Safety of DOACs in patients with Child-Pugh Class C cirrhosis and atrial fibrillation.

Background: Anticoagulation (AC) is used for stroke prevention in atrial fibrillation (AF). Direct Oral Anticoagulants (DOACs) are safe in patients with AF without cirrhosis, they are hardly studied in patients with advanced cirrhosis. Our study evaluates the safety and outcomes of DOACs in patients with Child-Pugh class C cirrhosis (CPC). Methods: We queried TriNetX Database. Patients with CPC and AF were divided into three cohorts: patients on DOACs, no AC, and warfarin. Three study arms were created using a 1:1 propensity score matching system (PSM). Results: Totally 16 029 patients met the inclusion criteria. Of those, 20.2% (n = 3235) were on DOACs, 47.1% (n = 7552) were not on AC, and 32.7% (n = 5242) were on warfarin. First arm comparing AC versus no AC, a statistically significant benefit was identified in 3-year mortality risk (47% vs 71%, P < 0.0001) and transplant status (17% vs 5%, p < 0.0001) with AC. However, no significant difference was identified regarding intracranial hemorrhage and GI bleeding risk. Second arm comparing patients on DOACs versus no AC, we identified mortality benefit (40% vs 72%, P < 0.0001) and a higher transplant rate (9% vs 3.2%, P < 0.0001) with DOACs. Intracranial hemorrhage rates (6% vs 4%, P = 0.03) were higher in patients on DOACs. Third arm comparing patients on DOACs versus Warfarin, a statistically significant lower risk of intracranial hemorrhage (6.6% vs 8.7%, P = 0.004) and GI bleed (2% vs 2.4%, P < 0.0001) were identified in patients on DOACs. Conclusion: Anticoagulation is safe in patients with CPC with AF and may provide a mortality benefit. DOACs are a safer alternative to warfarin.

Outcomes of Hospitalized Patients With Fecal Occult Positive Stool Prior to Cardiac Catheterization in Acute Coronary Syndrome (ACS).

Introduction Cardiac catheterization is an essential component of patient care in Acute Coronary Syndrome (ACS). Fecal occult blood testing (FOBT) has been used in the inpatient setting to evaluate the risk of bleeding with dual anti-platelet therapy prior to cardiac catheterization although no guidelines exist for this indication and FOBT testing in the inpatient setting is not recommended for evaluation of GI blood loss. We sought to assess the outcomes of patients with fecal occult positive stool prior to cardiac catheterization compared to those that did not undergo FOBT during admission for non-ST-elevation myocardial infarction (NSTEMI). Methods We identified patients between 18 and 90 years old with admission for NSTEMI in the Trinetx Research Network from January 1, 2019 to December 31, 2020. Patients were then divided into those who had an FOBT prior to cardiac catheterization and those that did not have an FOBT. We compared all-cause mortality, bleeding, troponin levels, and length of stay between propensity-matched (PSM) pairs of patients. Results We identified 46,349 that met inclusion criteria, of which 1,728 had an FOBT (3.7%) and 44,621 (96.3%) had no FOBT prior to cardiac catheterization. Patients in the FOBT group were older and had a higher prevalence of hypertension, coronary artery disease, heart failure, diabetes, chronic obstructive pulmonary disease, and higher BMI. Two well-matched groups of n=1,728/1,728 were used for comparing outcomes. The FOBT group had similar 30-day mortality (4.45% vs 4.01, P=0.56) as well as similar bleeding events (0.98% vs 0.69%, P=0.35). Troponin levels in the FOBT group were on average lower (0.41 vs 0.95, P=0.04). The FOBT groups also had a similar average length of stay of (14.1 days vs 14.2 days, P=0.42). 233 patients who received FOBT underwent endoscopic evaluation with either upper endoscopy or colonoscopy (13.5%), and there was no significant difference in 30-day mortality (6.86% vs 4.7%, P=0.321). Among patients who underwent endoscopy, 72 had some form of endoscopic intervention (30.9%). There was no difference in 30-day mortality between patients undergoing endoscopy with intervention and without intervention (14.49%/14.49%) P=1.00. Readmission was similar between patients undergoing endoscopy with and without intervention. Conclusions In a large multi-center national database, we observed similar outcomes in patients who were admitted with NSTEMI and had FOBT and those not receiving FOBT in terms of all-cause mortality and bleeding events. In patients with positive FOBT, endoscopy with and without intervention we observed no significant difference in 30-day mortality. We conclude that there is no compelling evidence for FOBT testing in patients with NSTEMI.

Risk of COVID-19 Infection After Full Immunization in Patients With Inflammatory Bowel Disease on Treatment: A Research Network Analysis.

BACKGROUND: Acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is an issue in treating patients with Inflammatory Bowel Disease (IBD) due to concerns for infection risk and poor post-vaccination antibody response. We examined the potential impact of IBD treatments on SARS-CoV-2 infection rates after full immunization against COVID-19. METHODS: Patients who received vaccines between January 2020 and July 2021 were identified. The post-immunization Covid-19 infection rate at 3 and 6 months was assessed in IBD patients receiving treatment. The infection rates were compared to patients without IBD.  Results: The total number of IBD patients was 143,248; of those (n=9405), 6.6% were fully vaccinated. In IBD patients taking biologic agents/small molecules, no difference in Covid-19 infection rate was found at 3 (1.3% vs. 0.97%, p=0.30) and 6 months (2.2% vs. 1.7%, p=0.19) when compared to non-IBD patients. No significant difference in Covid-19 infection rate was found among patients receiving systemic steroids at 3 (1.6% vs. 1.6%, p=1) and 6 months (2.6% vs. 2.9%, p=0.50) between the IBD and non-IBD cohorts.  Conclusions: The COVID-19 immunization rate is suboptimal among IBD patients (6.6%). Vaccination in this cohort is under-utilized and should be encouraged by all healthcare providers.

A Nationwide Analysis of Fluid Resuscitation Outcomes in Patients With Acute Pancreatitis.

BACKGROUND: Traditionally, fluid resuscitation has been the foundation of effective acute pancreatitis (AP) treatment. Experts advocate for aggressive intravenous fluid (IVF) resuscitation, especially within the first 24 hours. Research suggests limited efficacy of this approach; in fact, some studies show there may be a risk of increased complications. The aim of this study was to assess outcomes of aggressive IVF resuscitation in patients with AP. METHODS: We queried the TriNetX Research Network (Cambridge, Massachusetts, United States) for patients admitted between January 1, 2010, and December 31, 2020, with a diagnosis of AP and who had received IVF on admission for at least 24 hours. We compared two cohorts; cohort 1 consisted of patients receiving aggressive IVF resuscitation (>3 ml/kg/hr), and cohort 2 was comprised of patients receiving non-aggressive (≤1.5 ml/kg/hr) IVF resuscitation. We compared mortality during index hospitalization, hospital length of stay (HLS), mechanical ventilation rates, acute kidney injury (AKI), and severe sepsis between the cohorts with propensity scoring matched (PSM) pairs of patients. A sub-analysis of patients with severe AP was performed. RESULTS: After comparing the two well-matched PSM cohorts (3,680/3,680), we found no significant differences in mortality, HLS, mechanical ventilation rates, AKI, or severe sepsis. We found similar results after conducting the sub-analysis of patients with severe pancreatitis. CONCLUSIONS: We found no significant differences in mortality and HLS when comparing rates of IVF resuscitation.

Prevalence of advanced histological features and synchronous neoplasia in patients with flat adenomas.

BACKGROUND AND AIMS: The prevalence of advanced histology in flat adenomas is uncertain. There are limited data on the prevalence of synchronous adenomas in patients with flat adenomas. The aims of this study were to determine whether the flat adenomas harbor advanced histology more than the polypoid adenomas and whether the presence of flat adenomas is an independent predictor of synchronous adenomas. METHODS: A retrospective analysis of data from 3 prospective clinical trials conducted at 2 tertiary care referral centers that included patients undergoing screening or surveillance colonoscopy was performed. The location, size, and morphology of each polyp resected was documented and sent for histopathological examination in a unique specimen jar. RESULTS: A total of 2931 polyps were removed in 1340 patients. Of the 1911 adenomas (65.2%), 293 (15.3%) were flat and 1618 (84.7%) were polypoid. The prevalence of advanced histology did not differ between flat and polypoid adenomas (1.4% vs 3.1%; P = .13). Multivariate analysis confirmed that the presence of at least 1 flat adenoma was a predictor of the presence of a large adenoma (P < .01; odds ratio [OR], 2.80; 95% CI, 1.86-4.22), advanced adenoma (P < .01; OR, 2.70; 95% CI, 1.80-4.06), and 3 or more adenomas (P < .01; OR, 2.44; 95% CI, 1.66-3.59). CONCLUSION: Although the prevalence of advanced histology in flat adenomas is similar to that of polypoid adenomas, flat adenomas are associated with increased prevalence of synchronous large and advanced adenomas. Whether these results imply shorter surveillance intervals in patients with flat adenomas needs to be explored in future studies.