Incidence and risk factors of cardiovascular mortality in patients with gastrointestinal adenocarcinoma.

BACKGROUND: Gastrointestinal (GI) cancers are common and fatal. Improved cancer-directed therapies, with thier substantial role in improving cancer-specific survival, may increase non-cancer mortality-including cardiovascular mortality-in these patients. AIM: To identify the risk factors of cardiovascular mortality in GI adenocarcinoma patients. METHODS: Data of GI adenocarcinoma patients were gathered from the Surveillance, Epidemiology, and End Results database. We used Pearson's chi-square test to assess the relationships between categorical variables. We used the Kaplan-Meyer test in the univariate analysis and Cox regression test for the multivariate analysis. RESULTS: Among 556,350 included patients, 275,118 (49.6%) died due to adenocarcinoma, 64,079 (11.5%) died due to cardiovascular causes, and 83,161 (14.9%) died due to other causes. Higher rates of cardiovascular mortality were found in patients ≥ 50 years (HR, 8.476; 95% CI, 7.91-9.083), separated (HR, 1.27; 95% CI, 1.184-1.361) and widowed (HR, 1.867; 95% CI, 1.812-1.924), patients with gastric (HR, 1.18; 95% CI, 1.1-1.265) or colorectal AC (HR, 1.123; 95% CI, 1.053-1.198), and patients not undergone surgery (HR, 2.04; 95% CI, 1.958-2.126). Lower risk patients include females (HR, 0.729; 95% CI, 0.717-0.742), blacks (HR, 0.95; 95% CI, 0.924-0.978), married (HR, 0.77; 95% CI, 0.749-0.792), divorced (HR, 0.841; 95% CI, 0.807-0.877), patients with pancreatic AC (HR, 0.83; 95% CI, 0.757-0.91), and patients treated with chemotherapy (HR, 0.416; 95% CI, 0.406-0.427). CONCLUSIONS: Risk factors for cardiovascular mortality in GI adenocarcinoma include advanced age, males, whites, separated and widowed, gastric or colorectal adenocarcinoma, advanced grade or advanced stage of the disease, no chemotherapy, and no surgery. Married and divorced, and patients with pancreatic adenocarcinoma have a lower risk.

Gastrointestinal involvement in systemic sclerosis: An updated review.

The gastrointestinal tract (GI) is the second most affected organ system in individuals suffering from systemic/localized scleroderma (SSc) or localized scleroderma. SSc can affect any part of the GI, between the oral cavity and anorectum. The annual incidence of SSc in the United States is estimated to be 19.3 cases per million adults, with the highest incidence reported in people aged 44 to 55. Females are 5 times more likely than males to suffer from SSc. Morbidity and mortality rates associated with SSc are predominantly elevated among patients with GI manifestations. Esophageal and intestinal manifestations impact 90% and 40% to 70% of patients with systemic scleroderma, respectively. SSc patients are known to suffer from small bowel hypomotility and small intestinal bacterial overgrowth, which cause malabsorption and malnutrition, ultimately contributing to the 50% mortality rate. Fecal incontinence is a common symptom of SSc that can lead to depression. SSc patients may suffer from gastrointestinal complications that can negatively impact their quality of life on a daily basis. Multidisciplinary approaches are necessary for systematically managing gastrointestinal complications associated with SSc. A prospective study should focus on developing targeted therapies to improve recovery patterns and prognosis in cases of SSc. This article summarizes the epidemiology, commonly reported clinical manifestations, complications, and available treatments for treating GI pathology in SSc patients.

Biliary Anastomosis Using T-tube Versus No T-tube for Liver Transplantation in Adults: A Review of Literature.

The T-tube-directed biliary anastomosis in orthotopic liver transplantation (OLT) aims to minimize preventable biliary complications, including bile leaks and strictures. Biliary complications in patients with OLT increase the risk of morbidity and mortality. This review paper evaluated the current evidence on the routine use of T-tube reconstruction in OLT cases. A review of prospective, retrospective, observational, cohort studies as well as systematic reviews, meta-analyses, review papers, and opinion papers has been conducted to evaluate the therapeutic potential of T tube-based biliary anastomosis in cases of OLT. Our finding showed a bile leak incidence of 16.6% and 6.6% in T-tube and non-T-tube groups, respectively. The results indicated a lower incidence of anastomotic fistulae in the non-T-tube group (0.6%) compared to the T-tube group (4%). The findings negated statistically significant differences in the three-year actuarial survival rates based on biliary anastomosis with and without T-tube intervention (62.5% vs. 69.8%). The studies revealed a 6-11% and 2-11% incidence of cholangitis in OLT patients with T-tube-based reconstruction and those without a T-tube, respectively, and 26% and 20% incidence of total biliary complications in OLT patients with and without T-tube, respectively. In addition, the findings ruled out the influence of a T-tube on the incidence of perioperative complications, endoscopies, and reoperations in OLT cases. The current evidence correlates the increased incidence of bile leaks, cholangitis, and overall biliary complications with the use of a T-tube during OLT. In addition, T-tube-guided reconstruction has no impact on perioperative complications, overall survival, endoscopies, and reoperations in OLT cases.

Continuous Infusion Low-Dose Unfractionated Heparin for the Management of Hypercoagulability Associated With COVID-19.

INTRODUCTION: The Coronavirus Disease 2019 (COVID-19) is associated with severe hypercoagulability. There is currently limited evidence supporting the routine use of therapeutic anticoagulation in the setting of COVID-19. OBJECTIVES: The primary objective was to compare the incidence of thromboembolic events in adult patients with COVID-19 treated with an unfractionated heparin (UFH) infusion versus prophylactic dose anticoagulation. Secondary objectives included exploration of the efficacy and safety of an UFH infusion through the evaluation of organ function and incidence of minor and major bleeding. METHODS: Retrospective observational cohort study with propensity score matching of COVID-19 patients who received an UFH infusion targeting an aPTT between 40 and 60 seconds. RESULTS: Fifty-six patients were included in this study. There was no difference in the composite of thromboembolic events comprised of venous thromboembolism, arterial thrombosis, and catheter-related thrombosis between the UFH and control group (17.9% vs. 3.6%, P = 0.19). There was a significant increase in median D-dimer concentrations from day 1 to day 7 in the control group (475 ng/mL [291-999] vs. 10820 ng/mL [606-21033], P = 0.04). Patients treated with UFH had a higher incidence of minor bleeding (35.7% vs. 0%, P < 0.005) and required more units of packed red blood cell transfusion (0.8 units ± 1.6 vs. 0 units, P = 0.01). CONCLUSION: Continuous infusion of UFH for patients with COVID-19 infection did not decrease the overall incidence of thromboembolic complications. UFH was associated with stabilization of D-dimer concentrations and increased rates of minor bleeding and transfusions.

Cannabis and Its Potential Protective Role Against Inflammatory Bowel Disease: A Scoping Review.

Globally, around 15%-40% of patients suffering from inflammatory bowel disease (IBD) use Cannabis for pain reduction, increased appetite, and reduced need for other medications. Although many patients report having benefited by using Cannabis in IBD, there is still a lack of consensus regarding the use of Cannabis in IBD. The aim is to identify, explore and map literature on the potential protective role of Cannabis against IBD through this scoping review. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed during the search to answer the focal question: (1) Does Cannabis play a protective role against IBD as assessed by clinical remission; (2) If yes, what is the mechanism of action for this protective role. There were only three randomized controlled trials (RCTs) and three observational studies that satisfied the selection criteria of this scoping review. Although promising results including the improvement in general well-being/ Harvey-Bradshaw Index, health perception enhancement [4.1±1.43 to 7±1.42 (p = 0.0002)], weight gain, Crohn's Disease Activity Index (CDAI) score<150, Mayo scores (4-10), and reduction in clinical complications have been found in some studies, its medical use in IBD is still questionable due to the lack of high-quality evidence. Future RCTs studies should determine the cannabis treatment parameters and validate its safety and effectiveness in the IBD setting. The highlights include: the current literature provides inconclusive evidence concerning the protective role of cannabis for IBD patients; limited research evidence regarding the therapeutic use of cannabinoids for IBD warrants future investigation via RCTs; cannabis provides some benefits to IBD patients by improving their general well-being perceptions, Harvey-Bradshaw Index, Mayo scores, and minimizing their clinical complications.

Current systematic reviews and meta-analyses of COVID-19.

BACKGROUND: Coronavirus disease 2019 (COVID-19) has left a significant impact on the world's health, economic and political systems; as of November 20, 2020, more than 57 million people have been infected worldwide, with over 1.3 million deaths. While the global spotlight is currently focused on combating this pandemic through means ranging from finding a treatment among existing therapeutic agents to inventing a vaccine that can aid in halting the further loss of life. AIM: To collect all systematic reviews and meta-analyses published related to COVID-19 to better identify available evidence, highlight gaps in knowledge, and elucidate further meta-analyses and umbrella reviews that are yet to be performed. METHODS: We explored studies based on systematic reviews and meta-analyses with the key-terms, including severe acute respiratory syndrome (SARS), SARS virus, coronavirus disease, COVID-19, and SARS coronavirus-2. The included studies were extracted from Embase, Medline, and Cochrane databases. The publication timeframe of included studies ranged between January 01, 2020, to October 30, 2020. Studies that were published in languages other than English were not considered for this systematic review. The finalized full-text articles are freely accessible in the public domain. RESULTS: Searching Embase, Medline, and Cochrane databases resulted in 1906, 669, and 19 results, respectively, that comprised 2594 studies. 515 duplicates were subsequently removed, leaving 2079 studies. The inclusion criteria were systematic reviews or meta-analyses. 860 results were excluded for being a review article, scope review, rapid review, panel review, or guideline that produced a total of 1219 studies. After screening articles were categorized, the included articles were put into main groups of clinical presentation, epidemiology, screening and diagnosis, severity assessment, special populations, and treatment. Subsequently, there was a second subclassification into the following groups: gastrointestinal, cardiovascular, neurological, stroke, thrombosis, anosmia and dysgeusia, ocular manifestations, nephrology, cutaneous manifestations, D-dimer, lymphocyte, anticoagulation, antivirals, convalescent plasma, immunosuppressants, corticosteroids, hydroxychloroquine, renin-angiotensin-aldosterone system, technology, diabetes mellitus, obesity, pregnancy, children, mental health, smoking, cancer, and transplant. CONCLUSION: Among the included articles, it is clear that further research is needed regarding treatment options and vaccines. With more studies, data will be less heterogeneous, and statistical analysis can be better applied to provide more robust clinical evidence. This study was not designed to give recommendations regarding the management of COVID-19.

A Rare Case of Eosinophilic Gastroenteritis and Ampullitis Leading to Benign Papillary Stenosis.

Eosinophilic gastroenteritis is characterized by eosinophilic infiltration of the gastrointestinal wall. There have been limited studies of eosinophilic infiltration involving the ampulla. We present a 70-year-old woman with a history of asthma, eosinophilic esophagitis, and eosinophilic sinusitis, who underwent work up for postprandial abdominal pain and abnormal liver function tests. The patient had various imaging studies done, including computed tomography (CT) scan, magnetic resonance imaging (MRI), and magnetic resonance cholangiopancreatography (MRCP). Dilated extrahepatic bile duct with distal tapering towards the ampulla was noted on MRCP and afterwards on endoscopic ultrasound (EUS). Endoscopic retrograde cholangiopancreatography (ERCP) revealed an inflamed major ampulla with benign papillary stenosis. The patient was treated with sphincterotomy, sphincteroplasty/dilation of distal common bile duct, and placement of an 11.5 Fr × 7 cm plastic stent into the bile duct. Additionally, she was started on prednisone, which was gradually tapered down. The patient demonstrated significant improvement with systemic steroid therapy. Liver function tests (LFTs) completely normalized after ERCP. Ampullitis leading to papillary stenosis secondary to eosinophilic infiltration of the major papilla is a rare manifestation of eosinophilic gastrointestinal disorders (EGIDs). Early diagnosis would lead to appropriate medical and endoscopic management.

Community-Acquired Methicillin-Resistant Staphylococcus Aureus Hepatic Liver Abscess.

A methicillin-resistant Staphylococcus aureus (MRSA) liver abscess is a rare infection that if not recognized, and treated early, can be fatal. There is limited literature demonstrating possible etiologies of MRSA liver abscesses, whether nosocomial or community acquired. We present a case of a 45-year-old Guyanese male with a 30 pack-year smoking history. The patient presented with both generalized abdominal pain and a productive cough on two separate occasions. Laboratory results in his second presentation revealed leukocytosis with increased alanine transaminase (ALT). Imaging revealed a multiloculated abscess in the inferior aspect of the liver, measuring 5.1 cm x 3.4 cm x 4 cm, and chest X-ray revealed developing consolidation within the right perihilar region. The patient underwent percutaneous liver drainage via pigtail catheter. Fluid cultures grew MRSA. The patient was placed on vancomycin for three weeks. On subsequent examinations, there was a resolution of leukocytosis with no drainage from the pigtail catheter. Elevations of aspartate transaminase (AST), ALT, and gamma-glutamyl transferase (GGT) were observed. Therefore, in addition to restarting vancomycin, the patient was started on ciprofloxacin for two weeks and liver function tests (LFTs) trended downwards, without recurrence of symptoms. High suspicion for liver abscess should exist in patients that present with complaints of abdominal pain and elevated LFTs when a previous source of infection has been observed. MRSA liver abscesses are rare and potentially fatal, therefore, early recognition and appropriate management is essential.

The association between COVID-19 and type 1 diabetes mellitus: A systematic review.

BACKGROUND: /Aim: Various reports of the occurrence of type 1 diabetes mellitus (T1DM) in patients with COVID-19 have been published, denoting an association between both diseases. Therefore, we conducted this systematic review to summarize the prevalence of T1DM in COVID-19 patients and to identify the clinical presentations and outcomes in this patient population. MATERIALS AND METHODS: Up to 10/27/2020, Medline, Embase, cochrane and google scholar databases were searched for original studies investigating the association between COVID-19 and T1DM. A manual search was conducted to identify missing studies. The quality of included studies was analyzed by the National Institute of Health (NIH) risk of bias tool. Outcomes included length of hospital stay, hospitalization, intensive care unit (ICU) admission, diabetic ketoacidosis (DKA), severe hypoglycemia, and death. RESULTS: Fifteen studies were included in the qualitative analysis. Included studies reported data of both adult and pediatric patients. The prevalence of T1DM in COVID-19 patients ranged from 0.15% to 28.98%, while the rate of COVID-19 in patients with T1DM ranged from 0% to 16.67%. Dry cough, nausea, vomiting, fever and elevated blood glucose levels were the most commonly reported presentations. The investigated outcomes varied widely among studied populations. CONCLUSIONS: The prevalence of T1DM in patients with COVID-19 ranged from 0.15% to 28.98%. The most common presentation of COVID-19 in patients with T1DM included fever, dry cough, nausea and vomiting, elevated blood glucose and diabetic ketoacidosis. The outcomes of COVID-19 in terms of length of hospital stay, hospitalization, ICU admission, DKA rate, and severe hypoglycemia were reported variably in included studies. Due to the heterogeneous study populations and the presence of many limitations, more studies are still warranted to reach a definitive conclusion.

The Association Between BMI and Inpatient Mortality Outcomes in Older Adults With COVID-19.

Background and aim Coronavirus disease 2019 (COVID-19) is known to cause a broad spectrum of illnesses. There is evidence that obesity-related conditions may increase the severity of COVID-19 disease, especially in those below the age of 60. However, there has been limited research on mortality rate based on body mass index (BMI) in the older adult population, defined as age over 65. The objective of this study was to characterize outcomes in older adults infected with COVID-19 based on BMI. Study design and methods It is a single-center retrospective cohort study of older adults with COVID-19 infection. The primary outcome was hospital mortality. Secondary outcomes assessed were oxygen requirements, need for mechanical ventilation, duration of mechanical ventilation, and hospital length of stay. Data were analyzed with the Student's t-test, Fisher's exact test, and multiple logistic regression analyses as appropriate. Results A total of 290 patients were included in this study. The mean age was 77.6 years. The median BMI was >30 kg/m2. The primary outcome of hospital mortality occurred in 49.7% of patients. BMI was not found to be a predictor of mortality. Age 75-79 and age ≥ 85 were associated with an increased risk of mortality (OR: 2.58; 95% CI: 1.15 - 5.79; OR: 3.17; 95% CI: 1.35 - 7.44, respectively). Patients with a BMI < 18.5, BMI 18.5 - 25, and age ≥ 85 were less likely to require mechanical ventilation (OR: 0.06; 95% CI: 0.00 - 0.83; OR:0.11; 95% CI: 0.02 - 0.64 and OR:0.28; 95% CI: 0.09 - 0.92, respectively). Past medical history was not associated with mortality. Conclusion In a cohort of older adults with COVID-19 disease, BMI was not an independent predictor of in-hospital mortality. Patients with BMI ≤ 25 and age ≥ 85 years were less likely to require mechanical ventilation.

Intestinal Pseudo-Obstruction as the Initial Clinical Presentation in Systemic Lupus Erythematosus: A Rare and Severe Disorder.

Intestinal pseudo-obstruction (IPO) is a rarely recognized complication of systemic lupus erythematosus (SLE). We present a 36-year-old African American female, with only known past medical history of anemia, admitted for frequent vomiting, abdominal distension, abdominal pain, diarrhea, and fever that had been ongoing for 5 days. Laboratory results revealed leukopenia and thrombocytopenia. Imaging revealed dilated small bowel loops, abdominal ascites, as well as mild bilateral hydroureteronephrosis without obstructing calculus. Serologic testing confirmed a diagnosis of SLE. The patient was placed on immunosuppressive therapy and responded well. IPO has previously been described as a rare finding in patients with SLE, with bilateral hydroureteronephrosis and lupus interstitial cystitis having been noted as common concomitant factors. One must have a high level of suspicion to recognize it as being one of the initial clinical presentations. Early recognition and appropriate management preclude unnecessary invasive procedures that do not take into account the pathophysiology of the condition and allow for appropriate management and return of peristaltic function.

Small molecules and Alzheimer's disease: misfolding, metabolism and imaging.

Small molecule interactions with amyloid proteins have had a huge impact in Alzheimer's disease (AD), especially in three specific areas: amyloid folding, metabolism and brain imaging. Amyloid plaque amelioration or prevention have, until recently, driven drug development, and only a few drugs have been advanced for use in AD. Amyloid proteins undergo misfolding and oligomerization via intermediates, eventually forming protease resistant amyloid fibrils. These fibrils accumulate to form the hallmark amyloid plaques and tangles of AD. Amyloid binding compounds can be grouped into three categories, those that: i) prevent or reverse misfolding, ii) halt misfolding or trap intermediates, and iii) accelerate the formation of stable and inert amyloid fibrils. Such compounds include hydralazine, glycosaminoglycans, curcumin, beta sheet breakers, catecholamines, and ATP. The versatility of amyloid binding compounds suggests that the amyloid structure may serve as a scaffold for the future development of sensors to detect such compounds. Metabolic dysfunction is one of the earliest pathological features of AD. In fact, AD is often referred to as type 3 diabetes due to the presence of insulin resistance in the brain. A recent study indicates that altering metabolism improves cognitive function. While metabolic reprogramming is one therapeutic avenue for AD, it is more widely used in some cancer therapies. FDA approved drugs such as metformin, dichloroacetic acid (DCA), and methylene blue can alter metabolism. These drugs can therefore be potentially applied in alleviating metabolic dysfunction in AD. Brain imaging has made enormous strides over the past decade, offering a new window to the mind. Recently, there has been remarkable development of compounds that have the ability to image both types of pathological amyloids: tau and amyloid beta. We have focused on the low cost, simple to use, near infrared fluorescence (NIRF) imaging probes for amyloid beta (Aß), with specific attention on recent developments to further improve contrast, specificity, and sensitivity. With advances in imaging technologies, such fluorescent imaging probes will open new diagnostic avenues.