Relationship Between Recreational Cannabis Use and Helicobacter pylori Infection

Background: Cannabis plant extracts suppress gastric acid secretion and inflammation, and promote gastroduodenal ulcer healing, all of which are triggered by Helicobacter Pylori infection (HPI). Here, we evaluate the association between cannabis use and HPI among a representative community sample. Materials and Methods: We identified respondents who completed cannabis use questions and were tested for HPI (H. pylori IgG antibody seropositivity) from the National Health and Nutrition Examination Survey III dataset (n=4556). Cannabis usage was categorized as ever-use (ever, never), cumulative lifetime use (>10-times, 1-10-times, never), or recent use (>31-days-ago, within-31-days, never). We calculated the crude and adjusted risk (prevalence rate ratio, cPRR and aPRR) of having HPI with cannabis use using generalized Poisson models (SAS 9.4). The models were adjusted for demographics and risk factors for HPI. Results: The prevalence of HPI was lower among ever versus never cannabis users (18.6% vs. 33%, p<0.0001). Cannabis use was associated with a decreased risk of HPI (cPRR: 0.56 confidence interval [95% CI: 0.47-0.67]; p<0.0001), which persisted after adjusting for demographics (aPRR: 0.75 [95% CI: 0.63-0.90]; p=0.0016) and comorbidities (aPRR: 0.79 [95% CI: 0.66-0.95]; p=0.0145). Further, individuals with >10-times lifetime cannabis use had a decreased risk of HPI compared with those with 1-10-times lifetime use (aPRR: 0.70 [95% CI: 0.55-0.89]; p=0.0011) and never-users (aPRR: 0.65 [95% CI: 0.50-0.84]; p=0.0002). Conclusion: Recreational cannabis use is associated with diminished risk of HPI. These observations suggest the need for additional research assessing the effects of medical cannabis formulations on HPI.

Gender and Racial Differences in Hospitalizations for Primary Biliary Cholangitis in the USA

BACKGROUND/AIM

The prevalence, characteristics, burden and trends of primary biliary cholangitis (PBC) hospitalizations in the USA remain unclear.

METHOD

We identified primary PBC hospitalizations from the National Inpatient Sample (NIS) 2007 through 2014 using ICD-9-CM codes. We calculated the rates and trends of hospitalization for PBC per 100,000 US population among each gender (males and females) and racial categories (Whites, Blacks, Hispanics and other racial minorities), and measured the predictors of hospitalization, and of mortality, charges and length of stay (LOS) among PBC hospitalizations.

RESULT

There were 8460 (weighted: 41,191) PBC hospitalizations between 2007 and 2014. The mean national PBC hospitalization rate was 2.2 cases per 100,000 population (2.2/100,000), increasing from 1.7/100,000 (2007) to 2.5/100,000 (2014). From 2007 to 2014, the in-hospital mortality and LOS were unchanged while the charges increased from $65,993 to $73,093 ($225 million to $447 million overall expenses). Compared to Whites, the PBC hospitalization rate was 12% higher among Hispanics (RR: 1.12 [1.09-1.16]), 53% lower in Blacks (RR: 0.47 [0.45-0.49]) and 5% lower among other racial minorities (0.95 [0.91-0.99]). The rate was higher among females (RR:4.02 [3.93-4.12]) compared to males. On multivariate analysis, Blacks and other racial minorities, respectively, had higher odds of mortality (AOR: 1.47 [1.03-2.10] and 1.33 [0.96-1.84]), while other racial minorities had longer LOS (7.0 vs. 5.6 days) and higher hospital charges ($48,984 vs. $41,495) when compared to Whites.

CONCLUSION

The hospitalization rate and burden of PBC in the USA have increased disproportionately among females and Hispanics with higher mortality in Blacks.

Predictors, rates, and trends of opioid use disorder among patients hospitalized with chronic pancreatitis

Background

Patients with chronic pancreatitis (CP) suffer from pain and receive increased opioid prescriptions with a high risk of opioid use disorder (OUD). We studied the predictors, trends and outcomes of OUD among patients hospitalized with CP.

Methods

Records with CP (with/without OUD) were extracted from the Nationwide Inpatient Sample (NIS) 2012-2014, and the association of OUD with the burden of CP was calculated. We then charted the trends of OUD and its interaction with concomitant CP from NIS 2007-2014 (SAS 9.4).

Results

In the period 2012-2014, 4349 (4.99%) of the 87,068 CP patients had concomitant OUD, with higher risk among patients who were young, females, white vs. Hispanics, and individuals with chronic back pain, arthritis, non-opioid substance use, mental health disorders, and those hospitalized in urban centers. OUD was associated with a longer hospital stay (6.9 vs. 6.5 days, P=0.0015) but no significant difference in charges ($47,151 vs. $49,017, P=0.0598) or mortality (1.64% vs. 0.74%, P=0.0506). From 2007-2014, the average yearly rate of OUD was 174 cases per 10,000 hospitalizations (174/10,000), almost 3 times higher among CP vs. non-CP (479/10,000 vs. 173/10,000, P<0.001), and it increased from 2007 to 2014 (135/10,000 to 216/10,000, P<0.001). The yearly increase was 2.7 times higher among patients with CP vs. non-CP (29.9/10,000 vs. 11.3/10,000 hospitalizations/year, P<0.001).

Conclusions

CP is associated with higher rates and trends of OUD. Patients with CP at high risk of OUD may benefit from alternate analgesic regimens or surveillance for OUD when they are prescribed opioids.

Chronic Pancreatitis Patients Who Leave Against Medical Advice: Prevalence, Trend, and Predictors

BACKGROUND AND AIMS

Leaving against medical advice (LAMA) is an unfortunate occurrence in 1-2% of all hospitalized patients and is associated with worse outcomes. While this has been investigated across multiple clinical conditions, studies on patients with chronic pancreatitis (CP) are lacking. We aimed to determine the prevalence and determinants of this event among patients with CP.

METHODS

The Healthcare Cost and Utilization Project-Nationwide Inpatient Sample (NIS), 2007-2014, was used in the study. Patients with LAMA were identified, and the temporal trend of LAMA was estimated and compared among patients with and without CP. We then extracted patients with a discharge diagnosis of CP from the recent years of HCUP-NIS (2012-2014) and described the characteristics of LAMA in these patients. Multivariate logistic regression models were used to evaluate predictors of LAMA.

RESULTS

3.39% of patients with CP discharged against medical advice. LAMA rate in CP patients was higher and increased more steeply at quadruple the rate of those without. More likely to self-discharge were patients who were young, males, non-privately insured, or engaged in alcohol and substance abuse, likewise were those with psychosis and those admitted on a weekend or non-electively. The northeast and for-profit hospitals also had higher odds of LAMA. However, patients transferred from other healthcare facilities have reduced LAMA odds. Among all patients with CP, those with LAMA had shorter length of stay (2.74 [2.62-2.85] days vs. 5.78 [5.71-5.83] days) and lower hospitalization cost $23,271 [$22,171-$24,370] versus $45,472 [$44,381-$46,562] compared to the no-LAMA group.

CONCLUSION

LAMA occurs in approximately 1 in 29 patients with CP and is increasing at almost quadruple the rate of those without. Clinicians need to pay closer attention to the identified at-risk groups for ameliorative targeted interventions.

Early Endoscopy Is Associated with Better Clinical Outcomes in Patients Hospitalized with Ischemic Bowel Disease

BACKGROUND AND AIMS

Providing diagnostic and therapeutic interventions, lower gastrointestinal endoscopy is a salient investigative modality for ischemic bowel disease (IB). As studies on the role of endoscopic timing on the outcomes of IB are lacking, we sought to clarify this association.

METHODS

After identifying 18-to-90-year-old patients with a primary diagnosis of IB from the 2012-2014 Healthcare Cost and Utilization Project-Nationwide Inpatient Sample, we grouped them based on timing of endoscopy into three: early (n = 9268), late (n = 3515), and no endoscopy (n = 18,452). We explored the determinants of receiving early endoscopy, the impact of endoscopic timing on outcomes (mortality and 13 others), and the impact of the type of endoscopy (colonoscopy vs. sigmoidoscopy) on these outcomes among the early group (SAS 9.4).

RESULTS

Less likely to receive early endoscopy were Blacks compared to Whites (adjusted odds ratio [aOR] 0.81 95% CI [0.70-0.94]), and individuals on Medicaid, Medicare, and uninsured compared to the privately insured group (aOR 0.80 [0.71-0.91], 0.70 [0.58-0.84], and 0.68 [0.56-0.83]). Compared to the late and no endoscopy groups, patients with early endoscopy had less mortality (aOR 0.53 [0.35-0.80] and 0.09 [0.07-0.12]), shorter length of stay (LOS, 4.64 [4.43-4.87] days vs. 8.87 [8.40-9.37] and 6.62 [6.52-7.13] days), lower total hospital cost (THC, $41,055 [$37,995-$44,361] vs. $72,598 [$66,768-$78,937] and $68,737 [$64,028-$73,793]), and better outcomes. Similarly, among those who received early endoscopy, colonoscopy had better outcomes than sigmoidoscopy for mortality, THC, LOS, and adverse events.

CONCLUSION

Early endoscopy, especially colonoscopy, is associated with better clinical outcomes and decreased healthcare utilization in IB. Unfortunately, there are disparities against Blacks, and non-privately insured individuals in receiving early endoscopy.

Suboptimal Use of Inpatient Palliative Care Consultation May Lead to Higher Readmissions and Costs in End-Stage Liver Disease

Background/Aims: Patients with end-stage liver disease (ESLD) have a high risk for readmission. We studied the role of palliative care consultation (PCC) in ESLD-related readmissions with a focus on health care resource utilization in the United States. Methods: We performed a retrospective longitudinal analysis on patients surviving hospitalizations with ESLD from January 2010 to September 2014 utilizing the Nationwide Readmissions Database with a 90-day follow-up after discharge. We analyzed annual trends in PCC among patients with ESLD. We matched PCC to no-PCC (1:1) using propensity scores to create a pseudorandomized clinical study. We estimated the impact of PCC on readmission rates (30- and 90-day), and length of stay (LOS) and cost during subsequent readmissions. Results: Of the 67,480 hospitalizations with ESLD, 3485 (5.3%) received PCC, with an annual increase from 3.6% to 6.7% (p for trend <0.01). The average 30- and 90-day annual readmission rates were 36.2% and 54.6%, respectively. PCC resulted in a lower risk for 30- and 90-day readmissions (hazard ratio: 0.42, 95% confidence interval [CI]: 0.38-0.47 and 0.38, 95% CI: 0.34-0.42, respectively). On subsequent 30- and 90-day readmissions, PCC was associated with decreased LOS (5.6- vs. 7.4 days and 5.7- vs. 6.9 days, p < 0.01) and cost (US $48,752 vs. US $75,810 and US $48,582 vs. US $69,035, p < 0.01). Conclusion: Inpatient utilization of PCC for ESLD is increasing annually, yet still remains low in the United States. More importantly, PCC was associated with a decline in readmission rates resulting in a lower burden on health care resource utilization and improvement in cost savings during subsequent readmissions.

Prevalence, trends, outcomes, and disparities in hospitalizations for nonalcoholic fatty liver disease in the United States

Background

As the frequency of nonalcoholic fatty liver disease (NAFLD) continues to rise in the United States (US) community, more patients are hospitalized with NAFLD. However, data on the prevalence and outcomes of hospitalizations with NAFLD are lacking. We investigated the prevalence, trends and outcomes of NAFLD hospitalizations in the US.

Methods

Hospitalizations with NAFLD were identified in the National Inpatient Sample (2007-2014) by their ICD-9-CM codes, and the prevalence and trends over an 8-year period were calculated among different demographic groups. After excluding other causes of liver disease among the NAFLD cohorts (n=210,660), the impact of sex, race and region on outcomes (mortality, discharge disposition, length of stay [LOS], and cost) were computed using generalized estimating equations (SAS 9.4).

Results

Admissions with NAFLD tripled from 2007-2014 at an average rate of 79/100,000 hospitalizations/year (P<0.0001), with a larger rate of increase among males vs. females (83/100,000 vs. 75/100,000), Hispanics vs. Whites vs. Blacks (107/100,000 vs. 80/100,000 vs. 48/100,000), and government-insured or uninsured patients vs. privately-insured (94/100,000 vs. 74/100,000). Males had higher mortality, LOS, and cost than females. Blacks had longer LOS and poorer discharge destination than Whites; while Hispanics and Asians incurred higher cost than Whites. Uninsured patients had higher mortality, longer LOS, and poorer discharge disposition than the privately-insured.

Conclusions

Hospitalizations with NAFLD are rapidly increasing in the US, with a disproportionately higher burden among certain demographic groups. Measures are required to arrest this ominous trend and to eliminate the disparities in outcome among patients hospitalized with NAFLD.

Protein-Energy Malnutrition and Outcomes of Hospitalizations for Heart Failure in the USA

Chronically elevated cytokines from un-abating low-grade inflammation in heart failure (HF) results in Protein-Energy Malnutrition (PEM). However, the impact of PEM on clinical outcomes of admissions for HF exacerbations has not been evaluated in a national data. From the 2012 to 2014 Nationwide Inpatient Sample (NIS) patient's discharge records for primary HF admissions, we identified patients with concomitant PEM, and their demographic and comorbid factors. We propensity-matched PEM cohorts (32,771) to no-PEM controls (1:1) using a greedy algorithm-based methodology and estimated the effect of different clinical outcomes (SAS 9.4). There were 32,771 (∼163,885) cases of PEM among the 541,679 (∼2,708,395) primary admissions for HF between 2012 and 2014 in the US. PEM cases were older (PEM:76 vs no-PEM:72 years), Whites (70.75% vs 67.30%), and had higher comorbid burden, with Deyo-comorbidity index >3 (31.61% vs 26.30%). However, PEM cases had lower rates of obesity, hyperlipidemia and diabetes. After propensity-matching, PEM was associated with higher mortality (AOR:2.48 [2.31 to 2.66]), cardiogenic shock (3.11[2.79 to 3.46]), cardiac arrest (2.30[1.96 to 2.70]), acute kidney failure (1.49[1.44 to 1.54]), acute respiratory failure (1.57[1.51 to 1.64]), mechanical ventilation (2.72[2.50 to 2.97]). PEM also resulted in higher non-routine discharges (2.24[2.17 to 2.31]), hospital cost ($80,534[78,496 to 82,625] vs $43,226[42,376 to 44,093]) and longer duration of admission (8.6[8.5 to 8.7] vs 5.3[5.2 to 5.3] days). In conclusion, PEM is a prevailing comorbidity among hospitalized HF subjects, and results in devastating health outcomes. Early identification and prevention of PEM in HF subjects during clinic visits and prompt treatment of PEM both in the clinic and during hospitalization are essential to decrease the excess burden of PEM.

Predictors, Burden, and the Impact of Arrhythmia on Patients Admitted for Acute Myocarditis

A significant proportion of patients with acute myocarditis experience sudden cardiac death presumably due to cardiac arrhythmia. In this study, we explore the burden, the predictors of arrhythmia in acute myocarditis and the association between arrhythmias and adverse in-hospital outcomes. After evaluating the frequency of various tachyarrhythmias and bradyarrhythmia in myocarditis population, we built a logistic model to determine the independent predictors of arrhythmias in myocarditis and a 1:1 propensity-matched analysis to examine the impact of arrhythmias. Overall, cardiac arrhythmias were identified in 33.71% of the hospitalized myocarditis cases. Ventricular tachycardia and atrial fibrillation were most common arrhythmias. There were increased odds of in-hospital mortality, cardiogenic shock, use of mechanical circulatory support, pacemaker implantation, and nonroutine hospital discharges in the arrhythmia cohorts. Length of stay and cost of hospitalization were also significantly higher. A significant proportion of patients with myocarditis have cardiac arrhythmias. As the occurrence of arrhythmias in myocarditis is associated with worse outcomes, it may be important to risk stratify patient to identify those who will benefit from early intervention.

Reduced Prevalence of Alcoholic Gastritis in Hospitalized Individuals Who Consume Cannabis

BACKGROUND

Alcoholic gastritis, a superficial erosive disease of the stomach, is a common manifestation of risky alcohol use. In contrast, cannabis which is frequently co-used with alcohol suppresses gastric acidity and might counteract the deleterious effect of alcohol on the gastric mucosa. However, no clinical study has examined the impact of cannabis use on the development of alcoholic gastritis among risky alcohol users.

METHODS

We analyzed hospital discharge records of adults (age ≥ 18 years), from 2014 of the Nationwide Inpatient Sample, with a diagnosis of risky alcohol use (n = 316,916). We used a propensity-based matching algorithm to match cannabis users to nonusers on 1:1 ratio (30,713: 30,713). We then measured the adjusted relative risk (aRR) for having alcoholic gastritis using conditional Poisson regression models with generalized estimating equations.

RESULTS

Our study revealed that among risky alcohol users, cannabis co-users have a lower prevalence of alcoholic gastritis compared to noncannabis users (1,289 [1,169 to 1,421] vs. 1,723 [1,583 to 1,875] per 100,000 hospitalizations for risky alcohol use), resulting in a 25% decreased probability of alcoholic gastritis (aRR: 0.75 [0.66 to 0.85]; p-value <0.0001). Furthermore, dependent cannabis usage resulted in a lower prevalence of alcoholic gastritis when compared to both nondependent cannabis users (0.72 [0.52 to 0.99]) and to noncannabis users (0.56 [0.41 to 0.76]).

CONCLUSIONS

We reveal that risky alcohol drinking combined with cannabis use is associated with reduced prevalence of alcohol-associated gastritis in patients. Given increased cannabis legislation globally, understanding whether and how the specific ingredients in cannabis plant extract can be used in the treatment of alcoholic gastritis is paramount. In this regard, further molecular mechanistic studies are needed to delineate the mechanisms of our novel findings not only for alcoholic gastritis but also for gastritis from other causes.

Relation of Cannabis Use and Atrial Fibrillation Among Patients Hospitalized for Heart Failure

Left ventricular dysfunction triggers the activation of the sympathetic nervous system, providing inotropic support to the failing heart and concomitantly increasing the risk of atrial fibrillation (AF). The cardiovascular effects of cannabis have been characterized as biphasic on the autonomic nervous system with an increased sympathetic effect at low doses and an inhibitory sympathetic activity at higher doses. It is unknown if the autonomic effect of cannabis impacts the occurrence of AF in patients with heart failure (HF). We used data from the Healthcare Cost and Utilization Project-National Inpatient Sample for patients admitted with a diagnosis of HF in 2014. The outcome variable was the diagnosis of AF, with the main exposure being cannabis use. We identified a cannabis user group and a 1:1 propensity-matched non-cannabis user group, each having 3,548 patients. We then estimated the odds of AF diagnosis in cannabis users. An estimated 3,950,392 patients were admitted with a diagnosis of HF in the United States in 2014. Among these, there were 17,755 (0.45%) cannabis users. In the matched cohort, cannabis users were less likely to have AF (19.08% vs 21.39%; AOR 0.87 [0.77 to 0.98]). In conclusion, cannabis users have lower odds of AF when compared with nonusers, which was not explained by co-morbid conditions, age, insurance type, and socioeconomic status.

Cannabis use is associated with reduced prevalence of non-alcoholic fatty liver disease: A cross-sectional study

Cannabis use is associated with reduced prevalence of obesity and diabetes mellitus (DM) in humans and mouse disease models. Obesity and DM are a well-established independent risk factor for non-alcoholic fatty liver disease (NAFLD), the most prevalent liver disease globally. The effects of cannabis use on NAFLD prevalence in humans remains ill-defined. Our objective is to determine the relationship between cannabis use and the prevalence of NAFLD in humans. We conducted a population-based case-control study of 5,950,391 patients using the 2014 Healthcare Cost and Utilization Project (HCUP), Nationwide Inpatient Survey (NIS) discharge records of patients 18 years and older. After identifying patients with NAFLD (1% of all patients), we next identified three exposure groups: non-cannabis users (98.04%), non-dependent cannabis users (1.74%), and dependent cannabis users (0.22%). We adjusted for potential demographics and patient related confounders and used multivariate logistic regression (SAS 9.4) to determine the odds of developing NAFLD with respects to cannabis use. Our findings revealed that cannabis users (dependent and non-dependent) showed significantly lower NAFLD prevalence compared to non-users (AOR: 0.82[0.76-0.88]; p<0.0001). The prevalence of NAFLD was 15% lower in non-dependent users (AOR: 0.85[0.79-0.92]; p<0.0001) and 52% lower in dependent users (AOR: 0.49[0.36-0.65]; p<0.0001). Among cannabis users, dependent patients had 43% significantly lower prevalence of NAFLD compared to non-dependent patients (AOR: 0.57[0.42-0.77]; p<0.0001). Our observations suggest that cannabis use is associated with lower prevalence of NAFLD in patients. These novel findings suggest additional molecular mechanistic studies to explore the potential role of cannabis use in NAFLD development.