Splenic Infarction Due to Epstein-Barr Virus: A Case Report and Literature Review.

Splenic infarction is a rare and likely underdiagnosed complication of Epstein-Barr virus (EBV)-associated infectious mononucleosis (IM). Here, we describe an 18-year-old Guyanese male with persistent severe left-sided abdominal pain found to be EBV positive and have a large splenic infarct, along with a transient decrease in protein C, protein S, and antithrombin III activity levels. He was treated with supportive care and anticoagulated with heparin and apixaban. We review prior reports and perspectives on underlying pathophysiology, diagnosis, and the management of these cases, which likely do not require anticoagulation but may be considered on a per-case basis.

Chat Generative Pretrained Transformer Fails the Multiple-Choice American College of Gastroenterology Self-Assessment Test.

INTRODUCTION: Chat Generative Pretrained Transformer (ChatGPT) is a natural language processing model that generates human-like text. METHODS: ChatGPT-3 and ChatGPT-4 were used to answer the 2022 and 2021 American College of Gastroenterology self-assessment tests. The exact questions were inputted in both versions of ChatGPT. A score of 70% or higher was required to pass the assessment. RESULTS: Overall, ChatGPT-3 scored 65.1% on 455 included questions and GPT-4 scored 62.4%. DISCUSSION: ChatGPT did not pass the American College of Gastroenterology self-assessment test. We do not recommend its use for medical education in gastroenterology in its current form.

Pathogenesis to management of hepatocellular carcinoma.

Hepatocellular carcinoma (HCC) is the most common primary liver cancer whose incidence continues to rise in many parts of the world due to a concomitant rise in many associated risk factors, such as alcohol use and obesity. Although early-stage HCC can be potentially curable through liver resection, liver-directed therapies, or transplantation, patients usually present with intermediate to advanced disease, which continues to be associated with a poor prognosis. This is because HCC is a cancer with significant complexities, including substantial clinical, histopathologic, and genomic heterogeneity. However, the scientific community has made a major effort to better characterize HCC in those aspects via utilizing tissue sampling and histological classification, whole genome sequencing, and developing viable animal models. These efforts ultimately aim to develop clinically relevant biomarkers and discover molecular targets for new therapies. For example, until recently, there was only one approved systemic therapy for advanced or metastatic HCC in the form of sorafenib. Through these efforts, several additional targeted therapies have gained approval in the United States, although much progress remains to be desired. This review will focus on the link between characterizing the pathogenesis of HCC with current and future HCC management.

A Case of Acute Liver Failure in a Patient on Isoniazid Prophylaxis for Latent Tuberculosis.

Isoniazid (INH) is widely used for latent Mycobacterium tuberculosis despite the known risk of liver injury, with severe hepatitis occurring in up to 1% of patients. We report a patient who presented with two weeks of anorexia, nausea, and jaundice following six months of INH monotherapy for latent tuberculosis (TB). After other causes of liver injury were ruled out, she underwent a liver biopsy showing submassive necrosis, hepatocellular dropout, and lobular inflammation with no evidence of fibrosis. She was also found to have acute portal hypertension. She was diagnosed with drug-induced liver injury (DILI) and was treated with n-acetyl cysteine (NAC), ursodiol, and vitamin K. She recovered without the need for a liver transplant. This case supports the need for monitoring of liver tests in high-risk individuals on INH therapy to reduce the risk of hepatotoxicity.

Fecal Microbiota Transplant for Clostridioides Difficile Infection Is Safe and Efficacious in an Immunocompromised Cohort.

BACKGROUND: Immunocompromised patients are particularly vulnerable to Clostridioides difficile infection (CDI), hospitalizations and recurrences. Studies have shown that fecal microbiota transplant (FMT) is safe and effective in immunocompromised patients. AIMS: To examine the outcomes of FMT for CDI in a diverse cohort of immunocompromised patients stratified by medication class. METHODS: We performed a retrospective, long-term follow-up study of FMT in immunocompromised patients, including those undergoing chemotherapy, with inflammatory bowel disease (IBD) on immunomodulators, prior solid organ transplant on immunosuppressants, on chronic steroids 20 mg/day or higher for a minimum of three months, or HIV positive. Primary outcomes included adjusted primary cure rate within 8 weeks, as well as rates of non-response, recurrences, relapses and adverse events. Secondary outcomes included adjusted overall cure rate. Primary cure rate was defined as patients not requiring repeat CDI treatment within 8 weeks after index FMT, and overall cure rate was defined as resolution of CDI symptoms after index FMT or second FMT. RESULTS: Our cohort included 77 immunosuppressed patients (53.2% female, median age 39.1 years, range 7-95 years). The majority of our cohort were IBD patients on biologics (62.3%). Adjusting for colectomies and deaths, our primary and overall cure rates were 85.1% and 86.5%, respectively. Twelve patients received FMT for severe or fulminant CDI with a 3-month survival rate of 91.7%. 11.7% of patients experienced serious adverse events following FMT. CONCLUSIONS: Our study supports the efficacy and safety of FMT in immunocompromised patients, though future research is needed to further ascertain the potential effects of immunosuppression on FMT outcomes.

A Comparison of Etiologies and Characteristics of Solitary Versus Synchronous Pancreatic Masses Undergoing Endoscopic Ultrasound-Guided Biopsy.

OBJECTIVES: Pancreatic mass lesions are often solitary, although rarely synchronous pancreatic masses are encountered. No study has compared synchronous lesions with solitary lesions in the same population. The aim of the present study was to determine the prevalence, clinical, radiographic, and histologic findings of multiple pancreatic masses on consecutive patients undergoing endoscopic ultrasound (EUS) for pancreatic mass lesion. METHODS: All patients undergoing EUS for pancreatic mass lesions with histologic sampling over a 5-year span were identified. Charts were abstracted for demographics, medical history, radiographic findings, EUS findings, and histology and were reviewed. RESULTS: A total of 646 patients were identified, of which 27 patients (4.18%) had more than 1 pancreatic mass on EUS or cross-sectional imaging. The 2 groups were comparable with each other in terms of demographic factors and medical history. The 2 cohorts were comparable in location of the largest pancreas lesion and EUS characteristics. Patients with synchronous mass lesions were more likely to have metastatic lesions (P = 0.01). No other differences in histology were noted between the 2 groups. CONCLUSIONS: Patients with multiple pancreatic mass lesions were more likely to have metastatic lesions compared with patients with solitary lesions.

Gastroenterology Clinical Trials Transparency: An Analysis of Publication Rates From the ClinicalTrials.gov Database.

INTRODUCTION: There is limited information on the transparency of gastroenterology clinical trials. METHODS: The ClinicalTrials.gov database was searched for trials focused on most common gastrointestinal diseases up to August 2018. Adherence to reporting of results to the database or in publication form was recorded for each trial along with trial characteristics. RESULTS: Of the 2,429 trials included in the final analysis, 1824 (75%, 95% confidence interval: 73.4%-76.8%) had results on ClinicalTrials.gov or in the form of a publication. However, only 534 (29%) had results posted on ClinicalTrials.gov. DISCUSSION: Improvement of clinical trial transparency is needed in gastroenterology.

Secondary Invasive Breast Events among Patients with Hormone-Positive Breast Cancer and High-Risk Oncotype DX Recurrence Scores 26-30 and ≥31.

BACKGROUND: The Oncotype DX Recurrence Score (ODx RS) is the most widely adopted genomic assay used to guide treatment for patients with early-stage, hormone-positive (HR+) breast cancer (BC), with higher scores predicting greater risk of recurrence and benefit from chemotherapy. Patients with ODx RS >25 typically recieve adjuvant chemotherapy; however, data regarding efficacy of chemotherapy for reducing recurrence in this population have been mixed. OBJECTIVES: This study aimed to evaluate outcomes of patients with early-stage HR+ BC with high-risk ODx RS (26-30 and ≥31) in order to assess treatment patterns and outcomes. We hypothesized that the benefit of chemotherapy in these groups may be minimal and that select patients may forgo chemotherapy in favor of more aggressive endocrine therapy and ovarian suppression. METHODS: We performed a retrospective analysis of 515 patients with early-stage, HR+ BC with high-risk ODx RS 26-30 and ≥31 treated between 2006 and 2018. Patients were stratified by RS: low-risk (≤10), intermediate-risk (11-25), and high-risk (≥26). The Kaplan-Meier method was used to estimate the time to secondary invasive breast events (SIBE) or distributions overall and among different RS groups with the log rank test used to compare distributions between groups. RESULTS: Rates of chemotherapy administration were 7% among the low-risk group, 18% among the intermediate-risk group, and 83% among high-risk patients with 41 SIBE (8%) reported. When stratified by ODx RS, 5-year rates of SIBE were 4%, 6%, and 16% for low-risk, intermediate-risk, and high-risk RS, respectively. Among the 27 lymph node (LN)-negative patients with ODx RS 26-30, 74% received chemotherapy. The 5-year rate of SIBE was 25% among patients who received chemotherapy and 33% among those who did not (p = 0.5489). Among the 23 LN-negative patients with ODx RS ≥31, 91% of patients received chemotherapy. The 5-year rate of SIBE was 0% both with and without chemotherapy. CONCLUSIONS: There was no statistically significant difference in SIBE for patients with high-risk ODx RS based on chemotherapy treatment. More aggressive endocrine therapy with ovarian suppression has become an alternative to chemotherapy among patients with intermediate-risk ODx RS (16-25). This approach may be useful among patients with high-risk ODx RS, with additional studies needed in this patient population.

Complication Prevention and Cost Savings in Total Joint Arthroplasty. The Effect of Orthopedic Procedure Migration within Hospital Referral Regions in the United States.

BACKGROUND: The shift to value based total joint arthroplasty (TJA) reimbursement strategies has led to an increased focus on quality and the avoidance of poor outcomes. As a result, there has been greater encouragement for patients to undergo joint replacements in high volume centers of excellence. In this study, we examined the potential complications avoided if TJA procedure volume was shifted from poor quality (high incidence) facilities to high quality (low incidence) facilities within Hospital Referral Regions (HRRs). METHODS: Using Medicare 100% claims data linked to the Dartmouth Atlas of Health Care, we examined the clinical and cost benefits of shifting TJA procedures from low performing hospital to high performing hospitals within HRRs. RESULTS: Across all HRRs, we identified 1,878 cases of deep infection and 3,393 annual readmissions in the Medicare population that could have potentially been avoided, resulting in a mean cost savings of $41 million and $62 million, respectively, solely due to shifting procedure location from lower third performing hospitals to the upper third performing hospitals. CONCLUSIONS: Our study demonstrates that the incidence of deep infection and all-cause readmission varies widely among and within HRRs. Further, the potential reallocation of joint procedures from low quality facilities to high quality Centers of Excellence within an HRR could result in over $103 million in annual savings related to mitigated deep infections and readmissions.

Acute pancreatitis in children hospitalized with COVID-19.

BACKGROUND: Limited data exists on the association or prevalence of pancreatitis in children with COVID-19. METHODS: This is a retrospective study of pediatric patients admitted to a large health system in New York (Northwell Health System) from March 1, 2020-June 1, 2020 during the COVID-19 pandemic. RESULTS: 8159 pediatric patients were admitted to our healthcare system during the study period, of which 112 were diagnosed with COVID-19 (1.37%). Thirteen were diagnosed with pancreatitis for a point prevalence of 0.16% (13/8159) for all patients admitted. Of the thirteen patients admitted with pancreatitis, two patients were COVID-19 positive for a point prevalence of 1.8% (2/112) among COVID-19 patients compared to 0.14% (11/8047) in the non-COVID-19 population. CONCLUSIONS: This study shows that pancreatitis can occur in pediatric patients with COVID-19 and may be more common in the COVID-19 population.

Poor Access to Opioid Addiction Care for Total Joint Arthroplasty Patients.

INTRODUCTION: The United States is experiencing an opioid epidemic, and orthopedists prescribe a large proportion of these drugs. Patients often become dependent on painkillers and face barriers to treatment. Given that many joint arthroplasty patients are enrolled in Medicare, we aimed to examine the ease of orthopedic patients with various insurance types to access addiction and pain specialists. METHODS: Using three web-based directories, we identified addiction specialists within a 5-mile radius of our hospital. We contacted these practices and inquired as to whether they treated addiction, types of insurance they accepted, and appointment availability. RESULTS: We identified 190 addiction and pain management specialists and were able to reach 134/190 (70.5%). Nine (6.7%) of the 134 reachable physicians accepted Medicare or Medicaid, which is nine (4.7%) of the 190 physicians initially located. The average wait time to an appointment was 4.2 days, and a significant difference in wait time existed across insurance types (p = 0.0284). DISCUSSION: Orthopedic patients face many barriers to receiving treatment for painkiller addiction. Wait time to see an addiction specialist also varied based on insurance type. Online directories may not be useful for certain patient populations to identify physicians. Orthopedic surgeons should partner with addiction and pain specialists to help alleviate the barriers that patients face.

Tibial Shaft Fractures in Workers Compensation and No-Fault Insurance Is There a Difference in Resource Utilization?

BACKGROUND: Workers Compensation claims have been previously associated with inferior clinical outcomes. However, variation in inpatient stays for orthopedic trauma injuries according to insurance type has not been previously examined. METHODS: We investigated the differences according to insurance for tibial shaft fractures in regard to length of stay and disposition. Using the New York SPARCS database, we identified 1,856 adult non-elderly patients with an isolated tibial shaft fracture who underwent surgery. Patients were stratified by insurance type, including private, Medicaid, Workers Compensation, and no-fault, which covers medical expenses related to automobile or pedestrian accidents. RESULTS: Compared to private insurance (mean: 2.7 days), length of stay was longer for no-fault (mean: 3.9 days; adjusted difference +33%, p < 0.001) and Medicaid (mean: 3.5 days; adjusted difference +22%, p < 0.001), but not significantly different for Workers Compensation (mean: 3.5 days; adjusted difference +4%, p = 0.474). Compared to private insurance (rate: 3.5%), disposition to a facility was significantly higher for no-fault (rate: 10.1%; adjusted odds ratio [OR] = 3.3, p < 0.001) and Medicaid (rate: 7.6%; OR = 2.2, p = 0.003), but was not significantly different for Workers Compensation (rate: 6.3%; OR = 1.8, p = 0.129). CONCLUSIONS: Patients with no-fault insurance, but not Workers Compensation, are subject to longer hospital stays and are more likely to be discharged to a facility following operative fixation of an isolated tibial shaft fracture. These findings suggest that financial, social, and legal factors influence medical care for patients involved in automobile accidents with no-fault insurance.

Association of Magnet Nursing Status With Hospital Performance on Nationwide Quality Metrics.

INTRODUCTION: Magnet Recognition is the highest distinction a healthcare organization can receive for excellence in nursing. Although Magnet status is generally associated with superior clinical outcomes and patient satisfaction, its association with performance on nationwide quality metrics is currently unknown. METHODS: Within a propensity score-matched cohort, we compared performance on the Hospital-Acquired Condition Reduction Program (HACRP), Hospital Value-Based Purchasing (VBP), and Hospital Readmissions Reduction Program (RRP) initiatives. RESULTS: The mean HACRP total performance score was inferior at Magnet versus non-Magnet hospitals (p < .001), and HACRP penalties were more likely to be levied against Magnet hospitals (p = .003). There was no significant difference according to Magnet status for VBP penalties after correcting for multiple comparisons (p = .049). There were no significant difference in RRP penalties according to Magnet status (p = .999). CONCLUSIONS: Magnet hospitals performed worse on a number of hospitalwide quality metrics tied to reimbursement by the Centers for Medicare and Medicaid Service. Although Magnet hospitals are known for superior nursing care and organizational support for safety and quality improvement, this is not captured within these composite measures of quality, which can be influenced at many levels of care. These data underscore the need for comprehensive quality improvement across multiple domains of care outside of nursing. LEVEL OF EVIDENCE: Level III, retrospective study.

Are Histological Examinations of Arthroplasty Specimens Performed Consistently Across the Country? A Large Database Study.

BACKGROUND: It is currently unknown to what extent routine histological examination of joint arthroplasty specimens occurs across hospitals nationwide. Although this practice is neither supported nor refuted by the available evidence, given the increasing demand for joint arthroplasties, it is crucial to study overall utilization as well as its main drivers. QUESTIONS/PURPOSES: Using national data on joint replacements, we aimed to evaluate: (1) What is the current use of routine histological examination of joint arthroplasty specimens? (2) Does the use vary by geographic location and hospital characteristics? (3) Has use changed over time? METHODS: From the Premier Healthcare database (2006-2016) we included claims data from 87,667 shoulder (595 hospitals, median age 70 years, 16% nonwhite), 564,577 hip (629 hospitals, median age 65 years, 21% nonwhite), and 1,131,323 (630 hospitals, median age 66 years, 24% nonwhite) knee arthroplasties (all elective). Our study group has extensive experience with this data set, which contains information on 20% to 25% of all US hospitalizations. Included hospitals are mainly concentrated in the South (approximately 40%) with equal distributions among the Northeast, West, and Midwest (approximately 20% each). Moreover, the Premier data set has detailed billing information, which allows for evaluations of real-world clinical practice. There was no missing information on the main variables of interest for this specific study. We assessed frequency of histology examination (defined by Current Procedural Terminology codes) overall as well as by hospital characteristics (urban/rural, bed size, teaching status, arthroplasty volume), geographic region (Northeast, South, Midwest, West), and year. Given the large sample size, instead of p values, standardized differences were applied in assessing group differences where a standardized difference of > 0.1 (or 10%) was assumed to represent a meaningful difference between groups. For significance of trends, p values were applied. Percentages provided represent proportions of individual procedures. RESULTS: In most hospitals, histology testing was either rare (1%-10%, used in 187 of 595, 189 of 629, and 254 of 630 hospitals) or ubiquitous (91%-100%, used in 121 of 595, 220 of 629, and 195 of 630 hospitals) for shoulder, hip, and knee arthroplasties, respectively. Overall, histology testing occurred more often in smaller hospitals (37%-53% compared with 26%-45% in larger hospitals) and those located in the Northeast (59%-68% compared with 22%-44% in other regions) and urban areas (32%-49% compared with 20%-31% in rural areas), all with standardized differences > 10%. Histologic examination is slowly decreasing over time: from 2006 to 2016, it decreased from 34% to 30% for shoulder arthroplasty, from 50% to 45% for THAs, and from 43% to 38% for TKAs (all p < 0.001). CONCLUSIONS: Although overall use is decreasing, a substantial number of hospitals still routinely perform histology testing of arthroplasty specimens. Moreover, variation between regions and hospital types suggests that this practice is driven by a variety of factors. This is the first study addressing national utilization, which will be helpful for individual hospitals to assess how they compare with national utilization patterns. Moreover, the findings have clear implications for followup studies, which may be necessary given the exponentially growing demand for arthroplasties. LEVEL OF EVIDENCE: Level III, therapeutic study.

What are the prevalence and risk factors for repeat ipsilateral knee arthroscopy?

PURPOSE: The number of arthroscopic knee surgeries performed annually has increased over the last decade. It remains unclear what proportion of individuals undergoing knee arthroscopy is at risk for subsequent ipsilateral procedures. Better knowledge of risk factors and the incidence of reoperative ipsilateral arthroscopy are important in setting expectations and counselling patients on treatment options. The aim of this study is to determine the incidence of repeat ipsilateral knee arthroscopy, and the risk factors associated with subsequent surgery over long-term follow-up. METHODS: The New York Statewide Planning and Research Cooperative Systems outpatient database was reviewed from 2003 to 2016 to identify patients who underwent elective, primary knee arthroscopy for one of the following diagnosis-related categories of procedures: Group 1: cartilage repair and transfer; Group 2: osteochondritis dissecans (OCD) lesions; Group 3: meniscal repair, debridement, chondroplasty, and synovectomy; Group 4: multiple different procedures. Subjects were followed for 10 years to determine the odds of subsequent ipsilateral knee arthroscopy. Risk factors including the group of arthroscopic surgery, age group, gender, race, insurance type, surgeon volume, and comorbidities were analysed to identify factors predicting subsequent surgery. RESULTS: A total of 765,144 patients who underwent knee arthroscopy between 2003 and 2016, were identified. The majority (751,873) underwent meniscus-related arthroscopy. The proportion of patients undergoing subsequent ipsilateral knee arthroscopy was 2.1% at 1-year, 5.5% at 5 years, and 6.7% at 10 years of follow-up. Among patients who underwent subsequent arthroscopic surgery at 1-, 5-, and 10-year follow-up, there was a greater proportion of patients with worker's compensation insurance (p < 0.001), index operations performed by very high volume surgeons (p < 0.001), and cartilage restoration index procedures (p < 0.001), compared with those who never underwent repeat ipsilateral surgery. CONCLUSION: Understanding the incidence of subsequent knee arthroscopy after index procedure in different age groups and the patterns over 10 years of follow-up is important in counselling patients and setting future expectations. The majority of subsequent surgeries occur within the first 5 years after index surgery, and subjects tend to have higher odds of ipsilateral reoperation for up to 10 years if they have worker's compensation insurance, or if their index surgery was performed by a very high volume surgeon, or was a cartilage restoration procedure. LEVEL OF EVIDENCE: III.