Category: Nevin Manimala

Eur J Orthop Surg Traumatol. 2023 Jul 18. doi: 10.1007/s00590-023-03620-z. Online ahead of print.

ABSTRACT

PURPOSE: Early reports of 30-day mortality in COVID-positive patients with hip fracture were often over 30% and were higher than historical rates of 10% in pre-COVID studies. We conducted a multi-institutional retrospective cohort study to determine whether the incidence of 30-day mortality and complications in COVID-positive patients undergoing hip fracture surgery is as high as initially reported.

METHODS: A retrospective chart review was performed at 11 level I trauma centers from January 1, 2020 to May 1, 2022. Patients 50 years or older undergoing hip fracture surgery with a positive COVID test at the time of surgery were included. The primary outcome measurements were the incidence of 30-day mortality and complications. Post-operative outcomes were reported using proportions with 95% confidence interval (C.I.).

RESULTS: Forty patients with a median age of 71.5 years (interquartile range, 50-87 years) met the criteria. Within 30-days, four patients (10%; 95% C.I. 3-24%) died, four developed pneumonia, three developed thromboembolism, and three remained intubated post-operatively. Increased age was a statistically significant predictor of 30-day mortality (p = 0.01), with all deaths occurring in patients over 80 years.

CONCLUSION: In this multi-institutional analysis of COVID-positive patients undergoing hip fracture surgery, 30-day mortality was 10%. The 95% C.I. did not include 30%, suggesting that survival may be better than initially reported. While COVID-positive patients with hip fractures have high short-term mortality, the clinical situation may not be as dire as initially described, which may reflect initial publication bias, selection bias introduced by testing, or other issues.

LEVELS OF EVIDENCE: Therapeutic Level III.

PMID:37462783 | DOI:10.1007/s00590-023-03620-z

J Med Syst. 2023 Jul 18;47(1):76. doi: 10.1007/s10916-023-01964-x.

ABSTRACT

The fifth wave of COVID-19 outbreaks in Hong Kong (HK) from January to March 2022 has the highest confirmed cases and deaths compared with previous waves. Severe hospital boarding (to inpatient wards) was noted in various Emergency Departments (EDs). Our objective is to identify factors associated with hospital boarding during Omicron surge in HK. We conducted a retrospective cohort study including all ED visits and inpatient (IP) ward admissions from January 1^st to March 31^st, 2022. Vector Autoregression model evaluated the effects of a single variable on the targeted hospital boarding variables. Admissions from elderly homes with 6 lag days held the highest positive value of statistical significance (t-stat = 2.827, P < .05) caused prolonged admission waiting time, while medical patients with 4 lag days had the highest statistical significance (t-stat = 2.530, P < .05) caused an increased number of boarding patients. Within one week after impulses, medical occupancy’s influence on the waiting time varied from 0.289 on the 1^st day to -0.315 on the 7^th day. While occupancy of medical wards always positively affected blocked number of patients, and its response was maximized at 0.309 on the 2^nd day. Number of confirmed COVID-19 cases was not the sole significant contributor, while occupancy of medical wards was still a critical factor associated with patient boarding. Increasing ward capacity and controlling occupancy were suggested during the outbreak. Moreover, streamlining elderly patients in ED could be an approach to relieve pressure on the healthcare system.

PMID:37462766 | DOI:10.1007/s10916-023-01964-x

Zhonghua Zhong Liu Za Zhi. 2023 Jul 23;45(7):613-620. doi: 10.3760/cma.j.cn112152-20211201-00886.

ABSTRACT

Objective: To investigate the risk factors for the development of deep infiltration in early colorectal tumors (ECT) and to construct a prediction model to predict the development of deep infiltration in patients with ECT. Methods: The clinicopathological data of ECT patients who underwent endoscopic treatment or surgical treatment at the Cancer Hospital, Chinese Academy of Medical Sciences from August 2010 to December 2020 were retrospectively analyzed. The independent risk factors were analyzed by multifactorial regression analysis, and the prediction models were constructed and validated by nomogram. Results: Among the 717 ECT patients, 590 patients were divided in the within superficial infiltration 1 (SM1) group (infiltration depth within SM1) and 127 patients in the exceeding SM1 group (infiltration depth more than SM1). There were no statistically significant differences in gender, age, and lesion location between the two groups (P>0.05). The statistically significant differences were observed in tumor morphological staging, preoperative endoscopic assessment performance, vascular tumor emboli and nerve infiltration, and degree of tumor differentiation (P<0.05). Multivariate regression analysis showed that only erosion or rupture (OR=4.028, 95% CI: 1.468, 11.050, P=0.007), localized depression (OR=3.105, 95% CI: 1.584, 6.088, P=0.001), infiltrative JNET staging (OR=5.622, 95% CI: 3.029, 10.434, P<0.001), and infiltrative Pit pattern (OR=2.722, 95% CI: 1.347, 5.702, P=0.006) were independent risk factors for the development of deep submucosal infiltration in ECT. Nomogram was constructed with the included independent risk factors, and the nomogram was well distinguished and calibrated in predicting the occurrence of deep submucosal infiltration in ECT, with a C-index and area under the curve of 0.920 (95% CI: 0.811, 0.929). Conclusion: The nomogram prediction model constructed based on only erosion or rupture, local depression, infiltrative JNET typing, and infiltrative Pit pattern has a good predictive efficacy in the occurrence of deep submucosal infiltration in ECT.

PMID:37462018 | DOI:10.3760/cma.j.cn112152-20211201-00886

Am J Gastroenterol. 2021 Dec 1;116(Suppl 1):S20. doi: 10.14309/01.ajg.0000798908.85532.2d.

ABSTRACT

BACKGROUND: Intestinal strictures are a complication of the inflammatory bowel diseases (IBD, including ulcerative colitis (UC) and Crohn’s disease (CD)) that can lead to bowel obstruction and therapy failure. Intestinal strictures occurring after long-standing tissue damage and repair are more frequently reported in CD, but colonic strictures can occur in UC. However, there is a paucity of literature that comprehensively summarizes the available information regarding the incidence and etiology of colonic strictures in UC. The aim of this study was to perform a systematic review and meta-analysis of published reports on the incidence of colonic strictures in UC patients.

METHODS: Four independent reviewers performed a comprehensive review of all original articles describing the incidence of colonic strictures in UC published from inception to June 2021. Primary outcomes were (1) overall incidence of colonic strictures; (2) 10-year incidence of colonic strictures; and (3) incidence of colonic strictures containing high-grade dysplasia (HGD) or colorectal cancer (CRC). Subgroup analysis was performed to compare the outcomes between the pre-biologic era and post-biologic era. The meta-analysis was performed and the statistics were 2-tailed. Finally, probability of publication bias was assessed using funnel plots and with Egger’s test.

RESULTS: Eleven studies reporting on a total of — patients with colonic strictures were included in the analysis after comprehensive search. This yielded a pooled colonic stricture incidence rate of 5.4% (95% confidence interval (CI) 3.7-7.8). The incidence rate of colonic strictures was lower in the post-biologic era compared to the pre-biologic era but the difference was not statistically significant (2.6% vs 6%; p = 0.14). The pooled 10-year colonic stricture rate was 3.2% (95% CI 1.5-6.8). The pooled 10-year incidence rate of colonic strictures was lower in the post-biologic era compared to the pre-biologic era but the difference was not statistically significant (1% vs 1.8%; p = 0.1). The pooled incidence of strictures with associated high-grade dysplasia (HGD) or colorectal cancer (CRC) was 21.9% (95% CI 12.2-36.5). The incidence rate of HGD or CRC in colonic strictures was higher in the post-biologic era compared to the pre-biologic era but the difference was not statistically significant (23.6% vs 20.4%; p = 0.79).

CONCLUSION: This systematic review and meta-analysis on the incidence of colonic strictures in UC showed that the overall pooled incidence and 10-year incidence of colonic strictures in UC are low. There was a trend towards lower incidences of UC strictures in the post-biologic era, although the differences did not reach statistical significance. While the overall incidence of colonic strictures, in UC is low, a high proportion of colonic strictures are associated with HGD or CRC, even in the biologic era. Therefore, this study provides further support for importance of stricture biopsy and surgical evaluation for colectomy in the UC patient with colonic stricture.

PMID:37461993 | DOI:10.14309/01.ajg.0000798908.85532.2d

Am J Gastroenterol. 2021 Dec 1;116(Suppl 1):S19-S20. doi: 10.14309/01.ajg.0000805324.84795.58.

ABSTRACT

BACKGROUND: Urgency, the immediate need to defecate, is common in ulcerative colitis (UC). The frequently used patient reported outcome (PRO)-2 for UC includes only rectal bleeding and stool frequency. We sought to investigate the association of urgency in UC patients with 1) quality of life (QoL) domains and 2) future UC hospitalizations, steroid prescriptions, and colectomy.

METHODS: We conducted a cross-sectional and then a subsequent longitudinal study within IBD Partners, a patient-powered research network. We described associations of levels of urgency in UC patients with PROMIS QoL domains (depression, anxiety, social satisfaction, fatigue, sleep, and pain). Next, a longitudinal cohort determined associations between baseline urgency and subsequent clinical outcomes including UC hospitalization, steroid prescription, or colectomy within 12 months. We used bivariate statistics and logistic regression models to describe independent associations.

RESULTS: A total of 632 UC patients were included in the cross-sectional study. After adjusting for clinical variables, rectal bleeding, and stool frequency, “hurry”, “immediately” and “incontinence” increased the odds of social impairment by 2.05 [1.24-3.4] (p = 0.005), 2.76 [1.1-6.74] (p = 0.028), and 7.7 [1.66-38.3] (p = 0.009) respectively compared to “no hurry”. Urgency also significantly increased the odds of depression, anxiety, and fatigue. In the multivariate pooled logistic regression of the longitudinal cohort, Urgency was associated with a significant stepwise increase in risk of hospitalizations, steroids, and colectomy. “Hurry”, “immediately” and “incontinence” increased the odds of colectomy within 12 months by 1.41 [1.15-1.72] (p < 0001), and 3.29 [2.13-5.09] (p < 0001).

CONCLUSION: We demonstrate that urgency is a PRO independently associated with compromised QoL in patients with UC. Urgency is associated with future risk of hospitalizations, steroid prescription, and colectomy. Our findings support the consideration of urgency as a UC-specific PRO and its use as an outcome in clinical trials to capture QoL and risk of clinical decompensation.

PMID:37461991 | DOI:10.14309/01.ajg.0000805324.84795.58

Am J Gastroenterol. 2021 Dec 1;116(Suppl 1):S18. doi: 10.14309/01.ajg.0000798880.74975.18.

ABSTRACT

BACKGROUND: Inflammatory Bowel Disease (IBD) prevalence is rising. Quality of life (QOL) in chronic illness is affected by various physical and psychosocial factors. Recent studies in other chronic illnesses have used remote physiologic monitoring (RPM) to help predict changes in disease activity and provide opportunities for patient self-management. It has been proposed that bowel inflammation can lead to suboptimal sleep, circadian rhythm disruption and even additional immune system activation. Heart rate variability (HRV) is a validated metric that has been used to predict outcomes and help manage other disease states. To date, there is limited data on the benefit of RPM in IBD care. We wish to explore the potential benefit of the Whoop Strap (new wearable technology device) as a method of RPM for IBD patients.

METHODS: We recruited patients with Ulcerative Colitis from our tertiary care IBD center 18 years and older willing to wear the Whoop Strap 3.0 for 12 months with support from the Penn State Hershey Medical Center, 2020 Department of Medicine House Staff Grant; Clinical Trial Identifier is NCT04333810. During this time, participants were encouraged to use the Whoop mobile application to record symptoms. Physiologic metrics of interest included sleep, resting heart rate (RHR), and HRV; each were correlated to IBD related symptoms. Additionally, we performed monthly “check-ins” to collect disease activity (SCCAI), mood (HADS) and stress (PSS4) questionnaire data. Descriptive statistics were utilized along with correlation coefficient testing to explore potential relationships between Whoop metrics, disease activity scores and patient reported outcomes.

RESULTS: Enrollment is ongoing with 7 participants, one of which was lost to follow up. Of note, 2 patients proactively reached out to communicate concern for an underlying disease flare as they noticed significant change in their Whoop metrics in conjunction with worrying symptoms. Patient 1 subsequently had serologic testing after having increased HRV and elevated RHR several days prior to symptoms; results were consistent with active inflammation exhibiting a rise in C-reactive protein from 0.25 mg/dL in 2020 to 2.82 mg/dL. Fecal calprotectin was also elevated at 566 ug/g. Colonoscopy is scheduled for the near future. Patient 2 also had noticeable HRV and RHR changes alongside significant sleep disturbances, which has prompted additional testing.

CONCLUSION: Remote physiologic monitoring is a feasible way to give patients ownership of their medical care and involve them in the diagnostic and treatment process of their underlying IBD. As exhibited with our preliminary results, the Whoop device appears easy to use and may empower patients to reach out to providers even before symptoms occur, leading to an expedited evaluation for increased disease activity. Our feasibility study will hopefully lead to larger prospective efforts utilizing wearable technology devices such as the Whoop in IBD patients.

PMID:37461987 | DOI:10.14309/01.ajg.0000798880.74975.18

Am J Gastroenterol. 2021 Dec 1;116(Suppl 1):S17. doi: 10.14309/01.ajg.0000798864.82003.45.

ABSTRACT

BACKGROUND: Ustekinumab (UST) is a monoclonal antibody against the p40 subunit of IL-12/23. It is approved for the treatment of moderate to severe Crohn’s disease (CD) and Ulcerative Colitis. We performed a retrospective study to demonstrate the efficacy and outcomes of UST in CD patients who received prior anti-TNF therapies.

METHODS: We collected a list of all patients who received UST until May 2021. In addition, the list was screened for patients who were on anti-TNFs for treatment of CD in the past. Data was collected for patient demographics, disease characteristics, comorbidities, disease phenotype, age of initiation of UST, prior biologic therapy, time since last biologic therapy, concomitant use of steroids or immunomodulator, inflammatory markers, induction of remission, deep remission. Chi-square tests were used for statistical analysis.

RESULTS: We identified 34 patients (59% females) with CD on UST who failed at least one anti-TNFs before induction with UST. Clinical remission was documented in 70.5% of patients. 29 percent of patients who achieved clinical remission were on concomitant steroids or immunomodulators at the time of induction of remission along with UST. Fifty percent of patients had a fistulizing disease, of which 70% achieved clinical remission with UST. C-reactive protein (CRP) was reported in 70 percent of patients. Mean CRP prior to initiation of UST was 2.4. CRP trended down to 1.98 (p = 0.079, 95% CI: -0.064-1.08). Eighteen percent of patients had fecal calprotectin reported. Mean fecal calprotectin before initiation of UST was 386, and it trended down 175 while on UST (p = 0.148, 95% CI: -106.25-528.46).

CONCLUSION: Our study demonstrates that remission rates in CD patients who have failed prior anti-TNF therapy are high, including for patients with perianal disease. In patients with fistulizing CD, we suggest using UST for higher rates of remission after induction. We also found that for fecal calprotectin, although an excellent surrogate of colon inflammation, compliance amongst patients remains low.

PMID:37461983 | DOI:10.14309/01.ajg.0000798864.82003.45

Am J Gastroenterol. 2021 Dec 1;116(Suppl 1):S17. doi: 10.14309/01.ajg.0000805320.60076.03.

ABSTRACT

BACKGROUND: Inflammatory Bowel Disease (IBD) is a chronic gastrointestinal inflammatory condition and has been increasing in prevalence in the United States, with a 30-40% increase over the past few decades. Osteoporosis can be seen in up to 40% of IBD patients. Screening for osteoporosis in IBD patients involves the use of DEXA scans and is recommended by the IBD Cornerstone Committee for select patients, including steroid use > 3 months consecutively or a total of 1 year in the past 2 years, family history of osteoporosis, malnutrition, amenorrheic or post-menopausal. Our quality improvement study looked to improve osteoporosis screening among gastroenterologists.

METHODS: We conducted a retrospective chart review on all IBD patients within the St. Luke’s Network and extrapolated data on age (>50 in male and >65 in female), sex, chronic glucocorticoid use (3 month consecutively or cumulative), osteoporosis/osteopenia diagnosis, vitamin D (vit-D) levels, and DEXA scan between 2019 to 2021. We gave a 5-minute presentation on current DEXA screen recommendations for patients with IBD on 5/27/2021 to all the network’s gastroenterologists, which totaled 12. We performed a pre and post education survey consisting of 5 questions on provider knowledge and comfortability with osteoporosis screening. We assessed provider knowledge, as well as rates of osteoporosis screening. All statistical analyses were conducted in IBM SPSS for Windows Version 26. Chi Square tests were used to compare two groups in categorical variables while Mann-Whitney tests were done to compare continuous variables like age and vit-D levels.

RESULTS: There were a total of 5442 patients; 3927 patients before the educational intervention on 5/27/2021 and 1515 patients after the intervention. Both pre and post intervention groups were balanced in terms of age, gender, smoking status, and alcohol risk. Percent of DEXA scans were similar between both groups (13.0% vs 12.3%, p=0.5). DEXA screening rates among patients with chronic steroid use pre-intervention vs post-intervention was 44.45 vs 42.4% respectively. Vit-D levels compared between both groups was not statistically significant (30.5 vs 31.8, p=0.1). Surveys conducted before and after the intervention showed an overall increase in percentage of agreement responses about knowledge and confidence in DEXA screening (88.5% vs 97.5%).

CONCLUSION: DEXA scanning can help detect premature decrease in bone mineral density and provide physicians with the opportunity to prevent further morbidity. Our study showed no difference in DEXA screening rates before and after intervention. However, there was an increase in provider knowledge based on post-intervention surveys. A similar study showed that it took three interventions, including educational presentation, flyers, and on screen EMR reminders for there to be a sustainable improvement in the rate of DEXA screening. Our project may have required additional interventions to produce an effect and thus reinforces the need for further efforts to improve osteoporosis screening in IBD patients.

PMID:37461982 | DOI:10.14309/01.ajg.0000805320.60076.03

Am J Gastroenterol. 2021 Dec 1;116(Suppl 1):S16-S17. doi: 10.14309/01.ajg.0000798852.94629.98.

ABSTRACT

BACKGROUND: Frequently, existing therapies for inflammatory bowel disease (IBD) do not achieve complete remission of the disease and are commonly associated with adverse effects. Therefore, patients regularly turn to complementary or alternative medicine (CAM). International CAM use in IBD patients ranges from 21% to 60%. There are no reported statistics of CAM use in the Mexican population who suffer IBD. This study´s objective was to determine the prevalence and characterize the use of CAM in our IBD population.

METHODS: Observational, cross-sectional, retrospective study in patients diagnosed with IBD belonging to our Institution’s IBD center. The results were analyzed with measures of relative frequency, central tendency, and dispersion.

RESULTS: A total of 52 patients with IBD (78% ulcerative colitis and 22% Crohn’s disease) were included, 38.5% were exposed to CAM. A total of 27% used it as an aid in their IBD treatment. The remaining 11.5% used it for other reasons. Patients exposed to CAM for IBD averaged 51 ± 19 years, 64% were female and 71% had at least an undergraduate degree. The most used CAMs were acupuncture (42.8%), herbal (35.7%) and homeopathy (35.7%). Half of the patients used concomitantly two or more modalities, and 91.6% of the patients knew their diagnosis at the time that CAM was being used. The median exposure time to CAM was 4.5 ± 40.7 months. The main reasons for the use of CAM in IBD patients was as a complementary therapy in 58.3%, as the perception of lack of improvement was present in 33.3% of patients. Twenty-five percent of patients used CAM after a healthcare professional recommended it. CAM was used in 83.2% of patients with conventional treatment (Mesalamine: 74.6%, Mesalamine + Azathioprine: 8.3%) and only 16.5% were on biological therapy. A total of 58.3% CAM users perceived improvement in their symptoms. Currently 25% still use some modality of CAM. No statistically significant differences were found in sociodemographic variables and clinical outcomes when comparing the IBD group exposed to CAM vs the unexposed group.

CONCLUSION: Exposure to CAM for IBD treatment had a prevalence of 27%. The main CAM modalities for IBD patients were acupuncture, herbal, and homeopathy. No relationship was demonstrated between the use of CAM in IBD patients and their clinical outcomes.

PMID:37461980 | DOI:10.14309/01.ajg.0000798852.94629.98

Am J Gastroenterol. 2021 Dec 1;116(Suppl 1):S16. doi: 10.14309/01.ajg.0000798844.44337.f4.

ABSTRACT

BACKGROUND: Sleep disorders occur recurrently in patients with inflammatory bowel disease (IBD). The relationship between poor sleep quality and IBD activity has been subject to scarce attention. Poor sleep quality could be considered a relevant extraintestinal manifestation and a potential marker of subclinical inflammation, which could increase the severity of inflammation and the risk of relapse, however, we do not have enough information to confirm this hypothesis. Objective: Describe the impact of IBD on the quality of sleep, in patients treated in a referral hospital.

METHODS: Observational, analytical, and cross-sectional study. Patients with diagnosis of IBD treated at Centro Médico Nacional “20 de Noviembre” were evaluated. The Pittsburgh Sleep Quality Index (PSQI) was used to measure sleep quality. IBD activity was measured using the Harvey-Bradshaw index for Crohn’s disease (CD) and the Mayo scale for Ulcerative Colitis (UC).

RESULTS: A total of 51 patients were included, the Pittsburgh Sleep Index Questionnaire (PSQI) was performed, after informed consent was signed. Patients had a mean age of 52. Fifty five percent were female, 65% had UC. Biological therapy was administered to 70.5%. In CD 89% were in remission and 11% in moderate activity. In UC 48.5% were in remission, 45.5% had mild activity and 6% had moderate activity. Eighty percent of the patients did not use hypnotic drugs. Patients with UC in remission had a bad perception of sleep quality in 68%, quite good sleep quality in 18% and very good sleep quality in 12% with a PSQI of 10.5 ± 3.2. In patients with mild activity, the perception of sleep quality was very good in 6%, quite good in 46%, quite bad in 40% and very bad in 6%, with a PSQI of 8 ± 3.7. In patients with moderate activity, 100% had a rather bad perception of sleep quality with a PSQI of 11 ± 1.4. For CD in remission the perception of sleep was quite bad in 43%, quite good in 43%, very bad in 6% and very good in 6% with a PSQI of 9 ± 4.3. In patients with moderate activity 50% had a very bad sleep quality perception and 50% a fairly good sleep quality perception with a PSQI of 14 ± 4.2.

CONCLUSION: In this study a statistically significant association was obtained between PSQI and the perception of sleep reported by the patients, with a p < 0.005. Further research is still needed to better characterize sleep disturbances in this population. Due to the sample size, a prospective, randomized study is required to confirm these findings. The present analysis has no conflict of interest.

PMID:37461978 | DOI:10.14309/01.ajg.0000798844.44337.f4