Inappropriate use of proton pump inhibitors in hospitalized patients with lower gastrointestinal bleeding.

OBJECTIVES: Use of proton pump inhibitors (PPIs) is a mainstay in treating upper gastrointestinal bleeding (UGIB). However, the beneficial effects of PPIs are not anticipated to extend beyond the duodenum and may actually contribute to the risk of lower gastrointestinal bleeding (LGIB). However, in practice, PPIs are often used for inpatients with LGIB where no benefit exists. METHODS: A retrospective chart review was performed on inpatients during a 2-year period at an urban academic teaching hospital. Inpatients with consults to the gastroenterology (GI) service with confirmed or highly suspected LGIB were included. Outcomes regarding PPI use and the GI consulting service recommendations in these 225 patients were evaluated. RESULTS: About 37.8% of patients were started on a PPI during their inpatient course. Of those, 46% patients started on a PPI had no indication for PPI and 85% had no recommendation by the GI consultants to start a PPI. Of the 85 patients started on PPI, the GI consultants recommended stopping it in two (2.3%) patients. Lastly, 20 patients (9%) were discharged on PPI without an indication for PPI. CONCLUSION: To our knowledge, this is the first study that looked at the inappropriate utilization of PPIs in patients admitted for LGIBs utilizing GI consultant recommendations. Given the large proportion of patients started on PPI without a clinical indication and continued at discharge and the paucity of GI recommendations to discontinue inappropriate use, we found that clinical care may be improved with formal GI recommendations regarding use of PPI.

Cannabis use and cyclical vomiting syndrome: An open debate.

INTRODUCTION: Cyclical vomiting syndrome (CVS) carries a significant financial burden on the U.S. healthcare system due to the recurrent emergency department visits and inpatient hospitalizations. We aimed to update the literature on the predictors of hospital utilization and readmission among individuals admitted with CVS. METHODS: This is a retrospective nationwide study of patients hospitalized with a primary diagnosis of CVS. Using weighted data from the National Inpatient Sample (NIS) and the National Readmission Database (NRD), we conducted a multivariate regression analysis to assess predictors of length of stay (LOS), and 30-day readmission. RESULTS: Primary admissions for CVS totaled 35,055 in the NIS, and 31,240 in the NRD. 2012 patients (6.4%) were readmitted within 30 days. On multivariate regression, cannabis use was associated with reduced LOS (adjusted Mean Difference (aMD) = -0.53 days, 95% CI: -0.68 to -0.38), and 30-day readmissions (adjusted Hazard Ratio (aHR) = 0.63, 95% CI: 0.54-0.73). DISCUSSION: Cannabis use among CVS admissions was associated with reduced LOS and 30-day readmissions; these results could be in fact driven by Cannabis Hyperemesis Syndrome (CHS)-related hospitalizations and the effect of cannabis cessation on decreased symptomatology. ICD-10 coding for CHS should be transitioned to specific codes to improve the differentiation between CVS and CHS-related hospitalizations.

Human immunodeficiency virus patients with low CD4 counts are more likely to have precancerous polyps identified during index colonoscopy.

BACKGROUND: Antiretroviral treatment (ART) has improved the life expectancy of patients living with human immunodeficiency virus (HIV). As these patients age, they are at increased risk for developing non-acquired immunodeficiency syndrome defining malignancies (NADMs) such as colon cancers. AIM: To determine which factors are associated with the development of precancerous polyps on screening colonoscopy in patients with HIV and to investigate whether HIV disease status, measured by viral load and CD4 count, might influence precancerous polyp development. METHODS: A retrospective review of records at two urban academic medical centers was performed for HIV patients who had a screening colonoscopy between 2005-2015. Patients with a history of colorectal cancer or polyps, poor bowel preparation, or inflammatory bowel disease were excluded. Demographic data such as sex, age, race, and body mass index (BMI) as well as information regarding the HIV disease status such as CD4 count, viral load, and medication regimen were collected. Well-controlled patients were defined as those that had viral load < 50 copies, and poorly-controlled patients were those with viral load ≥ 50. Patients were also stratified based on their CD4 count, comparing those with a low CD4 count to those with a high CD4 count. Using colonoscopy reports in the medical record, the size, histology, and number of polyps were recorded for each patient. Precancerous polyps included adenomas and proximal serrated polyps. Data was analyzed using Fisher's exact tests and logistic regression through SAS 3.8 software. RESULTS: Two hundred and seven patients met our inclusion criteria. The mean age was 56.13 years, and 58% were males. There were no significant differences in terms of age, race or ethnicity, insurance, and smoking status between patients with CD4 counts above or below 500. BMI was lower in patients with CD4 count < 500 as compared to those with count > 500 (P = 0.0276). In patients with CD4 > 500, 53.85% of patients were female, and 70.87% of patients with CD4 < 500 were male (P = 0.0004). Only 1.92% of patients with CD4 ≥ 500 had precancerous polyps vs 10.68% of patients with CD4 < 500 (P = 0.0102). When controlled for sex, BMI, and ART use, patients with CD4 < 500 were 9.01 times more likely to have precancerous polyps [95% confidence interval (CI): 1.69-47.97; P = 0.0100]. Patients taking non-nucleoside reverse transcriptase inhibitors were also found to be 10.23 times more likely to have precancerous polyps (95%CI: 1.08-97.15; P = 0.0428). There was not a significant difference noted in precancerous polyps between those that had viral loads greater or less than 50 copies. CONCLUSION: Patients with low CD4 counts were more likely to have precancerous polyps on their screening colonoscopy although the etiology for this association is unclear. We also found an increased risk of precancerous polyps in patients taking non-nucleoside reverse transcriptase inhibitors, which is contradictory to prior literature showing ART has decreased the risk of development of NADMs. However, there have not been studies looking at colorectal cancer and ART by drug class, to our knowledge. Further prospective studies are needed to determine the effect of HIV control and therapies on polyp development.

The Readability of Patient Education Materials Pertaining to Gastrointestinal Procedures.

Introduction: Due to the ubiquity and ease of access of Internet, patients are able to access online health information more easily than ever. The American Medical Association recommends that patient education materials be targeted at or below the 6th grade level in order to accommodate a wider audience. In this study, we evaluate the difficulty of educational materials pertaining to common GI procedures; we analyze on the readability of online education materials for colonoscopy, flexible sigmoidoscopy, and esophagogastroduodenoscopy (EGD). Methods: Google search was performed using keywords of "colonoscopy," "sigmoidoscopy," and "EGD" with "patient information" at the end of each search term. The texts from a total of 18 studies, 6 for each of the procedures, were then saved. Each study was also subdivided into "Introduction," "Preparation," "Complications," and if available, "Alternatives." Furthermore, medical terminology that was properly explained, proper nouns, medication names, and other copyright text were removed in order to prevent inflation of the difficulty. Five validated readability tests were used to analyze each study and subsections: Coleman-Liau, New Dale-Chall, Flesch-Kincaid, Gunning Fog, SMOG. Results: Studies on colonoscopy, flexible sigmoidoscopy, and EGD had median readability grades of 9.7, 10.2, and 11.0, respectively. Analysis of the subsections revealed that the "Alternative" subsection was the most difficult to comprehend with a readability score of 11.4, whereas the "Introduction" subsection was the easiest to comprehend with a readability score of 9.5. Conclusion: Despite modifications to the studies that improved the readability scores, patient education materials were still significantly above the recommended 6th grade level across all websites. This study emphasizes that clear and simple language is warranted in order to create information that is suitable for most patients.

Do medicine residents triage patients with gastrointestinal bleeding appropriately?

BACKGROUND: Gastrointestinal specialists depend on internal medicine (IM) teams to accurately identify acute gastrointestinal bleeding (GIB). We evaluated whether IM residents' assessment of GIB correlated with the impressions of GI specialists during consultations at an inner-city university teaching hospital. METHODS: A questionnaire was distributed to house staff requesting GIB consultations and to the GI fellows performing the consults between August 2011 and April 2012. Residents and fellows were asked to assess GIB, specifically melena, using a stool color card and digital rectal examination (DRE) findings. Fellow DRE findings served as controls for stool color identification. RESULTS: Eighty-seven GI consults were eligible for the study. Residents and fellows completed 81 and 86 questionnaires, respectively. A total of 76 questionnaires were included for analysis. A DRE was performed by medical staff before calling a consult in 65% of cases compared with fellows (97% of cases, P = 0.0001). Residents more frequently labeled stool as melena (42%) in patients as compared with fellows (12%, P = 0.0001). Residents inaccurately identified melenic stools in 22 patients (11 based on stool color and 11 based on DRE findings). Residents were more likely to label a consult as emergent than fellows (13.5% vs 4%, P < 0.05). CONCLUSION: Residents are less likely to perform DRE during an evaluation for GIB and to accurately identify melena based on stool color or DRE findings. There appears to be a need to educate residents on the appropriate terminology for stool color and the importance of DRE to accurately triage patients with acute GIBs.

Treatment of irritable bowel syndrome in women.

Irritable bowel syndrome (IBS) is a complex clinical process with multiple pathophysiologic mechanisms. There has recently been a shift in the treatment of patients with severe IBS symptoms to disease-modifying therapies as opposed to symptomatic treatment. Because pathophysiologic differences exist between men and women, so does the efficacy of treatment options. These differences could further explain gender-related differences in disease prevalence and treatment response. A brief discussion of the definition, epidemiology, and diagnostic criteria of IBS is followed by a comprehensive review of the current treatment choices and potential future therapeutic options of IBS in women.