Cystic duct disimpaction for acute cholecystitis in the high-risk cholecystectomy patient: Case report.

Acute cholecystitis is a common cause of Emergency Department presentation and hospital admission. It is usually treated with early surgical removal of the gallbladder; however, some patients may not be fit to undergo the procedure due to critical illness or comorbidities. In these patients, options are limited. Endoscopic retrograde cholangiopancreatography interventions in this population are not well-studied. We present a case of a high-risk 59 year old female patient with a history of end-stage renal disease, heart failure, hypertension, pulmonary hypertension, and type 2 diabetes who presented with acute cholecystitis. She was successfully treated with cystic duct disimpaction without stenting, and continues to do well post-procedure with complete resolution of symptoms and abnormal lab findings.

Efficacy and safety of anticoagulation in non-malignant portal vein thrombosis in patients with liver cirrhosis: a systematic review and meta-analysis.

BACKGROUND: The role of anticoagulation in treating non-malignant portal vein (PV) thrombosis (PVT) in patients with liver cirrhosis remains unclear. In our meta-analysis, we aimed to evaluate the efficacy and safety of anticoagulation for the treatment of non-malignant PVT in these patients. METHODS: We conducted a meta-analysis to estimate the effects of anticoagulation on non-malignant PVT in patients with liver cirrhosis. We assessed the rates of PV recanalization, variceal bleeding, and any bleeding. RESULTS: We included 9 observational studies which involved 474 patients. The rate of PV recanalization was significantly higher in patients who received anticoagulation compared to those who did not: 65.2% vs. 25.2%; relative risk (RR) 2.31, 95% confidence interval (CI) 1.80-2.96; P<0.00001. Variceal bleeding was significantly lower in patients who received anticoagulation: 0.1% vs. 18.5%; RR 0.15, 95%CI 0.04-0.55; P=0.004. Any bleeding was similar between patients who received anticoagulation and those who did not: 10.3% vs. 22.7%; RR 0.43, 95%CI 0.09-1.99; P=0.28. CONCLUSIONS: Anticoagulation use increased the rate of PV recanalization in cirrhotic patients with non-malignant PVT. Anticoagulation decreased the rate of variceal bleeding and did not increase the rate of any bleeding.

Hospitalization and Post-hospitalization Outcomes Among Teaching Internal Medicine, Employed Hospitalist, and Locum Tenens Hospitalist Services in a Tertiary Center: a Prospective Cohort Study.

BACKGROUND: There are no prospective studies comparing hospitalization and post-hospitalization outcomes between teaching internal medicine services and non-teaching hospitalists, and no prospective studies comparing these outcomes between locum and employed hospitalists. OBJECTIVE: To compare the length of stay, hospital costs readmission rate, and mortality rate in patients treated by teaching internal medicine services vs. hospitalists and among patients treated by locum vs. employed hospitalists. DESIGN: Prospective cohort study. Propensity score was used to obtain weighted estimates. SETTING: Referral center. PATIENTS: All patients 18 years and older admitted to internal medicine services. INTERVENTION: Treatment by teaching internal medicine services vs. hospitalists. Treatment by locum hospitalists vs. employed hospitalists. MAIN MEASURES: Primary outcome was adjusted length of stay and secondary outcomes included hospital cost, inpatient mortality, 30-day all-cause readmission, and 30-day mortality. KEY RESULTS: A total of 1273 patients were admitted in the study period. The mean patient age was 61 ± 19 years, and the sample was 52% females. Teaching internal medicine physicians admitted 526 patients and non-teaching hospitalists admitted 747 patients. Being seen exclusively by teaching internal medicine physicians comports with a shorter adjusted hospital stay by 0.6 days (95% CI - 1.07 to - 0.22, P = .003) compared to non-teaching hospitalists. Adjusted length of stay was 1 day shorter in patients seen exclusively by locums compared to patients seen exclusively by employed services (95% CI - 1.6 to - 0.43, P < .001) with an adjusted average hospital cost saving of 1339 dollars (95% CI - 2037 to - 642, P < .001). There was no statistically significant difference in other outcomes. CONCLUSIONS: Teaching internal medicine services care was associated with a shorter stay but not with increased costs, readmission, or mortality compared to non-teaching services. In contrary to the "expected," patients treated by locums had shorter stays and decreased hospital costs but no increase in readmissions or mortality.

Sex differences in outcomes of acute pancreatitis: Findings from a nationwide analysis.

BACKGROUND: Sex is thought to play a significant role in predicting outcomes in numerous diseases. The role sex plays in acute pancreatitis (AP) remains limited. We sought to determine if sex is associated with hospitalization outcomes in this population, using a large national database. METHODS: This was a retrospective study of adult patients with AP utilizing the 2016 and 2017 National Inpatient Sample via ICD-10 codes. The clinical courses of females were compared to that of males. The primary outcome was all-cause inpatient mortality. Secondary outcomes, including healthcare utilization, were assessed. Statistical analyses were performed using STATA, version 16.1. RESULTS: Of the 553 480 adult patients hospitalized with AP; 25.3% had AP secondary to alcohol (61.4% male, 38.6% female) and 17.44% secondary to gallstones (48.6% male, 51.4% female). Females were significantly older than males (52.81 years vs 50.97 years, P < .01). Females had a significantly lower likelihood of mortality (aOR: 0.69), shock (aOR: 0.64), sepsis (aOR: 0.70), acute kidney injury (aOR 0.66), intensive care unit admission (aOR 0.53), and pancreatic drainage (aOR 0.61) as compared to males (all with P < .01). There was no significant difference between females and males with regards to mean length of stay and hospitalization charges and costs. CONCLUSIONS: In this large cohort of patients admitted for AP, despite being significantly older, we found that females had significantly improved clinical outcomes, including lower mortality, compared to males. Further prospective studies are needed to accurately understand these differences to guide clinical practice.

Pancreaticopleural Fistula: A Rare Presentation and a Rare Complication.

Pancreaticopleural fistula (PPF) is a rare complication of pancreatitis that requires a high index of clinical suspicion as patients typically present with pulmonary symptoms related to the pleural effusion rather than pancreatitis. Diagnosis is made by detection of amylase in the pleural fluid. Magnetic resonance cholangiopancreatography can aid in visualizing the fistula. We present a case of massive left pleural effusion secondary to a PPF due to acute on chronic pancreatitis.

Shortness of Breath: An Unusual Presentation of Bladder Injury. A Case Report and Literature Review of Urinothorax.

Urinothorax is the presence of urine in the pleural space. It can occur at any age and is more common in males. It typically results from obstructive uropathy but can also be caused by malignancy or trauma. Urinothorax is a rare cause of transudative pleural effusion and the only cause of low pH (pH <7.4) transudative effusion. We present the case of a 51-year-old female patient who had recently undergone a urological procedure and came to the emergency department reporting shortness of breath. A chest X-ray revealed a newly developed, large, right-sided pleural effusion. Thoracentesis yielded a transudative yellow fluid of normal pH with a creatinine-to-serum creatinine ratio of 1.7. A computed tomography (CT) cystogram showed extravasated contrast material within the pelvis, from which a diagnosis of urinothorax was confirmed and treated. Urinothorax is a rare diagnosis that requires a multidisciplinary treatment approach, usually including a pulmonologist and a urologist. After the genitourinary disease is treated, the urinothorax usually resolves.