period for complete recovery in such cases is 5 months; however, the management remains controversial. Through this report, we present one such case of left sided complete CPNP after bilateral TKA who was conserved with various modalities. Even though the recovery was delayed, the patient made full recovery. Case Report: A 70-year-old female patient was diagnosed to have bilateral tricompartmental knee osteoarthritis with varus deformity, both clinically and radiologically (Kellgren-Lawrence grade 4). She underwent bilateral TKA in a single sitting as per the standard protocols practiced by the primary author. On post-operative day 1, she had left-sided foot drop with a complete sensory deficit. The patient underwent routine rehabilitation with an ankle foot orthosis splint in the immediate post-operative period, with simultaneous faradic current stimulation for the left lower limb. Periodic electromyography and nerve conduction study was done at the end of 4-week and 3-month post-TKA. At 6.5-month post-surgery, she made a full clinical recovery. Conclusion: The surgical maneuvers and full neurovascular examination before and after every TKA surgery should be carefully performed. Despite this, if a patient presents with CPNP, the surgeon need not take an aggressive approach, unlike fracture fixation cases. These patients can be managed conservatively using appropriate orthosis, physical therapy, and faradic current stimulation. Through this case, we attempt to report that CPNP patient can recover even after 6 months of surgery when there is no tangible cause for the palsy.

Rare Manifestation of Pancreaticobiliary Cancer With Extrahepatic Lesions.

Pancreaticobiliary cancers are uncommon neoplasms, frequently diagnosed at an advanced stage with metastasis to the liver, lung, or peritoneum. Here, we report an extraordinary case of a patient presenting with both hepatic and extrahepatic lesions, including bone involvement, but without discernible disease in the biliary system or pancreas. Eventual pathological evidence supports the origin of primary pancreaticobiliary carcinoma. This case report aims to stimulate discourse regarding the consideration of pancreaticobiliary cancers as a potential cause of extrahepatic metastatic lesions. Increased awareness of such atypical presentations is crucial for early diagnosis and optimal patient management.

Investigating the Correlation Between Clostridioides difficile Infection and Vitamin D Deficiency.

INTRODUCTION: Clostridioides difficile infection (CDI) is the most common healthcare-associated infection in the US. Symptoms include watery diarrhea, nausea, and anorexia and it can present with leukocytosis on laboratory evaluation. Treatment is based on disease severity and recurrence. Despite antibiotic usage being the highest risk factor for infection, they are also the first-line treatment for initial CDI. Prevention of CDI mostly involves good hand hygiene, antibiotic stewardship, and appropriate precautions when interacting with infected individuals. Vitamin D deficiency (VDD) has been linked to CDI, however, there is limited insight into the correlation between both states. Our aim was to further investigate the potential link between VDD and CDI. METHODS: Data were obtained from the National Inpatient Sample (NIS) from 2016 to 2019. Patients with CDI were identified and stratified based on a diagnosis of VDD. Primary outcomes were mortality, CDI recurrence, ileus, toxic megacolon, perforation, and colectomy. Chi-squared and independent t-tests were performed to assess categorical and continuous data, respectively. Multiple logistic regression was used to control for confounders. RESULTS: Patients with VDD had higher rates of CDI recurrence (17.4% versus 14.7%, p<0.05), but lower rates of mortality (3.1% versus 6.1%, p<0.05). Differences in rates of ileus, toxic megacolon, perforation, and colectomy were statistically insignificant. Length of stay was higher in the VDD group (10.38 days versus 9.83 days). Total charges were lower in the VDD group ($93,935.85 versus $102,527.9). DISCUSSION: CDI patients with comorbid VDD are at higher risk for the recurrence of CDI. This is likely due to the role of vitamin D in the expression of intestinal epithelial antimicrobial peptides, macrophage activation, and maintenance of tight junctions between gut epithelial cells. Furthermore, vitamin D plays a role in maintaining a healthy gut microbiome. Alternatively, deficiency results in poor gut health and detrimental changes to the gut microbiome. In effect, VDD promotes the proliferation of C. difficile within the large colon, resulting in an increased predisposition for CDI.

Pancreatic Cancer Biopsy Modalities: Comparing Insurance Status, Length of Stay, and Hospital Complications Based on Percutaneous, Endoscopic, and Surgical Biopsy Methods.

BACKGROUND: Pancreatic cancer is diagnosed histologically through percutaneous biopsy (PB), endoscopic biopsy (EB), or surgical biopsy (SB). Factors and outcomes associated with method type are not clearly understood. We aimed to evaluate the relationship between insurance status, length of hospital stay (LOS), complications, and different pancreatic biopsy modalities. STUDY: The 2001-2013 database from the National (Nationwide) Inpatient Sample (NIS) was queried for those with pancreatic cancer who underwent biopsies using International Classification of Diseases, Ninth Revision (ICD-9) codes. Data regarding insurance status, hospital stay, demographics, and complications were analyzed using chi-square and multivariate analysis with α < 0.001. RESULTS: A total of 824,162 patients with pancreatic cancer were identified. Uninsured and Medicaid patients were more likely to get PB compared to SB. Patients were more likely to have acute renal failure (ARF) with an EB compared to SB. Patients were more likely to have a urinary tract infection (UTI) with EB or PB compared to SB. All biopsy types were less likely to have pneumonia; pancreatitis was more prevalent in EB compared to PB and SB. CONCLUSIONS: Uninsured and Medicaid patients were most likely to have a PB compared to EB despite unclear indications which may represent an underlying discrepancy in healthcare utilization. EB patients had the shortest LOS while SB patients stayed three more days; those who underwent a combination of biopsies had the greatest LOS. Patients with EB were more likely to develop ARF, UTI, and pancreatitis than SB, possibly attributed to the advanced nature of endoscopic ultrasound. It is important to establish appropriate algorithm contributors to guide decision-making.

A Novel Case of Biliary Stent Migration Causing Sigmoid Diverticula Entrapment.

Pancreaticobiliary obstruction is a rare but life-threatening complication. Plastic biliary stents are a temporary utility to maintain the patency of the common bile ducts, typically lasting about four months. Biliary stents can rarely have complications, with the most common being migration through the gastrointestinal tract. We present a case of a patient with a plastic stent placed over five years, which was complicated by severe hematochezia due to the retention of the stent in a diverticulum. Given the increased risk of life-threatening complications post-stent life expectancy, there should be systems in place to prevent patients from being lost to follow-up.

Effect of Patient Age on Timing of Inpatient Esophagogastroduodenoscopy and Outcomes for Non-variceal Upper GI Bleeds.

Background Esophagogastroduodenoscopy (EGD) is typically performed within 24 hours of presentation for patients admitted to a hospital for patients presenting with a non-variceal upper gastrointestinal bleed (UGIB). To date, no studies have been performed to identify the impact of patient age on the timing of inpatient EGD and patient outcomes in non-variceal UGIB. Our aim was to assess the differences in the timing of EGD, blood transfusion requirements, development of hemorrhagic shock, development of acute renal failure, mortality, length of stay, and total hospital charges for patients aged 18-59 and those aged 60 and older. Methods Admissions for non-variceal UGIB were identified from the National (Nationwide) Inpatient Sample (NIS) database from 2016 and 2017. Patients who initially presented with hemorrhagic shock were excluded. Patients were divided into two age groups, those aged 18-59 and those aged 60 or older. We classified EGDs as early and delayed. Since the NIS database identifies days as midnight to midnight, we categorized early EGDs as those performed on day 0 and day 1. Delayed EGD were categorized as those performed on days 2 and 3. Multivariate logistic regression was performed on propensity-matched data to compare EGD timing, blood transfusion requirements, development of post-hospitalization hemorrhagic shock, development of acute renal failure, and mortality. The following patient and hospital variables were used in regression models: race, sex, insurance status, income quartile, mortality risk score, illness severity score, admission month, admission day, type of admission, region, bed size, and hospital teaching status. Finally, weighted two-sample T-tests were used to compare the length of stay and total hospitalization cost. Results A total of 12,449 weighted cases of inpatient non-variceal UGIB were included in this study. Patients aged 60 and older were more likely to die during the hospitalization (OR= 1.661, 95%CI: 1.108-2.490, p= 0.014), require blood transfusion (OR= 1.257, 95%CI: 1.131-1.396, p<0.001), and develop acute renal failure (OR= 1.672, 95%CI: 1.447-1.945, p<0.001). Patients aged 60 and older were also less likely to receive an early EGD (OR= 0.850, 95%CI: 0.752-0.961, p= 0.009). Total hospital costs (95%CI: -1397.77 - -4005.68, p<0.001) and length of stay (95%CI: -0.428 - -0.594, p<0.001) were both lower in patients aged 18-59 years. There was no difference in the development of post-hospitalization hemorrhagic shock between the two groups (OR= 0.984, 95%CI: 0.707-1.369, p= 0.923). Conclusions Patients aged 60 and older were less likely to have an early EGD and more likely to have worse outcomes. They had increased rates of inpatient mortality, blood transfusion requirements, development of acute renal failure, increased total hospital costs, and longer lengths of stay. There were no differences in the development of post-hospitalization hemorrhagic shock between the two groups.

Does Dysphagia Predict Inpatient Morbidity and Mortality in Geriatric Patients Admitted for Aspiration Pneumonia?

Background Aspiration pneumonia is common in older adults admitted for community-acquired pneumonia and is associated with significant morbidity and mortality. Factors that put this population at higher risk of aspiration include cognitive impairment, neuromuscular dysfunction, and dysphagia. This study aimed to determine whether a concurrent diagnosis of dysphagia conferred a higher risk of complications in the elderly admitted for aspiration pneumonia. Methods The National Inpatient Sample 2001-2013 database was queried for patients, aged 65 or older, with a diagnosis of aspiration pneumonia using International Classification of Diseases, Ninth Revision (ICD-9) codes. Sepsis, respiratory failure, and intubation were identified with their respective ICD-9 codes. A chi-square test and binary logistic regression analysis were used to examine socio-demographic and complication variables, with a significance level of α <0.001. Results A total of 1,097,325 patients were admitted for aspiration pneumonia, of which 349,861 (24.2%) had dysphagia. After incorporating socio-demographic variables, the dysphagia group had a significantly lower likelihood of having sepsis (OR=0.72), respiratory failure (OR=0.92), intubation (OR=0.52), and inpatient mortality (OR = 0.59). Patients with dysphagia had a significantly higher likelihood of increased length of stay (OR=1.24). Conclusions Elderly patients admitted with aspiration pneumonia with a co-diagnosis of dysphagia were less likely to have inpatient morbidity and mortality compared to their counterparts. This may be due to improved speech evaluation and treatment in patients with dysphagia allowing for better control of macro and micro aspiration. Future research is needed to examine if universal speech therapy can reduce hospitalization and long-term mortality for such patients.

Role of Gastroesophageal Reflux Disease in Morbidity and Mortality for Patients Admitted With Pulmonary Hypertension.

INTRODUCTION: The association between gastroesophageal reflux disease (GERD) and morbidity and mortality in patients with pulmonary arterial hypertension (PH) is unknown. Our objective was to examine the difference in socio-demographics, comorbidities, and morbidity/mortality in PH patients also diagnosed with GERD, compared to PH patients without GERD. METHODS: We performed a retrospective cross-sectional study of the large U.S. National Inpatient Sample identifying patients with a primary diagnosis of primary pulmonary hypertension (PH). All patients ≥ 18 years old that were admitted with a primary diagnosis of PH from January 1, 2001, to December 31, 2013, in the NIS database were included. We analyzed the socio-demographic and clinical comorbidities in PH patients with and without GERD. We investigated the predictors for complications of PH and differences in hospital utilization in this population. RESULTS: PH patients with GERD were more likely to be older than 18-29 years. They were more likely to be Caucasian and female and less likely to be part of the top 75% median income compared to the bottom 25%. Patients with GERD were more likely insured with Medicare or private insurance but less likely to have Medicaid or be uninsured. Patients were more likely to be obese, and have asthma, chronic bronchitis, obstructive sleep apnea, hypertension, and hypothyroidism but were less likely to have diabetes or a history of alcohol use. PH Patients with GERD were less likely to have myocardial infarctions, cardiac arrests, pulmonary embolisms, pulmonary hemorrhages, cardiac interventions, acute respiratory failure, acute renal failure, or urinary tract infections compared to those without GERD. Patients with GERD were, however, more likely to have acute heart failure exacerbations and aspiration pneumonia. Patients with a diagnosis of GERD had lower mortality, length of stay (LOS), and hospital costs compared to their counterparts. CONCLUSIONS: The concomitant presence of GERD is associated with fewer adverse outcomes in patients with PH. Though it is well understood that treatment of GERD is beneficial for lung disease, the exact role of GERD in PH has not been identified. This study helps characterize the important role appropriately treated GERD may play in preventing morbidity and mortality due to PH.

Role of concomitant percutaneous pie crusting and local corticosteroid injection in lateral epicondylitis: a prospective, case control study.

BACKGROUND: Lateral epicondylitis is an increasingly debilitating condition in working population. Evidence for conservative treatment modalities has been inconclusive. Percutaneous pie crusting of the common extensor origin at the lateral epicondyle at the time of local corticosteroid injection (CSI) has been proposed sparsely. The objective of this study was to analyze if concomitant CSI and pie-crusting of the common extensor origin provides better outcome than CSI alone in lateral epicondylitis. METHODS: This case-control study on 236 patients was conducted at a single center between January 1, 2020, and May 31, 2022. Patients were divided into two groups (n=118 each) based on their preference. Group A underwent CSI alone and group B underwent pie crusting along with CSI. The clinical and functional outcomes of all patients were evaluated at 2, 4, 6, and 12-week post-procedure using the visual analog scale (VAS) and Nirschl score. The mean time for return to daily activities was also compared. RESULTS: Both groups showed significant improvement in post-procedure outcome at successive follow-ups on intragroup longitudinal analysis (VAS: F=558.384 vs. F=1,529.618, Nirschl: F=791.468 vs. F=1,284.951). On intergroup analysis, VAS of group B was superior to that of group A; however, it was statistically significant (P<0.05) only from the 6-week follow-up onwards. Nirschl score of group B was significantly better throughout the period of follow-up (P<0.05). Group B returned to daily activities faster than Group A (6.2±0.44 weeks vs. 7.18±0.76 weeks). CONCLUSIONS: Concomitant pie crusting with CSI is recommended for lateral epicondylitis as it provides significantly better results than CSI alone.

Effects of glenohumeral corticosteroid injection on stiffness following arthroscopic rotator cuff repair: a prospective, multicentric, case-control study with 18-month follow-up.

BACKGROUND: This study aimed to analyze the efficacy of single-dose corticosteroid injection (CSI) administered at 6 weeks postoperative to treat stiffness following arthroscopic rotator cuff repair (ARCR). METHODS: In this prospective, multicentric, case-control study, post-ARCR stiffness at 6 weeks was treated with either a single dose of intra-articular CSI (CSI group) or physical therapy with oral analgesics (non-CSI group). Pain intensity according to visual analog scale (VAS), functional outcome using the Constant Murley Shoulder Score, time to return to activities of daily living (ADLs), and retear rate were recorded at 6 weeks, 9 weeks, 12 weeks, 6 months, 12 months, and 18 months postoperatively in both groups. RESULTS: A total of 149 patients (54.5%) in the CSI group and 124 patients (45.5%) in the non-CSI group were included in this study. Pain and function were significantly better in the CSI group at 9-week, 12-week, and 6-month (P<0.001) follow-up, whereas they were not significantly different when the groups were compared at 12- and 18-month follow-up. The mean duration to return to ADLs was significantly shorter (P<0.001) in the CSI group. The incidence of retears was not significantly different (P=0.36) between groups at the end of 18 months of follow-up. CONCLUSIONS: Single-dose intra-articular CSI administered at 6 weeks postoperative to treat post-ARCR stiffness significantly improved pain, function, and duration of return to ADLs without increasing the risk of retears compared to patients who did not receive intra-articular CSI.

Trends in Mortality and Health Care Burden of Cirrhotic Decompensation in Hospitalized Patients: A Nationwide Analysis.

INTRODUCTION: Mortality caused by cirrhosis is now the 14th most common cause of death worldwide and 12th most common in the United States. We studied trends in inpatient mortality and hospitalization charges associated with cirrhotic decompensation from esophageal variceal bleeding, ascites, hepatic encephalopathy, spontaneous bacterial peritonitis, and hepatorenal syndrome from 2007 to 2017. MATERIALS AND METHODS: Using the National Inpatient Sample databases, we first isolated patients 18 years or older with the diagnosis of cirrhosis using International Classification of Diseases, Ninth Revision (ICD-9) or International Classification of Diseases, Tenth Revision (ICD-10) codes. We then identified patients with the admission diagnosis of esophageal variceal bleeding, ascites, hepatic encephalopathy, spontaneous bacterial peritonitis, and hepatorenal syndrome. Time-series regression was used to determine whether a trend occurred over the study period. We also evaluated for patient-related demographic changes over the study period. RESULTS: A total of 259,897 cirrhotic patients with the studied decompensations were captured. During the study period, time-series regression confirmed downtrends in mortality rates and length of stay for all types of decompensations. Conversely, we found increases in hospitalization charges for all types of decompensations. Patient age increased over the study period. Patients were also more likely to be White and pay with. CONCLUSION: From 2007 to 2017, inpatient mortality rates and lengths of stay decreased for cirrhotic decompensations for all causes of decompensation. Total charges, conversely, increased for all causes.

Role of debulking mucoid ACL in unicompartmental knee arthroplasty: a prospective multicentric study.

BACKGROUND: Mucoid degeneration of the anterior cruciate ligament (ACL) has been shown to cause restricted terminal range of motion and rest pain. If present in a patient undergoing unicompartmental knee arthroplasty, it can deteriorate the final outcome. This study aims to compare functional and clinical outcomes of debulking the mucoid ACL in patients undergoing mobile-bearing unicompartmental knee arthroplasty (UKA). METHODS: Patients with mucoid ACL undergoing mobile-bearing UKA at five different centres by five different arthroplasty surgeons were included. They were segregated into two groups matched for all demographic and pre-operative values: group A did not undergo debulking; group B underwent open debulking by a 15-number blade prior to UKA. Patient-related outcome measures, rest pain, clinical outcomes, and subjective patient satisfaction were recorded and compared at 2 years follow-up. RESULTS: A total of 442 patients (226 patients underwent debulking, 216 patients did not undergo debulking) were included. Both groups showed overall improvement after surgery, however, patients who underwent debulking performed better at 2 years follow-up in terms of Knee Society functional score, International Knee Documentation Committee scores, range of motion, rest pain and overall patient satisfaction (p < 0.05) as compared with their counterparts. CONCLUSIONS: Debulking of mucoid ACL in patients undergoing unicompartmental knee arthroplasty significantly reduces the rest pain and improves the final range of motion of the knee joint, subsequently improving the overall functional and clinical outcome of the patient and resulting in greater patient satisfaction.

Functional and clinical outcome of anterior cruciate ligament reconstruction with peroneus longus autograft and correlation with MRI after 3 years.

Introduction: Autograft options for anterior cruciate ligament reconstruction over the years have gone from bone-patellar tendon-bone to hamstring to peroneus longus tendon. Considering the drawbacks of other autografts, we analyse peroneus longus autograft holistically as a viable alternative. Materials and methods: This was a prospective study of 113 patients undergoing anterior cruciate ligament reconstruction with peroneus longus autograft between January 2017 and November 2018 for isolated, full-thickness ACL tears. Functional analysis was done using the Tegner-Lysholm score pre-operatively, at 6 months, 1 year, 2 years, and 3 years postoperatively. At terminal follow-up, stability was checked clinically by Lachman test, residual morbidity of donor site was assessed using foot and ankle disability index, and radiographic correlation was done with magnetic resonance imaging. Results: The mean diameter of the graft after tripling was 9 ± 0.71 mm and the average length before tripling was found to be 27.07 ± 2.76 cms. At terminal follow-up, 101 patients showed excellent, while 12 patients showed good outcomes. The mean foot and ankle disability index was 94.8 ± 3. 90.27% of patients had no laxity on clinical examination, and magnetic resonance imaging of all the patients at terminal follow-up showed good graft uptake. Conclusions: Peroneus longus autograft shows intraoperative consistency and gives excellent functional outcome, clinical stability, and no donor site morbidity even three years postoperatively.

Maternal-Fetal Characteristics of Pregnant Women With Severe COVID Disease and Maternal-Neonatal Characteristics of Neonates With Early-Onset SARS-CoV-2 Infection: A Prospective Data Analysis.

Introduction COVID-19 and its mutants have significantly impacted the health care system, claiming numerous lives and adding to the morbidity. The data are scarce to describe the effect of disease severity on pregnancy outcomes, the possibility of mother-to-child transmission, and neonatal outcomes of COVID-positive babies. This study aimed to report the maternal and fetal characteristics of pregnant women with severe COVID disease as well as maternal and neonatal characteristics of neonates with early-onset SARS-CoV-2 infection. Materials and methods This is a prospective data analysis of pregnant women with severe COVID disease and neonates with early-onset SARS-CoV-2 infection. The disease parameters including demographic data, clinical presentation, investigations, management, and maternal and neonatal outcomes were recorded and analyzed. Results India has faced three waves till now. At the study center, a total of 165 (60, 68, and 37 in the first, second, and third waves, respectively) COVID-positive pregnant women were admitted during all three waves. No severe COVID disease with pregnancy was noted in the first and third waves. During the second wave (March to June 2021), 15 pregnant women were found to have severe COVID disease. All of them had COVID-related symptoms, with the majority requiring supplementary oxygen at presentation. Nine of these women had intrauterine fetal demise at admission. Nearly 73% were in their second trimester, and the rest were in the third trimester. There was raised total leukocyte count and alanine transaminase in 73% and raised aspartate transaminase in all cases. All of them were admitted to the intensive care unit. Two women in their third trimester had a termination of pregnancy by cesarean section, and one of the neonates had early neonatal death due to perinatal asphyxia. Both the neonates were COVID-19 positive. Eleven women with critical illness succumbed to the disease. No neonate was found to have early-onset SAR-CoV-2 infection during the first and third waves. Only 11 neonates tested positive for SARS-CoV-2 at the time of birth during the second wave. None of them had any COVID-related symptoms. Preterm birth was reported in four cases. The average Apgar scores at 1 and 5 minutes were 6.9 and 8.09, respectively. The average birth weight was 2,551.81 grams. All neonates were initially kept in the neonatal intensive care unit. Out of 11, four neonates required treatment in the form of positive-pressure ventilation, chest compressions, high-flow nasal oxygen, and non-invasive and invasive ventilation. Neonatal mortality was documented in two cases. Six mothers had one or more positive results in either amniotic fluid, placental membrane, or vaginal or cervical swab, highlighting the possibility of antepartum or intrapartum transmission. Conclusion Severe COVID disease during pregnancy was associated with high rates of intrauterine fetal demise and maternal mortality. Raised liver enzymes might be taken as a predicting factor for severe disease. On the other hand, early-onset neonatal SARS-CoV-2 infection is mostly asymptomatic and has a good prognosis. Additionally, mother-to-child transmission of SARS-CoV-2 is possible in the antepartum and intrapartum periods.

Outcomes of Hospitalized Patients Undergoing Endoscopic Retrograde Cholangiopancreatography (ERCP) With and Without a History of Peripheral Artery Disease.

Introduction Peripheral artery disease (PAD) is a common illness associated with an increased risk of complications and mortality. Gastroenterologists considering endoscopic retrograde cholangiopancreatography (ERCP) in these patients should weigh the benefits and risks carefully. Our goal is to analyze the hospital burden and complication rates in patients with PAD undergoing ERCP. Methods Using data from the National Inpatient Sample (NIS), patients over the age of 18 with and without PAD undergoing ERCP were identified utilizing the International Classification of Diseases (ICD)-9 codes. Primary outcomes included inpatient mortality, length of stay, and hospital charges. Secondary outcomes included rates of bile duct perforation, post-ERCP bleeding, acute pancreatitis, and cholangitis. Supplemental data, including household income and primary payer, were also analyzed. Independent t-tests were used for continuous data, chi-square tests for categorical data, and confounding variables (diabetes, age, gender, race) were controlled via multiple logistic regression. Results Most of the PAD group were male, while those in the non-PAD group were female (adjusted p<0.05). Mortality was higher in the PAD group (11.2% versus 8%; adjusted p<0.05). Members of the PAD group had longer lengths of stay (11.6 days versus 11 days; adjusted p<0.05) and more costly hospital stays ($108,006.49 versus $94,399.09; p<0.05). Members of the PAD group had higher rates of post-ERCP bleeding (5.2% versus 3.7%; adjusted p<0.05) and lower rates of cholangitis (6% versus 4%; adjusted p<0.05) and acute pancreatitis (6.9% versus 3.4%; adjusted p<0.05).  Conclusion Patients with PAD had an increased hospital burden but had a decreased risk of post-ERCP complications, including cholangitis and pancreatitis. Physicians performing risk stratification for patients with PAD undergoing ERCP must consider these specific complications and ensure that patients undergoing this procedure are fully aware of the dangers and benefits of ERCP prior to consenting to the procedure.

Hospital Utilization, Treatment Modalities, and Mortality Using Different Biopsy Methods in Infants With Biliary Atresia.

Objectives To present a nationwide retrospective analysis of the sequelae and aftereffects of different liver biopsy methods in the care of pediatric patients with biliary atresia. Methods The National Inpatient Sample 2001-2013 database was queried for a primary diagnosis of biliary atresia and stratified based on biopsy type including percutaneous, surgical, laparoscopic, and transjugular. Patient demographics, length of stay, hospital costs, type of treatment, and mortality were compared by biopsy type. One-way analysis of variance test and multivariable logistic regression were used for analysis with α < 0.05. Results A total of 4,306 patients with biliary atresia were identified, of whom 2,293 underwent no biopsy, and 723 and 1,080 underwent a percutaneous or surgical biopsy, respectively. Significant differences in socio-demographics were demonstrated between the biopsy types. The length of stay and hospital charges were statistically significantly different between the biopsy types where patients without biopsies had the smallest length compared to percutaneous, surgical, and combination of biopsies. Overall, the Kasai procedure was done more frequently compared to direct liver transplantation, and compared to other biopsy types, undergoing a combination of biopsies had the highest odds of undergoing either procedure. Conclusions When comparing different biopsy methods, surgical biopsies of the liver outperformed percutaneous biopsies in hospital utilization and progression to definitive treatments with the Kasai procedure. Our research indicated that vulnerable populations such as minorities or the indigent may undergo inferior treatments or infrequently undergo definitive treatment. The need for definitive diagnostic guidelines is understated in patients with biliary atresia.

Do Socio-Demographics Play a Role in the Prevalence of Red Flags and Pursuant Colonoscopies in Patients With Irritable Bowel Syndrome?

Background Irritable bowel syndrome (IBS) is a "brain-gut disorder" that lacks laboratory, radiologic, or physical exam findings. Colonoscopies are not routinely performed unless "red flag" symptoms, such as bleeding or abnormal weight loss, are present. Socio-demographics have been implicated as sources of potential disparities in appropriate care. Aims We hypothesize that the incidence of red flag symptoms and pursuant colonoscopies differ by socio-demographic status in patients with IBS. Methods Patients diagnosed with IBS were extracted from the National Inpatient Sample 2001-2013 using the International Classification of Diseases, Ninth Revision (ICD-9) codes. Gastrointestinal bleed, blood in stool, weight loss, and anemia were pooled into red flag symptoms. Colonoscopies during the admission were identified using ICD-9 procedural codes. Chi-square analysis and binomial logistic regression were used to evaluate potential disparities with α<0.01. Results Patients with Medicaid or Medicare or those without insurance had higher odds of presenting with red flag symptoms compared to those with private insurance. Medicaid patients and uninsured patients had higher odds of undergoing colonoscopies. All patients that were not Caucasian had higher odds of presenting with red flags and subsequently undergoing colonoscopies. Older patients had higher odds of presenting with concerning red flag symptoms but lower odds of undergoing colonoscopies. Conclusions The incidence of red flag symptoms and performance of colonoscopies differed by socio-demographics in patients with IBS. Patients with non-private or those without insurance were more likely to have red flags and undergo a colonoscopy. Age and race also increased rates of red flag symptoms while having a mixed effect on pursuant colonoscopies. This may represent discrepancies in healthcare utilization in a vulnerable population.

Endoscopic Management of Ingested Narcotic Substances: A Case Report and Literature Review.

Management of swallowed narcotics remains in contention despite the increased frequency of occurrence. International societies recommend conservative therapy with escalation to surgical interventions in cases where drug packets do not progress. However, multiple studies demonstrate a treatment benefit of endoscopic intervention. We report the case of a 27-year-old male who presented after ingesting heroin bundles and failed the 48-hour of conservative therapy. Repeat computed tomography scanning demonstrated no movement of the package. Endoscopic retrieval was successful, and the patient was discharged the same day. Endoscopic intervention in the removal of bagged narcotics should be considered in patients presenting after purposely ingesting narcotics as means of planned concealment.