Sodium Polystyrene Sulfonate-Induced Gastric Pneumatosis: A Rare Side Effect.

Kayexalate has been used in the USA since 1975 for the treatment of hyperkalemia. Prior case reports have shown that sorbitol added to kayexalate has been known to cause rare side effects of colonic necrosis. We present a unique case report of gastric pneumatosis as a complication of kayexalate.

An Extremely Rare Presentation of an Alpha-Fetoprotein-Producing Esophageal Adenocarcinoma.

Alpha-fetoprotein (AFP)-producing esophageal adenocarcinoma (EAC) is an extremely rare occurrence with very few cases reported in the literature. We report the case of a 76-year-old female who presented with progressive weakness, fatigue, and a decrease in appetite for weeks and who was found to have an AFP-producing EAC with an extraordinarily high AFP level of 46,135 ng/mL. CT angiography revealed abnormal thickening of the esophagus and multiple metastatic masses throughout the liver. Upper endoscopy revealed a large mass in the distal esophagus with extension into the stomach. Biopsy confirmed the EAC. Most cases are unsuccessfully treated with surgery and chemotherapy. Serial measurement of serum AFP may be useful for monitoring clinical status and treatment response.

Incidence of congestive heart failure in rheumatoid arthritis: a review of literature and meta-regression analysis.

AIMS: Rheumatoid arthritis (RA) is a systemic inflammatory autoimmune disorder that not only affects peripheral joints but also increases the risk for cardiovascular disease (CVD) and mortality. Heart failure (HF) appears to be one of the most important contributors to the excess mortality risk among patients with RA. We assessed the incidence of HF in patients with RA compared with age-matched and sex-matched non-RA subjects, after accounting for traditional cardiovascular risk factors and clinical ischemic heart disease. METHODS AND RESULTS: We performed an aggregate analysis on three studies of RA patients having listed manifestations of HF. We performed a meta-regression analysis to evaluate the incidence of HF in RA patients with increased age and noted for any gender correlation. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using both fixed-effects and random-effects models. In the cumulative analysis of 5, 220, 883 patients, the incidence of HF was noted to be almost two-fold higher in patients with RA compared with a matched control population (OR 1.78, 95% CI 1.22-2.60, P < 0.003), HTN (OR 1.66, 95% CI 1.24-2.23, P < 0.001), and diabetes (OR 1.57, 95% CI 1.36-1.81, P < 0.001). Women had three-fold higher incidence of HF with RA (OR 3.38, 95% CI 2.59-4.40, P < 0.001). On meta-regression, the incidence of HF increased further with older age (coefficient = 0.12, P = 0.0004). CONCLUSIONS: Our systematic review that included over 5 million subjects confirms the suspected increased incidence of HF in RA patients. Women have the greatest risk for HF. Our analysis advocates the need for updating the current guidelines to incorporate screening and preventive methods for HF in RA patients.

A Rare Manifestation of a Bleeding Tubulovillous Duodenal Polyp Presenting as an Upper Gastrointestinal Hemorrhage.

Duodenal polyps have been reported in <1.5% of individuals who undergo esophagogastroduodenoscopy (EGD). We present a case of a 76-year-old male with recurrent hematemesis who was found to have an intestinal-type, pedunculated tubulovillous adenoma in the descending duodenum. An isolated occurrence of nonampullary sporadic duodenal adenoma is a rare finding. Presentation as an upper gastrointestinal hemorrhage is also extremely uncommon. Our patient's polyp was pedunculated, which is atypical, because most sporadic duodenal adenomas are morphologically flat or sessile. The purpose of this case is to present a rare cause of upper gastrointestinal bleeding and to depict characteristics of an isolated duodenal tubulovillous adenoma and its treatment options.

Increased cardiovascular events and mortality in females with NAFLD: a meta-analysis.

Non-alcoholic fatty liver disease (NAFLD) and cardiovascular diseases (CVD) share similar risk factors. Recent studies have focused on obesity and insulin resistance, but the link between NAFLD and CVD persists regardless of traditional risk factors. Despite the increased incidence and prevalence of NAFLD worldwide, there has been no thorough investigation of gender disparities nor a closer look taken into investigating the role gender may play in increased cardiovascular (CV) mortality in people with NAFLD. We assessed the incidence and prevalence of CV events and mortality based on gender in people with NAFLD, at any stage of fibrosis. A meta-regression was conducted to further analyze the impact of age on both genders. An aggregate analysis was performed on ten studies with NAFLD people. A random-effects model was used to pool the overall incidence and prevalence rates of CV events and mortality as well as all-cause mortality to examine any gender disparity. We also performed a meta-regression analysis to evaluate the effect of age on mortality for men versus women with NAFLD and CV events and mortality. Summary odds ratios (OR) and 95% confidence intervals (CI) were estimated using a random-effects model. In 108,711 people with NAFLD, of which 44% were females and 56% were males, all-cause mortality was 1.5x higher in women compared to men (OR 1.65, 95% CI 1.12-2.43, P<0.012). CV events and mortality were also 2x higher in women compared to men (OR 2.12 95% CI 1.65-2.73, P<0.001)). On meta-regression, females had higher mortality with advancing age starting at age 42 (coefficient =0.0518, P=0.00001). For people with NAFLD, women had a markedly higher incidence and prevalence of CV events, CV mortality, and all-cause mortality when compared to men. As the incidence and prevalence of NAFLD and concomitant CV events increase worldwide, we urge the medical community to increase surveillance and perform rigorous cardiovascular risk assessments for women, especially beginning at age 42. Additionally, we recommend heterogeneous surveys of gender disparities, increased focus on gender as a decisive factor for downstream CV events, the relationship between NAFLD severity and gender-based mortality differences, and larger studies representing equivalent male and female populations.

Gender disparity in cardiovascular mortality following radiation therapy for Hodgkin's lymphoma: a systematic review.

BACKGROUND: Radiation-induced coronary artery disease (R-CAD) has become an increasingly recognized phenomenon. Although the clinical relationship between radiation therapy and CAD risk is well known, there is minimal investigation of the gender relationship to radiation-induced CAD events and the resulting cardiovascular (CV) events/mortality. We study the gender variation in the incidence of CV events/mortality related to R-CAD in Hodgkin's Lymphoma (HL) patients. METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used in this systematic review and network meta-analysis. OVID, Cochrane Central Register of Controlled Trials via the Wiley Interface, Web of Science Core Collection, MEDLINE, EMBASE, and Google Scholar were investigated to identify prospective and retrospective observational studies comparing women and men following radiation treatment for Hodgkin's lymphoma. Ten studies were included (4 prospective, 6 retrospective). The primary outcome was incidence of cardiovascular events/mortality. The secondary outcome was all-cause mortality. Meta-regression for age was also performed. RESULTS: Of 13,975 patients, including 41% females and 59% males, CV events/mortality were noted to be significantly higher in women compared to men (OR 3.74, 95% CI 2.44-5.72, p < 0.001). All-cause mortality was also higher in women compared to men (OR 1.94, 95% CI 1.10-3.44, p < 0.023). On meta-regression analysis, elderly populations have a higher rate of mortality, which was even higher for women than men (coefficient = 0.0458, p = 0.0374). CONCLUSIONS: Women have a higher rate of R-CAD related CV events/mortality and all-cause mortality compared to men amongst radiation-treated patients. These data highlight the need for increased surveillance to better monitor for R-CAD in female patients treated with mantle or mediastinal radiation.

In-Hospital Outcomes of Patients With Pulmonary Hypertension and Cirrhosis: A 6-Year Population Cohort Study of Over One Million Patients.

INTRODUCTION: There is a paucity of data on the influence of sex, race, insurance, pulmonary hypertension-related complications, and cirrhosis-related complications on mortality, hospital length of stay (LOS), and total hospital charges. The aim of this study was to identify risk factors in a national population cohort (in the USA) admitted to hospital between 2012 and 2017. METHODS: All patients aged > 18 years with pulmonary hypertension and cirrhosis, who had been admitted to hospital between 2012 and 2017, were identified from the US Nationwide Inpatient Sample (NIS), a large publicly available all-payer inpatient care database in the USA. Multivariate regression analysis was used to estimate the odds ratios of in-hospital mortality, average length of hospital stay, and hospital charges, after adjusting for age, gender, race, primary insurance payer status, hospital type and size (number of beds), hospital region, hospital teaching status, and other demographic characteristics. RESULTS: Our study identified 1,111,594 patients who had been discharged from hospital from 2012 to 2017. Of these patients, 355,455 were admitted with pulmonary hypertension, with 9.8% having cirrhosis as a complication (n = 34,986). The analysis revealed that patients with both pulmonary hypertension and cirrhosis compared to patients with only pulmonary hypertension experience increased mortality, hospital LOS, total hospital charges, and pulmonary hypertension-related and cirrhosis-related complications. Independent positive predictors of mortality were Asian/Pacific Islander race and "other" insurance status (worker's compensation; other US health benefits plans [CHAMPUS/TRICARE, CHAMPVA, Title V]). Independent positive predictors of increased hospital LOS were black race and "other" patients (more than one race/mixed). Independent positive predictors of increased total hospital charges were male gender, Hispanic ethnicity, Asian/Pacific Islander race, and other insurance status. Pulmonary hypertension-related complications (cor pulmonale, pulmonary embolism, hemoptysis, cardiac arrest, atrial fibrillation, ventricular tachycardia) and cirrhosis-related complications (ascites, hepatorenal syndrome, hepatic encephalopathy, variceal bleeding, portal hypertension) were independent positive predictors of mortality, hospital LOS, and total hospital charges. CONCLUSIONS: Patients with pulmonary hypertension and cirrhosis have increased mortality and hospital utilization compared to patients with only pulmonary hypertension. We identified key drivers for these outcomes. Targeted interventions, such as novel medications, right-to-left shunts, more evaluations for lung transplantation, and reversal of pulmonary vacular remodeling, are needed for the subgroups identified in this study in order to improve outcomes.

The First Case of Impella RP Use in Acute Right Ventricular Failure From Air Embolism.

BACKGROUND: Air embolism can cause the following catastrophic complications that must be avoided: cardiogenic shock (from right heart failure), obstructive shock, myocardial infarction, stroke, RVOT obstructions, and pulmonary embolism. Currently there is a paucity of data on Impella RP use in rare causes of acute right ventricle (RV) failure, especially if caused by air embolism. CASE REPORT: We report a case of a patient with acute RV failure due to air embolism who recovered from temporary use of Impella RP. DISCUSSION: This case highlights the utility of right-sided mechanical support (MCS) devices for acute RV failure.

In-Hospital Outcomes of Patients with Acute Decompensated Heart Failure and Cirrhosis: An Analysis of the National Inpatient Sample.

INTRODUCTION: Heart failure increases morbidity and mortality in patients admitted for cirrhosis. Our objective was to determine if patients with acute decompensated heart failure (ADHF) and cirrhosis would have increased mortality, hospital length of stay (LOS), and total hospital charges compared to patients with only ADHF. There is also a paucity of data regarding the influence of gender, race, ethnicity, insurance, and cirrhosis-related complications on mortality, hospital length of stay, and total hospitalization charges. In this study, we aim to identify risk factors in a national population cohort from 2016. METHODS: All patients above 18 years old with cirrhosis and ADHF admitted in 2016 were identified from the Nationwide Inpatient Sample (NIS). Multivariate regression analysis was used to estimate the odds ratio of in-hospital mortality, average length of stay (LOS), and total hospital charges after adjusting for the following factors: age, gender, race, Charlson and Elixhauser scores, primary insurance payer status, hospital type, hospital bed size, hospital region, and hospital teaching status. Statistical analysis was performed by using the survey procedures function in the statistical analysis system (SAS) software. Statistical significance was defined by the two-sided t-test with a p value < 0.05. RESULTS: The overall sample contained 363,050 patients. A total of 355,455 patients were admitted with ADHF and 2% of these patients had concomitant cirrhosis (n = 7595) in 2016. The total mortality rate was 3.4%, hospital LOS was 6.6 days (with a median of 6.5 days), and the mean total hospital charge was $63,120.20. Patients with both ADHF and cirrhosis compared to patients without ADHF had increased mortality, hospital LOS, and cirrhosis-related complications. CONCLUSIONS: As the incidence and prevalence of ADHF and cirrhosis increases worldwide, we urge the medical community to increase surveillance of patients with both diseases and perform rigorous cardiovascular risk assessments as well to improve patient outcomes.

Amiodarone induced epididymo-orchitis.

Amiodarone has a well-established and extensive side effect profile: pulmonary fibrosis, thyroid toxicity, corneal deposits, and skin discoloration. However, in some rare instances epididymitis/orchitis is a side effect of amiodarone. Symptoms range from testicular pain to swelling and erythema.1,2 The mechanism of how this toxicity occurs is unknown. In this case report, we will discuss the case of an elderly patient who developed epididymitis and orchitis after several years of tolerating amiodarone without any adverse events. Our patient underwent a full workup with testicular ultrasound, evaluation by the urology and cardiology services. His amiodarone was discontinued with complete resolution of symptoms. DATA SOURCES: A community hospital in Stratford, NJ. STUDY SELECTION: 88 year old male patient with multiple comorbidities. DATA EXTRACTION: Obtaining medical records on Soarian Cerner system. DATA SYNTHESIS: Article analysis obtained from PubMed.

Impact of khat price increases on consumption behavior - price elasticity analysis.

BACKGROUND: The long border of Saudi Arabia with Yemen is the primary route for khat entry to the Kingdom. As of April 2015, the government of SA tightened the border, making it more difficult to import khat into the country. As a result, local user prices of khat probably increased due in part to higher supply costs and perhaps lower quantities. One anti-drug strategy is to increase consumption cost by increasing the price of supply. We aim in this study to measure the responsiveness of khat demand to price changes. METHODS: This study used a cross-sectional survey design. Two stage sampling was used to recruit 350 khat chewers from four selected primary healthcare centers in Jazan province (South western province of Saudi Arabia). The data were collected during the first quarter of 2017. This study used both contingent valuation and revealed preference methods to assess the impact of price increases on the purchasing of khat. Graphical analysis, paired-samples t-test, and one-way repeated measures analysis of variance (ANOVA) were used to assess the impact of price increases on khat consumption. RESULTS: The study results showed a significant decrease in khat consumption amount (t = 8.63, p ≤ 0.05), frequency (t = 30.42, p ≤ 0.05), and expenditure (t = 34.67, p ≤ 0.05) after the tightening of the Saudi-Yemeni border. Hence khat demand is price elastic. The price elasticity of khat demand in Jazan is estimated to be between - 2.38 and - 1.07. Therefore, each 1% increase in price is associated with 1-2% reduction in quantity demanded. This means khat chewers are relatively responsive to price changes (i.e., khat demand is price elastic). Repeated measures analysis of variance showed price increases significantly affect the quantity {F(4, 2.58) = 257, p ≤ 0.05, ηp2 = 0.423} and frequency {F(4, 1.83) = 415, p ≤ 0.05, ηp2 = 0.543} of khat chewing. CONCLUSIONS: Increased prices for khat would significantly decrease demand. Accordingly, we recommend implementing law enforcement strategies focused on disrupting the khat supply chain to realize high prices and so discourage use, hence reducing the incidence of khat-related illnesses.