bluuebunny/crossref_metadata_2025 huggingface dataset:
Hospital at home: A change in the course of care
Authors: Gaillard Garrett , Russinoff Ian
Published: February 2023

Acute care services in the United States are largely delivered in the hospital setting. Since the recent pandemic, acute care services in the hospital have become overwhelmed. An elderly population with comorbidities and lack of hospital capacity is leading to a “hospital without walls” approach to acute care. Hospital at Home (HaH) is a paradigm shift in the standard way to administer acute care. Model development coupled with innovations in telehealth and remote patient monitoring has led to HaH being considered a viable alternative to admitting patients to the hospital. Robust evidence suggests that HaH interventions are a new option for providers to assess, treat, and monitor patients. Outcomes equivalent to in-patient stays with no mortality difference makes this model a viable option for patient care outside of the hospital. An overall reduction in cost compared with an in-patient stay may be an economically viable option for overwhelmed hospital systems looking to care for their surrounding population. In this brief, we review some of the existing evidence and the growth of the HaH concept, and what it means for members of the interdisciplinary care team.
Patients are pragmatic and physicians are perfectionists? Comparing success after liver transplantation among patients and physicians
Authors: Woelfel Ingrid , Faulkner Daria , Wong Sandra , Washburn Kenneth , Schenk Austin
Published: February 2023

Although both patients and physicians are key stakeholders in health care outcomes, patients and physicians often define success differently. The purpose of this study was to compare patient and physician perceptions of success 1 year after liver transplantation. This was a single-institution, qualitative study. We conducted in-person, semi-structured interviews with liver transplant recipients 1 year after transplantation and virtual interviews with transplant surgeons and hepatologists. Transcripts were coded and iteratively analyzed for themes using the principles of phenomenology. Twenty patients, 8 caregivers, 5 transplant surgeons, and 4 hepatologists were interviewed. Subject interviews averaged 57 (patient) and 27 (physician) minutes. Overall, patients and physicians had significant agreement in their definitions of success, which included avoidance of death, restoration of physical and mental function, return to society, acquisition of new health care knowledge, and open communication between the patient and the physician. Patients highlighted relief from worry about their future health status, and physicians highlighted decreased health care costs. Patients noted that a liver transplant did not have to be perfect, that is free from complications, to be successful. Physicians had a more stringent view and felt that any deviation from an ideal course reduced the relative success of a transplant. Detailed assessment of patient and physician responses reveals similar overall goals of regaining physical, mental, and emotional function. Complications are perceived differently by patients and physicians. Awareness of this discordance may serve to enhance relationships between transplant patients and their providers.
Cerebral Small Vessel Disease in Elderly Patients with Sudden Sensorineural Hearing Loss
Authors: Oussoren Fieke K. , van Leeuwen Roeland B. , Schermer Tjard R. , Poulsen Louise N. F. , Kardux Joost J. , Bruintjes Tjasse D.
Published: February 2023

Background

The cause of sudden sensorineural hearing loss (SSNHL) is uncertain in a significant number of patients. A vascular etiology has been proposed because SSNHL increases the risk of developing a stroke. Cardiovascular risk factors can cause cerebral small vessel disease (CSVD). The presence of CSVD in turn raises the risk of stroke.

Aim

The aim of this study was to compare the presence of CSVD and cardiovascular risk factors in elderly patients with idiopathic SSNHL (iSSNHL) to a control cohort.

Method

Patients with iSSNHL of 50 years and older were compared with a control cohort with patients suspected of trigeminal neuralgia or vestibular paroxysmia. The primary outcome was the difference in the number of white matter hyperintensities using the ordinal Fazekas scale. Secondary outcomes were the presence of brain infarctions on MRI and the difference in cardiovascular risk factors.

Results

In the SSNHL cohort, Fazekas score 2 was most frequently seen compared with Fazekas 1 in the control cohort. The distribution of Fazekas scores did not differ significantly. The sum of the Fazekas scores were 13,925 and 14,042 for iSSNHL and controls, respectively (p = 0.908). Brain infarctions were seen in 8 patients with iSSNHL (n = 118) and in 13 patients in the control cohort (n = 118) (p = 0.361). None of the cardiovascular risk factors were more frequently seen in the iSSNHL cohort.

Conclusion

Patients with iSSNHL did not exhibit more CSVD on MRI than controls. This result is in contrast with previous literature demonstrating a higher risk of stroke in patients with iSSNHL than in controls. A prospective analysis with a larger study population is therefore warranted.
Real-world long-term effects on blood pressure and other cardiovascular risk factors for patients in digital therapeutics
Authors: Willis Michael , Darwiche Ghassan , Carlsson Martin , Nilsson Andreas , Wohlin Jonas , Lindgren Peter
Published: February 2023

Purpose

Hypertension is a leading causeof premature death worldwide and a major public health problem. This study investigated the long-term effects (>1 year) of digital hypertension monitoring by home blood pressure (HBP) measurements in combination with individualized remote treatment via a Swedish Digital Therapeutics platform in a large patient population.

Methods

The primary endpoint, HBP, and exploratory endpoints, BMI, alcohol consumption, stress level, physical activity, and smoking, were assessed every 3 months for 540 and 360 days, respectively, in 7752 Swedish primary hypertension patients. Patients received individualized medical treatments and lifestyle advice via asynchronous text-based communication in an app. Changes from baseline in endpoints were calculated for the whole population and for subgroups defined by baseline SBP ≥135 (high SBP), 125–135 (suboptimal SBP), 115–125 (optimal SBP), and <115 mmHg (low SBP).

Results

After 360 days of treatment, the whole population showed a significant increase of 57% (from 37 to 58%) in the proportion of patients with controlled SBP (i.e. SBP of 115–135 mmHg). The largest reduction in SBP of 13.8 mmHg was observed for the high SBP subgroup, whereas for the low SBP subgroup, SBP increased by 13.4 mmHg. BP improved most in the first three months, and for both the high and low BP subgroups, the improvement continued during the 540-day study period. Significant beneficial changes were also observed for some exploratory endpoints including BMI and smoking.

Conclusions

In conclusion, the digital therapeutics platform was associated with significant improvement in BP control and associated risk factors, which were maintained over a longer period.
Atypical Causes of Gastroparesis
Authors: Szeto Lauren , Yazdian Aaron , Parkman Henry P.
Published: February 2023

Background:

Gastroparesis is commonly attributed to idiopathic or diabetic causes.

Goals:

We aimed to describe atypical causes of gastroparesis and examine the clinical features and severity of delayed gastric emptying compared with idiopathic and diabetic causes.

Study:

Between 2018 and 2021, gastroparesis patients being evaluated at our tertiary care center completed a 4-hour gastric emptying scintigraphy and questionnaires assessing for gastrointestinal disorders, including patient assessment of upper gastrointestinal symptoms. Patients were divided into groups relating to gastroparesis cause: diabetic, postsurgical (PSGp), connective tissue (CTGp), neurological and idiopathic.

Results:

Two hundred fifty-six patients with delayed emptying on gastric emptying scintigraphy completed the questionnaires. Gastroparesis causes included 149 (58.2%) idiopathic, 60 (23.4%) diabetic, 29 (11.3%) postsurgical, 13 (5.1%) connective tissue, and 5 (2.0%) neurological. In each group, most patients were female and White. Gastric retention at 4 hours was significantly greater in patients with diabetic (39.3±25.7% P<0.001), postsurgical (41.3±24.0% P=0.002), and connective tissue gastroparesis (37.8±20.0% P=0.049) compared with patients with idiopathic gastroparesis (25.5±17.6%). In PSGp, diabetic and idiopathic causes, the main symptoms were early satiety and postprandial fullness, whereas in CTGp, bloating and abdominal distension were the predominant symptoms. Vomiting severity was significantly greater in patients with diabetes compared with idiopathic gastroparesis (2.9±1.9 vs. 2.1±1.8 P=0.006).

Conclusions:

Atypical causes contributed to gastroparesis in 47 of 256 (18.4%) patients with delayed gastric emptying. Gastric emptying was significantly more delayed in PSGp and CTGp patients. PSGp patients mainly experienced stomach fullness and early satiety, whereas CTGp patients had predominantly bloating and distension.
Integration of Cirrhosis Best Practices Into Electronic Medical Record Documentation Associated With Reduction in 30-Day Mortality Following Hospitalization
Authors: Sherman Zachary , Wahid Nabeel , Wagner Michael , Soltani Amin , Rosenblatt Russell , Fortune Brett , Lucero Catherine , Schoenfeld Emily , Brown Robert , Jesudian Arun
Published: February 2023

Background:

Hospital admissions for patients with cirrhosis continue to increase. In New York City, 25% to 30% of hospitalized cirrhotics are readmitted within 30 days. Rehospitalization is associated with increased mortality, poor quality of life, and financial burden to patients, hospitals, and payers. Preventable readmissions are partially accounted for by a well-documented quality gap between evidence-based guidelines for cirrhosis management and real-world adherence to these recommendations.

Methods:

We performed a prospective cohort study that compared outcomes among cirrhotic patients admitted to 4 internal medicine teams over a 6-month period. An electronic medical record (EMR) note template that outlined best-practice measures for cirrhotics was developed. Inpatient providers on 2 teams were instructed to include it in daily progress notes and discharge summaries. The recommended practices included diagnostic paracentesis and diuretics for ascites, rifaximin, and lactulose for hepatic encephalopathy, beta blockers for esophageal varices, and antibiotic prophylaxis for spontaneous bacterial peritonitis. The remaining 2 teams continued the standard of care for cirrhotic patients. The primary outcome was 30-day readmissions. Secondary outcomes included in-hospital mortality, 30-day mortality, length of stay, and adherence to best-practice guidelines.

Results:

Over a 6-month period, 108 cirrhotic patients were admitted, 83 in the interventional group and 25 in the control group. MELD-Na scores on admission did not differ between the groups (20.1 vs. 21.1, P=0.56). Thirty-day readmissions were not significantly different between the interventional and control groups (19.3% vs. 24%, P=0.61). However, 30-day mortality was significantly lower in the interventional group (8.4% vs. 28%, P=0.01). There was no difference between the 2 groups in in-hospital mortality (4.8% vs. 0%, P=0.27), 90-day mortality (15.7% vs. 28.0%, P=0.17) or length of stay (10.2 vs. 12.6 d, P=0.34). Adherence to best-practice metrics was similar between the groups, except for rates of diagnostic paracentesis, which were higher in the interventional group (98% vs. 80%, P=0.01).

Conclusion:

Implementation of an EMR note template with cirrhosis best practices was associated with lower 30-day mortality and higher rates of diagnostic paracentesis among admitted patients with cirrhosis. These findings suggest that the integration of best-practice measures into the EMR may improve outcomes in hospitalized cirrhotic patients. Larger studies are required to validate these findings.
The Impact of Intermittent Fasting on Patients With Suspected Gastroesophageal Reflux Disease
Authors: Jiang Yan , Sonu Irene , Garcia Patricia , Fernandez-Becker Nielsen Q. , Kamal Afrin N. , Zikos Thomas A. , Singh Sundeep , Neshatian Leila , Triadafilopoulos George , Goodman Steven N. , Clarke John O.
Published: February 2023

Goal:

The aim was to investigate the short-term impact of time restricted feeding on patients with suspected gastroesophageal reflux disease (GERD).

Background:

Lifestyle modifications are often suggested, but the role of diet in GERD is unclear. Intermittent fasting is popular in the media and has demonstrated potential benefits with weight loss and inflammatory conditions as well as alterations in gastrointestinal hormones.

Study:

Patients who were referred for 96-hour ambulatory wireless pH monitoring off proton pump inhibitor to investigate GERD symptoms were screened for eligibility. Patients were instructed to maintain their baseline diet for the first 2 days of pH monitoring and switch to an intermittent fasting regimen (16 consecutive hour fast and 8 h eating window) for the second 2 days. Objective measures of reflux and GERD symptom severity were collected and analyzed.

Results:

A total of 25 participants were analyzed. 9/25 (36%) fully adhered to the intermittent fasting regimen, with 21/25 (84%) demonstrating at least partial compliance. Mean acid exposure time on fasting days was 3.5% versus 4.3% on nonfasting days. Intermittent fasting was associated with a 0.64 reduction in acid exposure time (95% CI: −2.32, 1.05). There was a reduction in GERD symptom scores of heartburn and regurgitation during periods of intermittent fasting (14.3 vs. 9.9; difference of −4.46, 95% CI: −7.6,−1.32).

Conclusions:

Initial adherence to time restricted eating may be difficult for patients. There is weak statistical evidence to suggest that intermittent fasting mildly reduces acid exposure. Our data show that short-term intermittent fasting improves symptoms of both regurgitation and heartburn.
The Association Between Acidification Time on Wireless Motility Capsule and Gastroesophageal Reflux Disease
Authors: Rodriguez Steven J. , Blackett John W. , Jodorkovsky Daniela
Published: February 2023

Background and Aims:

Gastric physiological characteristics such as fundus accommodation, gastric distention, emptying/transit time, and basal acid output may contribute to the pathogenesis of gastroesophageal reflux disease (GERD). Wireless motility capsule (WMC) uses pH data to determine gastric transit time but has not been used in the evaluation of GERD. Certain metrics such as acidification time, nadir pH, and gastric transit time may provide insight into the mechanisms of GERD related to gastric physiology, allowing WMC to be a complementary tool in the diagnosis of GERD. We aimed to determine whether pH data and transit time on WMC tests correlated with the presence of GERD on ambulatory reflux testing.

Study:

This was a retrospective study of 28 patients who had undergone both WMC and reflux testing via wireless pH or pH/impedance. Acidification time (time from capsule ingestion to pH<2), nadir postprandial pH, and gastric transit time were manually determined from the WMC capsule proprietary software. Spearman correlation was used to compare these metrics with gastric transit time, percent esophageal acid exposure, and DeMeester score.

Results:

Acidification time moderately correlated with gastric transit time, R: 0.44, P=0.02, but not nadir pH, percent esophageal acid exposure, or DeMeester score. Patients with an abnormal reflux test had a significantly longer median acidification time (135.5 vs. 78.5 min, P=0.021). After stratifying by patients with normal versus prolonged gastric transit time, there was a trend toward longer acidification time in patients with positive reflux testing in both groups, but this was not statistically significant. Patients with prolonged gastric transit time >300 minutes were not more likely to have a positive reflux test (38% vs. 35%, P=1).

Conclusions:

The acidification time on WMC was significantly longer in patients with proven GERD and acidification time positively correlated with gastric transit time. Larger studies are needed to determine whether WMC could be used as a complementary tool in investigating patients with GERD symptoms.
Safety and Efficacy of Endoscopic Full Thickness Resection of Upper Gastrointestinal Lesions Using a Full Thickness Resection Device
Authors: Bomman Shivanand , Klair Jagpal S. , Canakis Andrew , Muthusamy Arun Kumar , Nagra Navroop , Chandra Shruti , Shanmugam Meena , Perisetti Abhilash , Aggarwal Avin , Gavini Hemanth K. , Krishnamoorthi Rajesh
Published: February 2023

Introduction:

Endoscopic full-thickness resection (EFTR) is a promising technique that allows for a minimally invasive resection of mucosal and submucosal lesions in the gastrointestinal (GI) tract. The data regarding the efficacy and safety of performing EFTR of upper GI lesions using a full-thickness resection device (FTRD) is limited. Hence, we performed a systematic review and meta-analysis of the studies that evaluated this technique.

Methods:

We performed a comprehensive systematic search of multiple electronic databases and conference proceedings that reported outcomes of EFTR using the FTRD system. The weighted pooled rates of technical success, complete (R0) resection, adverse events (AE), and residual or recurrent lesions were analyzed with 95% CI using the random effects model.

Results:

Eight studies with a total of 139 patients who underwent EFTR of upper GI lesions were included in the study. The pooled, weighted rate of technical success was 88.2% (95% CI: 81.4-92.7%, I
2: 0). The R0 resection rate was 70.7% (95% CI: 62.5-77.8%, I
2: 0). Overall AE rates were 22.1% (95% CI: 15.8-30.1%, I
2: 0), however, most of the AEs were minor. Of the patients who had follow-up endoscopies, the residual and/or recurrent lesion rate was 6.1% (95% CI: 2.4-14.4%, I
2: 0). Heterogeneity in the analysis was low.

Conclusions:

EFTR using the FTRD seems to be effective and safe with acceptable R0 resection rates and low recurrence rates. Further prospective studies are required to validate our results and to compare various modalities of endoscopic resection with this single-step EFTR device.
Clinical Implications of Low-grade Duodenal Eosinophilia in Functional Dyspepsia
Authors: Barreyro Fernando Javier , Caronia Maria Virgina , Elizondo Karina , Sanchez Nicolas , Jordá Graciela , Schneider Adolfo , Zapata Pedro Dario
Published: February 2023

Background:

Functional dyspepsia (FD) is a multifactorial disorder with no targeted therapy. Duodenal eosinophilia and low-grade inflammation are potential pathogenic mechanisms. However, the impact of duodenal eosinophils (D-EO) histologic evaluation in real-life clinical practice was not explored.

Aim:

To evaluate the clinical utility of D-EO and low-grade inflammation in FD in real-life practice.

Materials and Methods:

A multicenter prospective study was conducted. A total of 636 patients who meet Rome-III criteria were selected before upper endoscopy and 516 patients were included after normal endoscopy were assessed. Clinical parameters,Helicobacter pylori(H. pylori),and duodenal histology were evaluated.

Results:

FD subtypes were 231 (45%) patients who had epigastric pain syndrome (EPS), 168 (33%) postprandial distress syndrome (PDS), and 117 (22%) EPS/PDS overlap. Two hundred fifty-nine (50.3%) patients wereH. pylori+. Histologic duodenal grading of chronic inflammation and intraepithelial lymphocytes showed no difference between FD subtypes. Increased in D-EO densities (>10 per high power field) was significant in PDS compared with EPS and EPS/PDS overlap subtypes. The odds ratio of PDS in subjects with duodenal eosinophilia densities was 2.28 (95% CI, 1.66-3.14;P<0.0001), adjusting for age, gender,H. pyloriand nonsteroidal anti-inflammatory drug the odds ratio was 3.6 (95% CI, 2.45-5.28;P<0.0001). receiver operating characteristic curve analysis further demonstrated that low-grade duodenal eosinophilia, in particularH. pylori−, was highly accurate for PDS with the area under the curve 0.731 compared withH. pylori+area under the curve 0.598. Furthermore, low-grade duodenal eosinophilia was significantly correlated with treatment response under 4 to 6 weeks of proton pump inhibitor therapy.

Conclusion:

Our findings suggest that low-grade duodenal eosinophilia is associated with PDS subtype non-H. pyloriFD patients and could be a useful marker of treatment response.
Prevalence and Impact of Obesity in a Population-Based Cohort of Patients With Crohn’s Disease
Authors: Johnson Amanda M. , Harmsen William Scott , Aniwan Satimai , Tremaine William J. , Raffals Laura E. , Abu Dayyeh Barham K. , Loftus Edward V.
Published: February 2023

Background:

Obesity is on the rise within the inflammatory bowel disease population. The impact obesity has on the natural history of Crohn’s disease (CD) is not well-understood. We aimed to describe the prevalence of obesity in a population-based cohort of newly diagnosed patients with CD, and the impact obesity had on disease phenotype and outcomes of corticosteroid use, hospitalization, intestinal resection, and development of fistulizing or penetrating disease.

Materials and Methods:

A chart review was performed on Olmsted County, Minnesota residents diagnosed with CD between 1970 and 2010. Data were collected on demographics, body mass index, CD location and behavior, CD-related hospitalizations, corticosteroid use, and intestinal resection. The proportion of individuals considered obese at the time of CD diagnosis was evaluated over time, and CD-associated complications were assessed with Kaplan-Meier survival analysis.

Results:

We identified 334 individuals diagnosed with CD between 1970 and 2010, of whom 156 (46.7%) were either overweight (27.8%) or obese (18.9%) at the time of diagnosis. The proportion of patients considered obese at the time of their diagnosis of CD increased 2-3 fold over the course of the study period. However, obesity did not have a significant impact on the future risk of corticosteroid use, hospitalization, intestinal resection, or development of penetrating and stricturing complications.

Conclusions:

Obesity is on the rise in patients with CD, although in this cohort, there did not appear to be any negative association with future CD-related outcomes. Further prospective studies, ideally including obesity measures such as visceral adipose tissue assessment, are warranted to understand the implications of the rising prevalence of obesity on CD outcomes.
Gastrointestinal-isolated Distress is Common in Alpha-gal Allergic Patients on Mammalian Meat Challenge
Authors: McGill Sarah K. , Levin Michael E. , Shaheen Nicholas J. , Cotton Cary C. , Platts-Mills Thomas A. , Commins Scott P.
Published: February 2023

Background and Aims:

Alpha-gal allergy causes a delayed reaction to mammalian meats and has been reported worldwide. Patients with the allergy may present with isolated gastrointestinal (GI) symptoms, but this phenotype is poorly understood.

Methods:

We pooled and analyzed symptoms and demographics of patients from two prospective cohorts of patients with a diagnosis of alpha-gal allergy who reacted after eating mammalian meat under observation. We compared the characteristics of patients who demonstrated GI-isolated symptoms on a challenge with those who exhibited symptoms outside the GI tract (skin, respiratory, and circulatory).

Results:

Among the 91 children and adult alpha-gal allergic patients who exhibited symptoms after oral challenge with mammalian meat, 72.5% experienced GI distress with one or more GI symptoms, which was the most frequent class of symptoms, compared with skin changes in 57.1% and respiratory distress in 5.5%. The most common GI symptoms were abdominal pain (71%) and vomiting (22.0%). GI-isolated symptoms occurred in 37 patients (40.7%) who reacted, and those patients reacted more quickly than patients who exhibited systemic symptoms (median onset of symptoms in GI-isolated group 90 min vs 120 min) and were more likely to be children than adults (relative risk=1.94, 95% CI: 1.04-3.63).

Conclusions:

Isolated-GI distress occurred in 4 in every 10 alpha-gal allergic individuals who developed symptoms on oral food challenge with mammalian meat. Alpha-gal allergic patients, particularly children, may exhibit GI distress alone, and adult and pediatric gastroenterologists should be aware of the diagnosis and management of the allergy.
Midazolam versus morphine in acute cardiogenic pulmonary edema patients with and without atrial fibrillation: findings from the MIMO trial
Authors: Domínguez-Rodríguez Alberto , Hernandez-Vaquero Daniel , Suero-Mendez Coral , Burillo-Putze Guillermo , Gil Victor , Calvo-Rodriguez Rafael , Piñera-Salmeron Pascual , Llorens Pere , Martín-Sánchez Francisco J. , Abreu-Gonzalez Pedro , Miró Òscar ,   for the MIMO (MIdazolam versus MOrphine) Trial Investigators
Published: February 2023

Background and importance

The MIMO clinical trial showed that patients with acute cardiogenic pulmonary edema (ACPE) treated with midazolam had fewer serious adverse events than those treated with morphine. Atrial fibrillation (AF) is a common comorbidity in heart failure and affects patient’s outcome.

Objective

The primary endpoint of this substudy is to know if AF modified the reduced risk of serious adverse events in the midazolam arm compared to morphine. The first secondary endpoint is to know if AF modified the reduced risk of serious adverse events or death at 30 days in the midazolam arm. The second secondary objective of this substudy is to analyze whether AF modified the reduced risk of midazolam against morphine on the total number of serious adverse events per patient.

Design

We conducted a secondary analysis of the MIMO trial. Patients more than 18 years old clinically diagnosed with ACPE and with dyspnea and anxiety were randomized (1:1) at emergency department arrival to receive either intravenous midazolam or morphine.

Outcome measures and analysis

In this post hoc analysis, we calculated the relative risk (RR) of serious adverse events in patients with and without AF. Calculating the Cochran-Mantel-Haenszel interaction test, we evaluated if AF modified the reduced risk of serious adverse events in the midazolam arm compared to morphine.

Main results

One hundred eleven patients (median = 78.9 years; IQR, 72.3–83.7; women, 52.2%) were randomized in the MIMO trial, 55 to receive midazolam and 56 to morphine. All randomized patients received the assigned drug and there were no losses to follow-up. Forty-four patients (39.6%) had AF. In the AF group, the RR for the incidence of serious adverse events in the midazolam versus morphine arm was 0.42 (95% CI, 0.14–1.3). In the group without AF, the RR was 0.46 (95% CI, 0.21–1). The presence of AF did not modify the reduced risk of serious adverse events in the midazolam arm compared with morphine (P for interaction = 0.88).

Conclusion

This post hoc analysis of the MIMO trial suggests that the reduced risk of serious adverse events in the midazolam group compared to morphine is similar in patients with and without AF.
Statin Use and Delirium Risk: An Updated Systematic Review and Meta-Analysis
Authors: Chang Ya-Hui , Wang Jian-Ying , Peng Tzu-Rong , Lian Jia-Haur , Lee Ming-Chia , Chen Hui-Ming
Published: February 2023

Background:

Findings on the association of statin use with delirium risk are inconsistent.

The Study Question:

Is statin use associated with delirium risk?

Study Design:

We searched PubMed, the Cochrane Library, and the EMBASE database, limiting the search to human patients and articles in English published until December 31, 2021. The effect size and 95% confidence interval (CI) were defined as the odds ratio (OR) and 95% CI, respectively, to indicate the difference in the incidence of delirium between statin use and nonuse groups. A random-effects model was selected in the case of high heterogeneity of study populations. We used funnel plots, Egger test, Duval and Tweedie trim-and-fill approach, and the classic fail-safe N to assess publication bias.

Results:

Of a total of 264 identified studies, 13 were selected for the qualitative review—4 RCTs and 9 observational cohort studies. Statin use was not associated with low delirium risk (pooled OR, 0·82; 95% CI, 0·64–1·04; P = 0·09). Substantial statistical heterogeneity was observed (I
2, 90%). Visual inspection of the funnel plot of ORs from the studies revealed symmetry. Using the Grading of Recommendations Assessment, Development, and Evaluation approach, we assigned the evidence a rating of C and a weak recommendation for this review.

Conclusions:

Statin use is not associated with delirium risk. More comprehensive RCTs are required to confirm the results.
Chronic Illness in Children and Foregone Care Among Household Adults in the United States
Authors: Narm Koh Eun , Wen Jenny , Sung Lily , Dar Sofia , Kim Paul , Olson Brady , Schrager Alix , Tsay Annie , Himmelstein David U. , Woolhandler Steffie , Shure Natalie , McCormick Danny , Gaffney Adam
Published: February 2023

Background:

Childhood chronic illness imposes financial burdens that may affect the entire family.

Objective:

The aim was to assess whether adults living with children with 2 childhood chronic illnesses—asthma and diabetes—are more likely to forego their own medical care, and experience financial strain, relative to those living with children without these illnesses.

Research Design:

2009–2018 National Health Interview Survey.

Subjects:

Adult-child dyads, consisting of one randomly sampled child and adult in each family.

Measures:

The main exposure was a diagnosis of asthma or diabetes in the child. The outcomes were delayed/foregone medical care for the adult as well as family financial strain; the authors evaluated their association with the child’s illness using multivariable logistic regressions adjusted for potential confounders.

Results:

The authors identified 93,264 adult-child dyads; 8499 included a child with asthma, and 179 a child with diabetes. Families with children with either illness had more medical bill problems, food insecurity, and medical expenses. Adults living with children with each illness reported more health care access problems. For instance, relative to other adults, those living with a child with asthma were more likely to forego/delay care (14.7% vs. 10.2%, adjusted odds ratio: 1.27; 95% CI: 1.16–1.39) and were more likely to forego medications, specialist, mental health, and dental care. Adults living with a child with diabetes were also more likely to forego/delay care (adjusted odds ratio: 1.76; 95% CI: 1.18–2.64).

Conclusions:

Adults living with children with chronic illnesses may sacrifice their own care because of cost concerns. Reducing out-of-pocket health care costs, improving health coverage, and expanding social supports for families with children with chronic conditions might mitigate such impacts.
The Impact of Reimbursement for Non–Face-to-Face Chronic Care Management on Comprehensive Metabolic Biomarkers Among Multimorbid Patients With Type 2 Diabetes
Authors: Shao Yixue , Stoecker Charles , Hong Dongzhe , Nauman Elizabeth , Fonseca Vivian , Hu Gang , Bazzano Alessandra N. , Fort Daniel , Kabagambe Edmond K. , Shi Lizheng
Published: February 2023

Aims:

We evaluated the impact of reimbursement for non–face-to-face chronic care management (NFFCCM) on comprehensive metabolic risk factors among multimorbid Medicare beneficiaries with type 2 diabetes in Louisiana.

Materials and Methods:

We implemented a propensity score method to obtain comparable treatment (n=1501 with NFFCCM) and control (n=17,524 without NFFCCM) groups. Patients with type 2 diabetes were extracted from the electronic health records stored in REACHnet. The study period was from 2013 to February 2020. The comprehensive metabolic risk factors included the primary outcome of glycated hemoglobin (HbA1c) (as the primary outcome) and the secondary outcomes of body mass index (BMI), systolic blood pressure (BP), and low-density lipoprotein cholesterol.

Results:

Receiving any NFFCCM was associated with improvement in all outcomes measures: a reduction in HbA1c of 0.063% (95% CI: 0.031%–0.094%; P<0.001), a reduction in BMI of 0.155 kg/m2 (95% CI: 0.029–0.282 kg/m2; P=0.016), a reduction in systolic BP of 0.816 mm Hg (95% CI: 0.469–1.163 mm Hg; P<0.001), and a reduction in low-density lipoprotein cholesterol of 1.779 mg/dL (95% CI: 0.988 2.570 mg/dL; P<0.001). Compared with the control group, the treatment group had 1.6% more patients with HbA1c <7% (95% CI: 0.3%–2.9%; P=0.013).

Conclusions:

Patients with diabetes in Louisiana receiving NFFCCM experienced better control of HbA1c, BMI, BP, and low-density lipoprotein outcomes.
Stigma and Barriers in Health Care Among a Sample of Transgender and Gender-Diverse Active Duty Service Members
Authors: Johnson Nia , Pearlman Arielle T. , Klein David A. , Riggs David , Schvey Natasha A.
Published: February 2023

Background:

Transgender and/or gender-diverse (TGD) persons are vulnerable to stigma and health care inequities; however, data are particularly limited among TGD active duty military service members despite ongoing changes to service policies. TGD-related stressors may impede access to and utilization of health care due to fear of potential discrimination and distress, thereby adversely impacting military readiness.

Methods:

We examined stigma and barriers in health care and associations with physical and mental health in an online sample of 177 active duty service members who self-identified as TGD. To assess associations between stigma and barriers in health care with mental and physical health, linear regressions were conducted adjusting for age, gender identity, race, and rank.

Results:

Over half (65%) of the participants reported at least 1 instance of stigma and/or barrier in health care. Stigma and barriers to health care were significantly associated with greater self-reported depressive symptoms (β=0.20, P=0.03), anxiety (β=0.21, P=0.03), stress (β=0.30, P=0.001), and poorer overall mental health (β=−0.23, P=0.007), after adjusting for covariates. Nearly one-quarter of participants had not disclosed their gender identity to their primary care clinician.

Conclusions:

Findings suggested that stigma and barriers to affirming health care were prevalent among active duty service members identifying as TGD, specifically, difficulty accessing gender-affirming care and negative assumptions from clinicians. These experiences may adversely affect mental health and impede the quality of health care received by a population already vulnerable to health inequities. Given recent changes to military policy, efforts may be warranted to improve access to timely, affirming care and clinician training.
The relationship between tumor mean standard uptake value (SUVmax) in preoperative PET/computed tomography and prognostic risk groups in endometrial cancer
Authors: Bese Tugan , Bicer Elifnur , Tetikli Kosuk Asli , Akovali Burak , Turan Hasan , Kabasakal Levent , Demirkiran Fuat
Published: February 2023

Objective

Our aim in this study was to determine the relationship between tumor mean standard uptake value (SUVmax) value in preoperative PET/computed tomography (CT) and prognostic risk groups in cases with endometrial cancer.

Methods

A total of 368 patients operated on for endometrial cancer were evaluated in the study. The SUVmax value of endometrial primary tumor of the patients screened within 30 days of operation, was compared with prognostic parameters and risk groups. P value <0.05 was considered significant for all tests.

Results

A statistically significant relationship was found between the mean SUVmax value and risk groups (P < 0.001), grade (P < 0.001), stage (P < 0.001), myometrial invasion of the tumor (P < 0.001), cervical involvement (P = 0.002), lymphovascular space invasion (LVSI) (P < 0.001), lymph node metastasis (P < 0.001), tumor size (P < 0.001), lymph node involvement in PET/CT (P < 0.001). There was no significant relationship found between the histologic type of tumor and the mean SUVmax value (P = 0.113). Cutoff SUVmax value for endometrial cancer tumor tissue, which will be used to determine the possible lymph node metastasis, was accepted as 19 as a result of the ROC analysis. The risk of lymph node metastasis was found 4.74 times (confidence interval, 2.510–8.977) higher in patients with SUVmax value above cutoff 19 (P < 0.001). Considering risk groups, it was observed that patients with mean SUVmax value above 19 were in intermediate-high and high risk group, 2.3 times more than those in low and intermediate risk group (P < 0.001). As a result of logistic regression analysis, in determining intermediate-high and high-risk groups, histological type (P < 0.001), myometrial invasion (P = 0.003), cervical invasion (CI) (P < 0.001), grade (P = 0.018) and SUVmax value (P = 0.028) had statistically significant importance.

Conclusion

The higher the mean SUVmax value in the endometrial cancer tumor tissue in preoperative PET/CT in patients with endometrial cancer, the higher the risk group of the patients.
State-of-the-art: septal perforation repair
Authors: Garaycochea Octavio , Santamaría-Gadea Alfonso , Alobid Isam
Published: February 2023

Purpose of review

To provide a comprehensive overview of the evolution of the different techniques described for the surgical repair of nasal septal perforation, and a surgical decision-making algorithm for its surgical treatment.

Recent findings

Septal perforation surgery has evolved and improved in recent years. It has gone from being an avoided or discouraged surgical procedure to a procedure with success rates of >90%. Nowadays, there is no standard approach or single technique. The different techniques described include unilateral random pattern flaps, interposition grafts, unilateral pedicle septal local flaps, free mucosal grafts and bilateral random patter flaps. The incidence of success is higher in pediculated septal flaps such as the anterior ethmoidal artery flap or the greater palatine artery pedicled flap combined with additional techniques.

Nowadays, surgical closure of septal perforation is possible and should be an option to consider in symptomatic patients without response to medical treatment. The surgical approach that we recommend when planning the surgical closure of nasal septum (or nasoseptal) perforation is based on the osseocartilaginous support and the location of the defect.
Splenic Stiffness Is the Best Predictor of Clinically Significant Varices in Children With Portal Hypertension
Authors: Upadhyay Piyush , Khanna Rajeev , Sood Vikrant , Lal Bikrant Bihari , Patidar Yashwant , Alam Seema
Published: February 2023

Background and Aims:

We studied splenic stiffness measurement (SSM) by transient elastography (TE) and portal hemodynamics parameters (PHDp) on Doppler as predictors of clinically significant varices (CSV) in children.

Methods:

All children of 6 months to 18 years of age with portal hypertension (PHT) (chronic liver disease, CLD and non‐cirrhotic portal hypertension, NCPH) were enrolled. TE for spleen (SSM) and liver (liver stiffness measurement, LSM) and PHDp by Doppler ultrasonography were measured. Noninvasive indices for PHT were calculated. CSV were defined as esophageal varices ≥grade 2 and/or gastric varix. Binary logistic regression analysis (LRA) and receiver operating characteristic statistics were applied.

Results:

A total of 150 (120 CLD and 30 NCPH) children formed the study cohort. Prevalence of CSV was higher in NCPH than CLD [73.3% vs 53.3%, Odd’s ratio (OR) 2.369, P = 0.04]. On LRA, SSM was found to be the only independent predictor of CSV in children with CLD [OR 1.19 (95% Confidence Interval (CI) 1.018–1.16), P = 0.000] as well as in NCPH [OR 1.088 (95% CI 1.018–1.16), P = 0.013]. This model improved prediction of CSV in CLD from 52.5% to 83.9% and in NCPH from 73.3% to 86.7%. In children with CLD, SSM at a cut‐off ≥27.6 kPa and in NCPH, SSM at a cut‐off ≥29.5 kPa predicted CSV. In children with CLD, SSM correlated with LSM (R = 0.610, P <0.001) and with noninvasive PHT indices except aspartate aminotransferase‐to‐platelet ratio index.

Conclusion:

SSM is the best noninvasive predictor of CSV in childhood CLD and NCPH and can be used as screening test for endoscopy in children with PHT.
Evaluating Transition Readiness
Authors: Huang Jeannie S. , Cruz Rusvelda , Kruth Robin , Parker Jacob
Published: February 2023

Objective:

Determination of transitional readiness is an essential component of delivery of transition services to adolescents and young adults with chronic diseases, including those with inflammatory bowel disease (IBD). To date, this has been performed using the transition checklist (TC). However, clinical experience suggests the validity of the checklist may not be ideal. We sought to evaluate the validity of the TC among adolescents and young adults with IBD (AYA IBD).

Methods:

We evaluated the validity of the TC compared with a skills‐based practicum (TKSP) in a cross‐sectional study using a real‐world clinical cohort of AYA IBD. Extent of concordance between TC and TKSP was assessed using confusion matrices and calculation of Matthews correlation coefficients.

Results:

Concordance between self‐reported TC answers and TKSP performance varied based on skill/knowledge base assessed, ranging from 81.3% for mastery of knowing one’s medical condition to 39.2% for mastery of knowing one’s medication schedule and 29.3% for mastery of knowing how to refill medications. Matthews correlation coefficients were closer to random prediction than perfect correlation for all skills/knowledge tested.

Conclusions:

Self‐reported TC answers lack sufficient concordance with TKSP performance. Our findings suggest that a TKSP should be performed to assess for transition readiness and to identify individual AYA IBD patient needs during the transition process.
Prevalence and Etiologies of Renal and Urinary Manifestations in a Large Cohort of Children With Inflammatory Bowel Disease
Authors: Cordesse Anne , Delbet Jean‐Daniel , Lemoine Anaïs , Dubern Béatrice , Tounian Patrick , Lemale Julie
Published: February 2023

Background and objectives:

Renal and/or urinary manifestations (RUM) have been reported in pediatric patients with inflammatory bowel disease (IBD) but their incidence is unknown. The aims of this study were to assess the prevalence and causes of these manifestations in children with IBD and determine the causal link with 5‐aminosalicylic acid (5‐ASA) treatment.

Methods:

A retrospective observational study was performed with children with diagnosis of IBD. All children with RUM during follow‐up and/or impaired renal function [estimated glomerular filtration rate (eGFR) < 90 mL/min/1.73 m2] were identified.

Results:

Of 228 included patients, 9 (3.9%) had a RUM during follow‐up [follow‐up: 5 years (1–12 years)] at a median age of 16 years (8–17 years). It concerned 7 of 171 patients with Crohn disease and 2 of 57 with ulcerative colitis. Seven patients were taking 5‐ASA at the time of the RUM. Only 1 of them had an iatrogenic renal complication related to this treatment. Patients with RUM had a more severe disease with increased anti‐tumor necrosis factor‐α use (P = 0.031), more abscesses (P = 0.003), and a higher rate of digestive surgery (P = 0.04). For the whole cohort, a significant decrease in eGFR was found during follow‐up (121 vs 107 mL/min/1.73 m2, P < 0.001). At the end of follow‐up, 38 of 202 (19%) patients had an eGFR < 90 mL/min/1.73 m2.

Conclusion:

In children with IBD, RUM can occur, independently of treatment with 5‐ASA. During follow‐up, a significant decrease in eGFR was observed. We suggest monitoring renal function in all patients with IBD.
Length of Bowel Rest Does Not Predict Gastrojejunostomy Tube‐Associated Intussusception Recurrence
Authors: Abebe Abel Tsehay , Worede Fikadu , Elsingergy Mohamed , Cahill Anne Marie , Acord Michael R.
Published: February 2023

Objectives:

One potential treatment for gastrojejunostomy (GJ) tube‐related intussusception is bowel rest, whereby the GJ tube is replaced with a gastrostomy tube. The aim of this study was to determine whether bowel rest length was associated with decreased risk of re‐intussusception.

Methods:

Pediatric patients with GJ tube‐related intussusceptions were identified during the study period of January 1, 2010 and August 1, 2021. Records were reviewed for demographics, symptoms, need for central access to initiate parenteral nutrition, and length of stay. Comparison was made between patients with intussusception recurrence within 30 days and those without. Those undergoing earlier replacement, defined as the first quartile of rest time, or 72 hours, were then compared to longer periods of bowel rest.

Results:

Forty‐six intussusceptions were included, with a median age of 2.8 years (interquartile range, IQR: 1.4–4.1) and weight of 12 kg (IQR: 8.9–15.4). All patients diagnosed as outpatient (54.3%) required hospital admission and 9 of 46 (19.6%) required central access. There were 7 recurrences (15.2%). There was no difference in recurrence based on time of bowel rest (5 days in those without vs 6 days in those with, P = 0.30) nor a difference in recurrence with <72 hours of bowel rest compared to >72 hours (1/15, 6.7% vs 6/31, 19.3%). Patients undergoing earlier exchange had a shorter median length of hospital stay (3 vs 8.5 days, P = 0.003).

Conclusion:

Length of bowel rest was not associated with recurrent GJ tube‐related intussusceptions. If bowel rest is utilized, <72 hours may be sufficient to decrease length of hospital stay.
Inter and Intraobserver Variation in Interpretation of Fecal Loading on Abdominal Radiographs
Authors: Yallanki Narendra , Small‐Harary Lesley , Morganstern Jeffrey , Tobin Michelle , Milla Lucia , Chawla Anupama
Published: February 2023

Objectives:

The current gold standard for the diagnosis of functional constipation is the ROME IV criteria. European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and North American Society for Pediatric Gastroenterology, Hepatology & Nutrition (NASPGHAN) guidelines do not support the use of abdominal X‐rays in establishing the diagnosis of constipation. Despite these recommendations, abdominal radiography is frequently performed to diagnose constipation. The objective of our study is to evaluate inter and intraobserver variation in interpretation of fecal loading on abdominal radiographs.

Methods:

Electronic records of 100 children seen in the emergency room for gastrointestinal symptoms who had an abdominal radiograph performed were included. Four physicians from each specialty including gastroenterology, radiology, and emergency medicine interpreted the radiographs independently. Initially, subjective interpretations, followed by interpretations for intraobserver variation were obtained. Subsequently, all physicians were trained and asked to score the X‐rays objectively using Barr and Blethyn scoring systems. Consistency between inter and intraobserver ratings of radiographic interpretation was evaluated using the Kappa coefficient (k) which ranges from 0 (no agreement) to 1.0 (perfect agreement).

Results:

For subjective interpretations, k values showed a fixed margin k of 0.18 indicating poor agreement among 12 observers. Intraobserver k to look for reproducibility showed significant variability ranging from 0.08 (poor) to 0.61 (fair) agreement. Objective scoring results for Blethyn showed a k of 0.14 indicating poor agreement among 12 providers.

Conclusions:

Reliability and reproducibility of X‐rays for diagnosis and grading of constipation is questionable given poor to fair agreement for both inter and intraobserver comparisons. Our study supports the current recommendation of ESPGHAN and NASPGHAN to not use abdominal X‐rays to diagnose constipation.