Ascitic calprotectin and lactoferrin for detection of spontaneous bacterial peritonitis: a systematic review and meta-analysis.

Background: Spontaneous bacterial peritonitis (SBP) is a common bacterial infection in cirrhotic patients associated with a high mortality rate. Prompt diagnosis and early antibiotic administration are crucial in minimizing adverse outcomes. Although detection of ≥250 polymorphonuclear leukocytes (PMN) in ascitic fluid is the current gold standard to diagnose SBP, consideration for rapid detection with biomarkers is warranted. Methods: A literature search for studies evaluating ascitic calprotectin and lactoferrin for detection of SBP was performed using PubMed, Embase, Scopus, Google Scholar, Cochrane library, and Clinical Trial Registries. Summary sensitivity, specificity, log diagnostic odds ratio (LDOR), and area under the summary receiver operating curve (AUC) were calculated. Results: In total, 12 and 13 studies evaluated ascitic calprotectin and lactoferrin, respectively, for detection of SBP. Summary sensitivity, specificity, and LDOR for calprotectin were 0.942 (95% CI, 0.916, 0.967), 0.860 (95% CI, 0.799, 0.935), and 4.250 (95% CI, 3.504, 4.990), respectively. AUC for calprotectin was 0.91. Summary sensitivity, specificity, and LDOR for lactoferrin were 0.954 (95% CI, 0.930, 0.979), 0.890 (95% CI, 0.836, 0.945), and 4.630 (95% CI, 3.800, 5.452), respectively. AUC for lactoferrin was 0.958. Conclusions: The overall performance of ascitic calprotectin and lactoferrin was substantial, potentially serving as a screening tool or an alternative to manual cell count. However, a variety of manufacturers, cut-off values, and significant heterogeneity between studies should be noted. Point-of-care testing for calprotectin and lactoferrin may resolve disadvantages associated with the current methods. Future studies on this topic are, therefore, needed.

Performance of Leukocyte Esterase Reagent Strips in the Detection of Spontaneous Bacterial Peritonitis in Cirrhotic Patients: A Systematic Review and Meta-analysis.

Background: Spontaneous bacterial peritonitis (SBP) is a bacterial infection associated with a high mortality rate in cirrhotic patients. The gold standard for the detection of SBP is a manual cell count from ascitic fluid; however, alternative screening methods are under investigation. In particular, leukocyte esterase reagent strips (LERS) has been studied as an alternative method to detect SBP with a low cost and instant turnaround time. Therefore, this study aims to evaluate the performance of LERS in the detection of SBP. Methods: A literature search was performed for studies evaluating LERS for the detection of SBP on PubMed, Embase, Scopus, Cochrane, and clinical trial registries. Summary sensitivity, specificity, log diagnostic odds ratio (LDOR), and the area under the summary receiver operating curve (AUC) were calculated according to the respective manufacturer. Results: In total, 31 studies were evaluated. The summary sensitivity of Aution Sticks, Combur, Multistix, Periscreen reagent strips was 0.962 (95% confidence interval [CI] 0.926, 0.998), 0.892 (95% CI 0.846, 0.938), 0.806 (95% CI 0.738, 0.874), and 0.939 (95% CI 0.900, 0.979), respectively. The summary specificity of Aution Sticks, Combur, Multistix, and Periscreen reagent strips was 0.940 (95% CI 0.904, 0.976), 0.922 (95% CI 0.874, 0.970), 0.974 (95% CI 0.962, 0.985), and 0.672 (95% CI 0.381, 0.963), respectively. Conclusion: LERS appears to have a notable overall performance for the detection of SBP. LERS appeared to be an acceptable alternative to diagnose SBP in facilities without ability to perform cell count. However, there were significant differences in performance between each manufacturer.

Increased morbidity and mortality of hepatocellular carcinoma patients in lower cost of living areas.

BACKGROUND: The incidence and mortality rates of hepatocellular carcinoma (HCC) are increasing in the United States. However, the increases in different racial and socioeconomic groups have not been homogeneous. Access to healthcare based on socioeconomic status and cost of living index (COLI), especially in HCC management, is under characterized. AIM: The aim was to investigate the relationship between the COLI and tumor characteristics, treatment modalities, and survival of HCC patients in the United States. METHODS: A retrospective study of the Surveillance, Epidemiology, and End Results (SEER) database was conducted to identify patients with HCC between 2007 and 2015 using site code C22.0 and the International Classification of Disease for Oncology, 3rd edition (ICD-O-3) codes 8170-8173, and 8175. Cases of fibrolamellar HCC were excluded. Variables collected included demographics, COLI, insurance status, marital status, stage, treatment, tumor size, and survival data. Interquartile ranges for COLI were obtained. Based on the COLI, the study population was separated into four groups: COLI ≤ 901, 902-1044, 1045-1169, ≥ 1070. The χ 2 test was used to compare categorical variables, and the Kruskal-Wallis test was used to compare continuous variables without normal distributions. Survival was estimated by the Kaplan-Meier method. We defined P < 0.05 as statistically significant. RESULTS: We identified 47,894 patients with HCC. Patients from the highest COLI areas were older (63 vs 61 years of age), more likely to be married (52.8% vs 48.0%), female (23.7% vs 21.1%), and of Asian and Pacific Islander descent (32.7% vs 4.8%). The patients were more likely to have stage I disease (34.2% vs 32.6%), tumor size ≤ 30 mm (27.1% vs 23.1%), received locoregional therapy (11.5% vs 6.1%), and undergone surgical resection (10.7% vs 7.0%) when compared with the lowest quartile. The majority of patients with higher COLIs resided in California, Connecticut, Hawaii, and New Jersey. Patients with lower COLIs were more likely to be uninsured (5.7% vs 3.4%), have stage IV disease (15.2% vs 13%), and have received a liver transplant (6.6% vs 4.4%) compared with patients from with the highest COLI. Median survival increased with COLI from 8 (95%CI: 7-8), to 10 (10-11), 11 (11-12), and 14 (14-15) mo (P < 0.001) among patients with COLIs of ≤ 901, 902-1044, 1045-1169, ≥ 1070, respectively. After stratifying by year, a survival trend was present: 2007-2009, 2010-2012, and 2013-2015. CONCLUSION: Our study suggested that there were racial and socioeconomic disparities in HCC. Patients from lower COLI groups presented with more advanced disease, and increasing COLI was associated with improved median survival. Future studies should examine this further and explore ways to mitigate the differences.

Transmission of SARS-CoV-2: an update of current literature.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the etiologic agent for the 2019 coronavirus disease (COVID-19) pandemic, has caused a public health emergency. The need for additional research in viral pathogenesis is essential as the number of cases and deaths rise. Understanding the virus and its ability to cause disease has been the main focus of current literature; however, there is much unknown. Studies have revealed new findings related to the full transmission potential of SARS-CoV-2 and its subsequent ability to cause infection by different means. The virus is hypothesized to be of increased virulence compared with previous coronavirus that caused epidemics, in part due to its overall structural integrity and resilience to inactivation. To date, many studies have discussed that the rationale behind its transmission potential is that viral RNA has unexpectedly been detected in multiple bodily fluids, with some samples having remained positive for extended periods of time. Additionally, the receptor by which the virus gains cellular entry, ACE2, has been found to be expressed in different human body systems, thereby potentiating its infection in those locations. In this evidence-based comprehensive review, we discuss various potential routes of transmission of SARS-CoV-2-respiratory/droplet, indirect, fecal-oral, vertical, sexual, and ocular. Understanding these different routes is important as they pertain to clinical practice, especially in taking preventative measures to mitigate the spread of SARS-CoV-2.

Gastrointestinal, hepatobiliary, and pancreatic manifestations of COVID-19.

There is an increasing number of confirmed cases and deaths caused by the Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) contributing to the Coronavirus disease 2019 (COVID-19) pandemic. At this point, the need for further disease characterization is critical. COVID-19 is well established as a respiratory tract pathogen; however, recent studies have shown an increasing number of patients reporting gastrointestinal manifestations such as diarrhea, nausea, vomiting, and abdominal pain. The time from onset of gastrointestinal symptoms to hospital presentation is often delayed compared to that of respiratory symptoms. It has been noted that SARS-CoV-2 RNA can be detected in fecal matter for an extended period of time, even after respiratory samples have tested negative and patients are asymptomatic. In this article, SARS-CoV-2 and its disease COVID-19 will be reviewed with consideration of the latest literature about gastrointestinal symptomatology, the mechanisms by which the virus may inflict damage, and the possibility of viral replication contributing to a fecal-oral route of transmission.

Index admission cholecystectomy for acute biliary pancreatitis favorably impacts outcomes of hospitalization in cirrhosis.

BACKGROUND AND AIM: Despite higher rates of gallstones in patients with cirrhosis, there are no population-based studies evaluating outcomes of acute biliary pancreatitis (ABP). Therefore, we sought to evaluate the predictors of early readmission and mortality in this high-risk population. METHODS: We utilized the Nationwide Readmission Database (2011-2014) to evaluate all adults admitted with ABP. Multivariable logistic regression models were used to assess independent predictors for 30-day readmission, index admission mortality, and calendar year mortality. RESULTS: Among 184 611 index admissions with ABP, 4344 (2.4%) subjects had cirrhosis (1649 with decompensation). Subjects with cirrhosis, when compared with those without, incurred higher rates of 30-day readmission (20.9% vs 11.2%; P < 0.001), index mortality (2.0% vs 1.0%; P < 0.001), and calendar year mortality (4.2% vs 0.9%; P < 0.001). Decompensation in cirrhosis was associated with significantly fewer cholecystectomies (26.7% vs 60.2%; P < 0.001) and endoscopic retrograde cholangiopancreatographies (23.3% vs 29.9%; P < 0.001). Multivariate analysis revealed that severe acute pancreatitis (odds ratio [OR]: 14.8; 95% confidence interval [CI]: 5.3, 41.2), sepsis (OR: 12.6; 95% CI: 5.8, 27.4), and decompensation (OR: 3.1; 96% CI: 1.4, 6.6) were associated with increased index admission mortality. Decompensated cirrhosis (OR: 1.8; 95% CI: 1.1, 3.0) and 30-day readmission (OR: 5.6; 95% CI: 3.3, 9.5) were predictors of calendar year mortality. However, index admission cholecystectomy was associated with decreased 30-day readmissions (OR: 0.6; 95% CI: 0.4, 0.7) and calendar year mortality (OR: 0.44; 95% CI: 0.25, 0.78). CONCLUSIONS: The presence of cirrhosis adversely impacts hospital outcomes of patients with ABP. Among modifiable factors, index admission cholecystectomy portends favorable prognosis by reducing risk of early readmission and consequent calendar year mortality.

Endoscopic intervention and cholecystectomy in pregnant women with acute biliary pancreatitis decrease early readmissions.

BACKGROUND AND AIMS: Acute biliary pancreatitis (ABP) is associated with increased rates of morbidity in pregnancy. Because there is a paucity of population-based studies evaluating ABP in pregnancy, we sought to investigate clinical outcomes in hospitalized pregnant women on a national level. METHODS: By using the Nationwide Readmission Database (2011-2014), we identified all women (age ≥18 years) with an index admission for ABP in the United States. Multivariate and propensity-score matched analyses were performed to evaluate the impact of pregnancy on the clinical outcomes of early readmission and severe acute pancreatitis (SAP) in ABP. RESULTS: There were 7787 hospitalizations for ABP in pregnant women during the study period. The rate of 30-day readmission was 16.26%; 57% of these early readmissions were due to adverse events of ABP. Compared with nonpregnant women with ABP, ERCP (21.1% vs 25.2%; P < .001) and cholecystectomy (52.8% vs 55.2%; P = .02) were performed less frequently during pregnancy. Propensity-score matched analysis revealed an increased risk of 30-day readmissions in pregnancy (odds ratio [OR], 1.96; 95% confidence interval [CI], 1.67-2.30), whereas there was no difference in the risk of SAP (OR, 1.09; 95% CI, 0.76-1.57). Multivariate analysis demonstrated that weekend admission (OR, 1.40; 95% CI, 1.10-1.79) and >1 week of hospitalization (OR, 1.75; 95% CI, 1.24-2.48) increased the risk of 30-day readmission, whereas ERCP (OR, 0.40; 95% CI, 0.27-0.57) and cholecystectomy (OR, 0.13; 95% CI, 0.10-0.18) reduced the odds of early readmission in pregnancy. CONCLUSIONS: Pregnant women with ABP less frequently undergo timely endoscopic biliary decompression and cholecystectomy. These modifiable factors can potentially lower early readmissions in pregnant women.