Nosocomial spontaneous bacterial peritonitis is associated with high mortality - a systematic review and meta-analysis.

INTRODUCTION: It is unclear if Nosocomial Spontaneous Bacteria Peritonitis (NSBP) is associated with higher mortality compared with community acquired spontaneous bacterial peritonitis. METHODS: Database search from inception to May 2022 was conducted. The databases included MEDLINE, EMBASE, Cochrane registry of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus. Inclusion criteria were as follows: adult patients, age >18 years, with a diagnosis of NSBP. Pooled estimates of mortality were calculated following the restricted maximum likelihood method. The mortality rate between NSBP and CA-SBP was reported as odds ratio (OR) and 95% confidence interval (CI). Data synthesis was obtained using random effects meta-analysis. Heterogeneity was reported as I2. RESULTS: A total of 482 unique titles were screened. Twenty-two articles were included. A total of 2,145 patients with NSBP were included. Patients were followed for a median of 90 days. The pooled mortality rate of NSBP was 52.51% (95% CI 42.77-62.06%; I2 83.72%). Seven studies compared the mortality outcome of patients with NSBP and CA-SBP. NSBP was significantly associated with a higher rate of mortality (OR 2.78, 95% CI 1.87-4.11; I2 36.00%). CONCLUSION: NSBP was associated with higher mortality rate compared to CA-SBP, which could be due to a higher rate of resistance organisms.

Cardiac Metastasis After Curative Treatment of Hepatocellular Carcinoma: Assessment of Risk Factors, Treatment Options, and Prognosis.

Hepatocellular carcinoma (HCC) is primary hepatic malignancy with a high incidence of recurrence. The risk of recurrence directly correlates to patient's overall prognosis. Management of advanced HCC involves a combination of surgical resection, locoregional therapy, and systemic treatment. Distant metastases are rare, and intraventricular cardiac metastases are even more infrequent. This brief review details an illustrative case of cardiac metastasis after curative treatment of primary HCC and then summarizes the literature on risk factors, treatment options, and patient prognosis in the setting of distant metastases from HCC. Prognosis of metastasis to the heart is generally poor, and available evidence emphasizes the importance of maintaining regular posttreatment screening for metastases in patients with HCC. Given the variable presentation and high risk of recurrence, it is critical to have individualized multimodality treatment plans.

Oral health status among transgender young adults: a cross-sectional study.

BACKGROUND: Transgender and gender nonconforming (TGNC) people are a marginalized set of the population that continues to experience health care inequalities. This study aimed to assess oral health parameters including Candida growth and intensity among TGNC adults. METHODS: This cross-sectional study recruited two subgroups: 40 transgender and 40 control adults. Consented participants were interviewed and clinically examined. Data using the WHO oral health assessment forms were obtained. Samples for Candida growth and intensity analysis were collected from the dorsum surface of the tongue. RESULTS: 27.5% of the transgender group was HIV seropositive. Oral nicotine stomatitis and leukoplakia are reported to be the most prevalent intra-oral lesions showing a prevalence of 27.5% and 20%, respectively. The dental and periodontal health parameters of the transgender group were worse than those of the control group. The intensity of Candida colonies was significantly higher in the test group (p = 0.014). CONCLUSION: Poor oral health and significant oral mucosal disorders were reported in transgender adults that have shown a higher rate of behavioral risk factors such as tobacco and alcohol consumption. Further longitudinal studies in different world regions are warranted to understand the barriers to good oral health in transgender adults and how to implement effective prevention and management strategies.

Worse Outcomes Associated With Liver Transplants: An Increasing Trend.

Background and aim Since individuals in the early stages of liver cirrhosis are typically asymptomatic, the prevalence of liver cirrhosis may be underestimated. Liver cirrhosis has a significant morbidity and mortality rate, with 1.03 million deaths worldwide each year. For end-stage liver disease, liver transplantation is a potential therapeutic option. The goal of our research was to examine the current trend in liver transplants using data from a national database. Methods Using the International Classification of Diseases (ICD)-9 codes, we identified individuals who had a liver transplant during the index hospital admission in the Nationwide Inpatient Sample from 2007 to 2011. This national sample of patients is from the United States. We looked at the yearly trend in liver transplants and related outcomes, such as duration of hospitalization (DOH), hospital expenses, and mortality in the hospital. In order to find determinants of mortality, we used a multivariate analysis. Results There were 25,331 patients hospitalized (weighted for national estimate). Between 2007 and 2011, the number of transplants grew by 1.2%. The majority of transplant recipients were Caucasian (57%), with an average age of 54 years, had a private healthcare plan (53%), and had average earnings in the upper quartile by zip code (26%). Patients with a higher Charlson Comorbidity Index (79% had a score of four) were more likely to be admitted to a southern hospital (33%), an academic hospital (>99%), and a large capacity hospital (90%). Seventy percent of liver transplant recipients received cadaver donors. Hepatitis C was the most prevalent reason for transplant (30%), followed by hepatocellular carcinoma (HCC) (29%) and alcoholic liver disease (25%). In 2011, compared to 2007, there was an upward rise in fatality (from 3.8% to 5.1%), average hospital expenditures (from $335,504 to $498,369), and DOH (from 17.4 to 22.7 days). The cost of hospitalization was two billion dollars per year. The independent variables related to an increased mortality on multivariate analysis were African American race (OR: 2.0, 95%, CI: 1.2-3.2; p=0.005) and large capacity hospitals (OR: 2.5, 95% CI: 1.6-4.1; p=0.0002). Predictors linked to lower mortality included private healthcare coverage (vs. Medicare: OR: 0.7, 95%, CI: 0.51-0.97; p=0.03), academic hospital (OR: 0.6, 95% CI: 0.4-0.8; p=0.005), cadaver donor (OR: 0.6, 95% CI: 0.5-0.8; p=0.002), HCC (OR: 0.6, 95% CI: 0.4-0.9; p=0.01), and non-alcoholic steatohepatitis (NASH) cirrhosis (OR: 0.4, 95% CI: 0.2-0.9; p=0.02). Conclusion Our study found an increasing trend in worse outcomes (increased mortality, average hospital costs, and average DOH) after a liver transplant. Patients of the African American race and large capacity hospitals were associated with a higher risk of death, whereas private healthcare plans, academic hospitals, cadaver donors, HCC, and NASH cirrhosis were associated with a lower risk.

Hepatitis C Virus in the Elderly in the Direct-Acting Antiviral Era: from Diagnosis to Cure.

PURPOSE OF REVIEW: Hepatitis C (HCV) is the most common cause of viral hepatitis in elderly individuals. This patient population previously experienced suboptimal outcomes with interferon-based regimens. Unfortunately, patients aged 65 years and older were underrepresented in phase 2 and 3 clinical trials with newer direct acting antiviral (DAA) therapies. Since the advent of second-generation DAA in 2013, numerous robust real-world experiences highlighting the efficacy and safety of DAA in the elderly have been published. This review article summarizes the cascade of care for hepatitis C from diagnosis to cure from an evidence-based perspective of the aging population. RECENT FINDING: In a large study from the Veterans Affairs Healthcare System, the overall sustained virologic response (SVR) of 15,884 patients treated with DAA regimens was 91.2%. These newer therapies remained highly effective in the subset of patients aged 65 years and older with SVR rates above 90%. A Spanish National Registry reported outcomes in patients ≥ 65 years old treated for HCV with oral DAA regimens over a 2-year period. The overall SVR was 94% in the study of 1252 subjects. SUMMARY: Current real-world data imply DAA treatment regimens remain highly effective and safe in elderly patients when compared to the general population.

Change in the Mortality Trend of Hospitalized Patients with Clostridium difficile Infection: A Nation-wide Study.

Background According to the Healthcare Cost and Utilization Project (HCUP), mortality in Clostridium difficile infection (CDI) has been rising since 2009, and an upward trend in mortality has been noted. Although there have been studies exploring the incidence of CDI and mortality in the national database, those studies were limited to one particular year. With the advent of newer modalities of diagnosis and treatment for CDI, the recent multiyear trend in disease-specific outcomes from large administrative databases is unknown. Objective To study the recent trend in nationwide hospital admissions and mortality along with hospital outcomes. Methods We queried the identified National Inpatient Sample from 2007 to 2011 to identify patients of age >18 years, with a discharge diagnosis of CDI identified by the International Classification of Diseases, 9th edition (ICD-9), clinical modification codes 008.45, respectively. Results We identified a decline in CDI mortality to 2.67% in 2011 as compared to 3.83% in 2007 (P<0.0001) with CDI as the primary discharge diagnosis and a downward trend in all-cause mortality from 9.2% in 2007 to 7.9% in 2011 (P<0.0001). We identified an upward trend in CDI-related hospital discharges from 2007 (N=325,022) to 2011 (N=333498). Hospital discharges with CDI as a primary discharge diagnosis also increased from 2007 (N=104,123) to 2011 (123,898). The mean length of stay decreased from 7.16 days in 2007 to 6.40 days in 2011 (P 0.0001). CDI was noted to be more common in the elderly (61-80), with a mean age of 68 years. Patients were of Caucasian descent (67%), female (64%), and primarily a Medicare payer (69%). Mean hospital charges increased from $31,551 to 35,654$ (P .04). Of interest, CDI was noted to be more common in large bed-sized non-teaching hospitals (57%) than large bed-sized teaching hospitals (42%). In terms of the geographical distribution of CDI, the southern states of the US had an increased incidence of CDI (36%) and the west coast (16%) had the least incidence. Conclusion  Our study shows an improved trend in-hospital mortality outcomes and a decreased length of stay likely related to the advancement in CDI treatments. Hospital charges were increased from 2007 to 2011 in spite of a decrease in hospital length of stay.

Association of Pretransplant Renal Function With Liver Graft and Patient Survival After Liver Transplantation in Patients With Nonalcoholic Steatohepatitis.

Nonalcoholic steatohepatitis (NASH) is one of the top 3 indications for liver transplantation (LT) in Western countries. It is unknown whether renal dysfunction at the time of LT has any effect on post-LT outcomes in recipients with NASH. From the United Network for Organ Sharing-Standard Transplant Analysis and Research data set, we identified 4088 NASH recipients who received deceased donor LT. We divided our recipients a priori into 3 categories: group 1 with estimated glomerular filtration rate (eGFR) <30 mL/minute/1.73 m2 at the time of LT and/or received dialysis within 2 weeks preceding LT (n = 937); group 2 with recipients who had eGFR ≥30 mL/minute/1.73 m2 and who did not receive renal replacement therapy prior to LT (n = 2812); and group 3 with recipients who underwent simultaneous liver-kidney transplantation (n = 339). We examined the association of pretransplant renal dysfunction with death with a functioning graft, all-cause mortality, and graft loss using competing risk regression and Cox proportional hazards models. The mean ± standard deviation age of the cohort at baseline was 58 ± 8 years, 55% were male, 80% were Caucasian, and average exception Model for End-Stage Liver Disease score was 24 ± 9. The median follow-up period was 5 years (median, 1816 days; interquartile range, 1090-2723 days). Compared with group 1 recipients, group 2 recipients had 19% reduced trend for risk for death with a functioning graft (subhazard ratio [SHR], 0.81; 95% confidence interval [CI], 0.64-1.02) and similar risk for graft loss (SHR, 1.25; 95% CI, 0.59-2.62), whereas group 3 recipients had similar risk for death with a functioning graft (SHR, 1.23; 95% CI, 0.96-1.57) and graft loss (SHR, 0.18; 95% CI, 0.02-1.37) using an adjusted competing risk regression model. In conclusion, recipients with preserved renal function before LT showed a trend toward lower risk of death with a functioning graft compared with SLKT recipients and those with pretransplant severe renal dysfunction in patients with NASH.

Decreased trend in hospital mortality from pancreatic cancer despite increase in number of hospital admissions.

BACKGROUND AND AIM: Pancreatic cancer is one of the common cancers in US and is associated with high mortality and morbidity. The objectives of our study were to look at the recent trends in the number of hospitalizations with pancreatic cancer. METHODS: We identified patients with a discharge diagnosis of pancreatic cancer in the National Inpatient Sample from 2007 to 2011 using International Classification of Diseases-Clinical Modification, 9th revision (ICD-9-CM) codes. We looked at the yearly trend in the hospitalizations with pancreatic cancer and the outcomes which included length of stay (LOS), hospital charges and in-hospital mortality. We also performed multivariate analysis to look for the predictors of mortality. RESULTS: There were 450, 414 patients with discharge diagnosis of pancreatic cancer. There was 18% increase in hospitalizations with pancreatic cancer in 2011 compared to 2007. Most of the patients were Caucasian (63%) with the mean age of 68 ± 0.14 years, had Medicare (57%) as primary insurance, were from Southern region (35%) and had higher Charlson Comorbidity Index (CCI) (87% with CCI > = 5). 6% underwent Whipple's procedure in the index hospitalization. After the adjustment for inflation, the mean hospital charges increased from $ 47,331 in 20007 to $ 53, 854 in 2011 (p = 0.01). LOS decreased from 7.31 ± 0.11 days in 2007 to 6.70 ± 0.09 days in 2011 (<0.001). Despite the increase in the number of hospitalizations of patients with pancreatic cancer, mortality decreased from 9.8% in 2007 to 8.1% in 2011 (p<0.001). On multivariate analysis, the independent factors associated with higher mortality were older age, male sex African-American race, insurance status other than Medicare, higher CCI and enrollment in palliative care. There was regional variation in mortality. Whipple's procedure conferred lower mortality. CONCLUSIONS: Our study showed downward trends in LOS and in-hospital mortality despite increasing hospitalizations with pancreatic cancer.

Increased Rate of Venous Thromboembolism in Hospitalized Inflammatory Bowel Disease Patients with Clostridium Difficile Infection.

BACKGROUND: Risk of venous thromboembolism (VTE) in patients with inflammatory bowel disease (IBD) is well established; however, there is paucity of data on the potential added risk of VTE in patients with IBD with Clostridium difficile infection (CDI). We sought to study the difference in VTE rates in hospitalized patients with IBD with CDI compared to those without CDI. METHODS: We queried Nationwide Inpatient Sample from year 2011 to identify patients ≥18 years of age with a discharge diagnosis of IBD (i.e., Crohn's disease and ulcerative colitis) based on ICD-9-CM codes 555.xx and 556.xx, respectively. Patients were further divided into 2 groups: those with and without CDI. To adjust and control for potential baseline differences between groups, 1:1 propensity matching was performed. Multivariate regression analysis was used to evaluate the difference in VTE rates in 2 groups. RESULTS: Of 312,147 patients with the discharge diagnosis of IBD, 12,560 (4%) had CDI. VTE was present 6% in group with CDI versus 3% in group without CDI (P < 0.001). On performing multivariate analysis after propensity-score matching, CDI was significantly associated with VTE (adjusted odds ratio 1.7, 95% confidence interval 1.4-2.2, P < 0.001). On subgroup analysis, Crohn's disease with CDI had a higher association with VTE compared with Crohn's disease only. Similarly, ulcerative colitis with CDI had a higher association with VTE compared with ulcerative colitis only. CONCLUSIONS: Rate of VTE was higher in hospitalized patients with IBD with CDI compared with those without CDI, necessitating extra vigilance in this patient population.

Peripheral ivory osteoma of the mandible in a young female patient.

Osteoma is an uncommon benign neoplasm composed of mature bone. Growth is slow and continuous and located principally in the cranio-maxillo-facial region, and can be central (endosteal) or peripheral (periosteal). Osteomas can be solitary or multiple masses, and they are generally asymptomatic. We discuss a case of ivory osteoma of the mandible in a 35-year-old female, which was present at the left body of the mandible since she was 10 years old, and was gradually increasing in size. The osteoma was removed surgically through an intraoral approach, and no recurrence was observed.

Serum total protein, albumin and advanced oxidation protein products (AOPP) - implications in oral squamous cell carcinoma

Background: The role of oxygen free radicals in the initiation, promotion and progression of carcinogenesis and the protective role of anti-oxidant defenses have been the subject of much speculation in the recent past with confl icting reports in the literature. Objectives: The aim of this study was to measure the concentration/levels of serum total proteins, albumin and advanced oxidation protein products as markers of oxidative stress in sera of patients with an oral pre-cancerous lesion and frank oral cancer. Materials and methods: The study consisted of sera analysis of 30 new patients of histologically proven well-differentiated, oral squamous cell carcinoma and 10 patients, clinically diagnosed with a potentially malignant epithelial lesion, speckled leukoplakia, aged between 40 to 60 years, in addition to 25 healthy controls. One way analyses of variance were used to test the difference between groups. The normality of data was checked before the statistical analysis was performed. Results: The study revealed variations in sera levels of albumin and advanced oxidation protein products to be statistically signifi cant (p < 0.001). Conclusion: The results obtained emphasize the need for more studies with larger sample sizes to be conducted before a conclusive role could be drawn in favour of sera levels of total protein, albumin and advanced oxidation protein products as markers of diagnostic signifi cance and of the transition from the various oral pre-cancerous lesions and conditions into frank oral cancers.

Serum folic acid levels in epilepsy patients before and after phenytoin therapy

Background & Objectives: Low serum folate level is often reported as an adverse drug sequela of long term phenytoin usage seen with prolonged duration of phenytoin therapy. There is no previous study to prospectively track the serum folate level with usage of phenytoin, which is the objective of this study. Methods: Twenty-fi ve patients between the ages of 18-50 years diagnosed to have epilepsy and planning to start phenytoin were recruited in this study. Assessment of serum folic acid was done by chemiluminiscent method prior to the start of phenytoin and after 6 months of treatment. The serum folate level of 10 age and sex matched healthy control was also taken. Results: The average serum folate level was 7.48 + 2.04 ng/mL prior to the start of phenytoin therapy, which fell to 3.9 + 1.95 ng/mL after 6-month of phenytoin therapy (p-value <0.001). The average serum folate level for the age and sex matched 10 control samples was 14.46 + 2.81 ng/mL. Conclusion: A signifi cant fall of serum folic acid levels is seen in epilepsy patients after 6 months treatment with phenytoin.