1
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Hung KW. The Future is Bright (Red) for Hemostasis of Peptic Ulcers. Dig Dis Sci 2024:10.1007/s10620-024-08308-w. [PMID: 38446312 DOI: 10.1007/s10620-024-08308-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 01/18/2024] [Indexed: 03/07/2024]
Affiliation(s)
- Kenneth W Hung
- Section of Digestive Diseases, Department of Internal Medicine, Yale School of Medicine, P.O. Box 208019, New Haven, CT, 06520, USA.
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2
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Hung KW. Is Adherence to Guidelines Helpful? Endoscopic Hemostasis of Bleeding Peptic Ulcers with Adherent Clots. Dig Dis Sci 2023; 68:3843-3845. [PMID: 37634183 DOI: 10.1007/s10620-023-08082-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/04/2023] [Indexed: 08/29/2023]
Affiliation(s)
- Kenneth W Hung
- Section of Digestive Diseases, Department of Internal Medicine, Yale University School of Medicine, P.O. Box 208019, New Haven, CT, 06520, USA.
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3
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Hung KW. Runaway Insufflation: Does Anesthesia or Spasm Hinder Insufflation During Colonoscopy? Dig Dis Sci 2023; 68:7-8. [PMID: 35759157 DOI: 10.1007/s10620-022-07594-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/23/2022] [Indexed: 02/01/2023]
Affiliation(s)
- Kenneth W Hung
- Department of Internal Medicine, Section of Digestive Diseases, Yale School of Medicine, P.O. Box 208019, New Haven, CT, 06520, USA.
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4
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Li DK, Ong SY, Hughes ML, Hung KW, Agarwal R, Alexis J, Damianos J, Sharma S, Pires J, Nanna M, Laine L. Deprescription of aspirin for primary prevention is uncommon at discharge in hospitalised patients with gastrointestinal bleeding. Aliment Pharmacol Ther 2023; 57:94-102. [PMID: 36394111 DOI: 10.1111/apt.17278] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 10/17/2022] [Accepted: 10/19/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Guidelines recommend against aspirin for primary prevention of cardiovascular events in individuals with a history of gastrointestinal bleeding (GIB). It is unknown how often patients on primary prevention aspirin hospitalised with GIB have aspirin discontinued at discharge. AIMS To determine the rate of aspirin deprescription and explore long-term outcomes in patients taking aspirin for primary prevention of cardiovascular events. METHODS We evaluated all patients hospitalised at Yale-New Haven Hospital between January 2014 and October 2021 with GIB who were on aspirin for primary prevention. Our primary endpoint was the frequency of aspirin deprescription at discharge. Our secondary endpoints were post-discharge hospitalisations for major adverse cardiovascular events (MACE) or GIB. Time-to-event analysis was performed using Kaplan-Meier curves and the log-rank test. RESULTS We identified 320 patients with GIB on aspirin for primary prevention: median age was 72 (interquartile range [IQR] 61-81) years and 297 (92.8%) were on aspirin 81 mg daily. Only 25 (9.0%) patients surviving their hospitalisation were deprescribed aspirin at discharge. Among 260 patients with follow-up (median 1103 days; IQR 367-1670), MACE developed post-discharge in 2/25 (8.0%) with aspirin deprescription versus 37/235 (15.7%) with aspirin continuation (log-rank p = 0.28). 0/25 patients with aspirin deprescription had subsequent hospitalisation for GIB versus 17/235 (7.2%) who continued aspirin (log-rank p = 0.13). CONCLUSIONS Aspirin for primary cardiovascular prevention was rarely deprescribed at discharge in patients hospitalised with GIB. Processes designed to ensure appropriate deprescription of aspirin are crucial to improve adherence to guidelines, thereby improving the risk-benefit ratio in patients at high risk of subsequent GIB hospitalisations with minimal increased risk of MACE.
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Affiliation(s)
- Darrick K Li
- Section of Digestive Diseases, Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Shawn Y Ong
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Michelle L Hughes
- Section of Digestive Diseases, Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Kenneth W Hung
- Section of Digestive Diseases, Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Ritu Agarwal
- Joint Data Analytics Team, Information Technology Service, Yale University, New Haven, Connecticut, USA
| | - Jamil Alexis
- Section of Gastroenterology, Department of Medicine, Bridgeport Hospital, Bridgeport, Connecticut, USA
| | - John Damianos
- Joint Data Analytics Team, Information Technology Service, Yale University, New Haven, Connecticut, USA
| | - Shreyak Sharma
- Joint Data Analytics Team, Information Technology Service, Yale University, New Haven, Connecticut, USA
| | - Jacqueline Pires
- Section of Cardiovascular Diseases, Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Michael Nanna
- Section of Cardiovascular Diseases, Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Loren Laine
- Section of Digestive Diseases, Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA.,VA Connecticut Healthcare System, West Haven, Connecticut, USA
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Mezzacappa C, Hughes ML, Hung KW. An Uncommon Cause of Coffee Ground Emesis in a Young Woman With Remote Roux-en-Y Gastric Bypass. Gastroenterology 2022; 163:e16-e17. [PMID: 35490784 DOI: 10.1053/j.gastro.2022.04.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 04/07/2022] [Indexed: 12/02/2022]
Affiliation(s)
- Catherine Mezzacappa
- Section of Digestive Diseases, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Michelle L Hughes
- Section of Digestive Diseases, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Kenneth W Hung
- Section of Digestive Diseases, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut.
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6
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Hung KW, Maratt JK, Cho WK, Shah BJ, Anjou CI, Leiman DA. AGA Institute Quality Measure Development for the Management of Gastric Intestinal Metaplasia With Helicobacter pylori. Gastroenterology 2022; 163:3-7. [PMID: 35337856 DOI: 10.1053/j.gastro.2022.03.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 03/10/2022] [Accepted: 03/20/2022] [Indexed: 12/13/2022]
Affiliation(s)
- Kenneth W Hung
- Section of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut
| | - Jennifer K Maratt
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
| | - Won Kyoo Cho
- Department of Gastroenterology and Hepatology, Georgetown University School of Medicine, Washington, DC; Inova Health System, Falls Church, Virginia
| | - Brijen J Shah
- Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - David A Leiman
- Division of Gastroenterology, Duke University School of Medicine, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina
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Ilagan-Ying YC, Almeida MN, Kahler-Quesada A, Ying L, Hughes ML, Do A, Hung KW. Increased Mortality in Patients Undergoing Inpatient Endoscopy During the Early COVID-19 Pandemic. Dig Dis Sci 2022; 67:5053-5062. [PMID: 35182250 PMCID: PMC8857390 DOI: 10.1007/s10620-022-07414-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 01/25/2022] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS The Coronavirus disease 2019 (COVID-19) pandemic led to the restructuring of most healthcare systems, but the impact on patients undergoing inpatient endoscopic procedures is unknown. We sought to identify factors associated with 30-day mortality among patients undergoing inpatient endoscopy before and during the first wave of the pandemic within an academic tertiary care center. METHODS We studied patients who underwent inpatient endoscopic procedures from March 1-May 31 in 2020 (COVID-19 era), the peak of the pandemic's first wave across the care center studied, and in March 1-May 31, 2018 and 2019 (control). Patient demographics and hospitalization/procedure data were compared between groups. Cox regression analyses were conducted to identify factors associated with 30-day mortality. RESULTS Inpatient endoscopy volume decreased in 2020 with a higher proportion of urgent procedures, increased proportion of patients receiving blood transfusions, and a 10.1% mortality rate. In 2020, male gender, further distance from hospital, need for intensive care unit (ICU) admission, and procedures conducted outside the endoscopy suite were associated with increased risk of 30-day mortality. CONCLUSIONS Patients undergoing endoscopy during the pandemic had higher proportions of ICU admission, more urgent indications, and higher rates of 30-day mortality. Greater proportions of urgent endoscopy cases may be due to hospital restructuring or patient reluctance to seek hospital care during a pandemic. Demographic and procedural characteristics associated with higher mortality risk may be potential areas to improve outcomes during future pandemic hospital restructuring efforts.
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Affiliation(s)
- Ysabel C. Ilagan-Ying
- grid.47100.320000000419368710Section of Digestive Diseases, Department of Internal Medicine, Yale School of Medicine, 333 Cedar Street, New Haven, CT 06520 USA
| | | | | | - Lee Ying
- grid.47100.320000000419368710Department of Surgery, Yale School of Medicine, New Haven, CT USA
| | - Michelle L. Hughes
- grid.47100.320000000419368710Section of Digestive Diseases, Department of Internal Medicine, Yale School of Medicine, 333 Cedar Street, New Haven, CT 06520 USA ,grid.47100.320000000419368710Section of Digestive Diseases, Yale School of Medicine, New Haven, CT USA
| | - Albert Do
- grid.47100.320000000419368710Section of Digestive Diseases, Department of Internal Medicine, Yale School of Medicine, 333 Cedar Street, New Haven, CT 06520 USA ,grid.47100.320000000419368710Section of Digestive Diseases, Yale School of Medicine, New Haven, CT USA
| | - Kenneth W. Hung
- grid.47100.320000000419368710Section of Digestive Diseases, Department of Internal Medicine, Yale School of Medicine, 333 Cedar Street, New Haven, CT 06520 USA ,grid.47100.320000000419368710Section of Digestive Diseases, Yale School of Medicine, New Haven, CT USA
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8
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Tran AN, Wang M, Hundt M, Chugh R, Ohm J, Grimshaw A, Ciarleglio M, Hung KW, Proctor DD, Price CC, Laine L, Al-Bawardy B. Immune Checkpoint Inhibitor-associated Diarrhea and Colitis: A Systematic Review and Meta-analysis of Observational Studies. J Immunother 2021; 44:325-334. [PMID: 34380976 DOI: 10.1097/cji.0000000000000383] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 06/08/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Immune checkpoint inhibitors (ICIs) have transformed the management of advanced malignancies but are associated with diarrhea and colitis. The objective of our systematic review and meta-analysis was to determine the incidence and outcomes of ICI-associated diarrhea and colitis. Bibliographic databases were searched through August 13, 2019, for observational studies of ICI therapy reporting the incidence and/or treatment of diarrhea or colitis. The primary outcome was ICI-associated diarrhea and colitis. Meta-analyses were performed with random-effects models. Twenty-five studies (N=12,661) were included. All studies had a high risk of bias in at least 1 domain. The overall incidence of diarrhea/colitis was 12.8% [95% confidence interval (CI), 8.8-18.2, I2=96.5]. The incidence was lower in patients treated with anti-programmed cell death 1/programmed death-ligand 1 (4.1%, 95% CI, 2.6-6.5) than in those treated with anti-cytotoxic T-cell lymphocyte-associated antigen 4 (20.1%, 95% CI, 15.9-25.1). The remission of diarrhea and/or colitis was higher in patients treated with corticosteroids plus biologics (88.4%, 95% CI, 79.4-93.8) than in those treated with corticosteroids alone (58.3%, 95% CI, 49.3-66.7, Q=18.7, P<0.001). ICI were permanently discontinued in 48.1% of patients (95% CI, 17.8-79.1). ICI were restarted after temporary interruption in 48.6% of patients (95% CI, 18.2-79.4) of whom 17.0% (95% CI, 6.4-30.0) experienced recurrence. Real-world incidence of ICI-associated diarrhea/colitis exceeds 10%. These events lead to permanent ICI discontinuation in just over 50% of patients, while <20% have recurrence of symptoms if ICI are resumed. Further studies are needed to identify patients who would benefit from early treatment with biologics as well as appropriate patients to resume ICI therapy.
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Affiliation(s)
| | | | | | | | | | - Alyssa Grimshaw
- Harvey Cushing/John Hay Whitney Medical Library, Yale University, New Haven
| | | | | | | | - Christina C Price
- Section of Allergy and Immunology, Yale School of Medicine
- VA Connecticut Healthcare System, West Haven, CT
| | - Loren Laine
- Section of Digestive Diseases
- VA Connecticut Healthcare System, West Haven, CT
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Ramos GP, Dimopoulos C, McDonald NM, Janssens LP, Hung KW, Proctor D, Ruggiero E, Kane S, Bruining DH, Faubion WA, Raffals LE, Loftus EV, Al-Bawardy B. The Impact of Vedolizumab on Pre-Existing Extraintestinal Manifestations of Inflammatory Bowel Disease: A Multicenter Study. Inflamm Bowel Dis 2021; 27:1270-1276. [PMID: 33165569 DOI: 10.1093/ibd/izaa293] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND There are limited data on how vedolizumab (VDZ) impacts extraintestinal manifestations (EIMs) in inflammatory bowel disease (IBD). The aim of this study was to determine the clinical outcomes of EIMs after initiation of VDZ for patients with IBD. METHODS A multicenter retrospective study of patients with IBD who received at least 1 dose of VDZ between January 1, 2014 and August 1, 2019 was conducted. The primary outcome was the rate of worsening EIMs after VDZ. Secondary outcomes were factors associated with worsening EIMs and peripheral arthritis (PA) specifically after VDZ. RESULTS A total of 201 patients with IBD (72.6% with Crohn disease; median age 38.4 years (interquartile range, 29-52.4 years); 62.2% female) with EIMs before VDZ treatment were included. The most common type of EIM before VDZ was peripheral arthritis (PA) (68.2%). Worsening of EIMs after VDZ occurred in 34.8% of patients. There were no statistically significant differences between the worsened EIM (n = 70) and the stable EIM (n = 131) groups in term of age, IBD subtype, or previous and current medical therapy. We found that PA was significantly more common in the worsening EIM group (84.3% vs 59.6%; P < 0.01). Worsening of EIMs was associated with a higher rate of discontinuation of VDZ during study follow-up when compared with the stable EIM group (61.4% vs 44%; P = 0.02). Treatment using VDZ was discontinued specifically because of EIMs in 9.5% of patients. CONCLUSIONS Almost one-third of patients had worsening EIMs after VDZ, which resulted in VDZ discontinuation in approximately 10% of patients. Previous biologic use or concurrent immunosuppressant or corticosteroid therapy did not predict EIM course after VDZ.
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Affiliation(s)
| | - Christina Dimopoulos
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | | | | | - Kenneth W Hung
- Section of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut, USA
| | - Deborah Proctor
- Section of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut, USA
| | - Elizabeth Ruggiero
- Section of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut, USA
| | - Sunanda Kane
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - David H Bruining
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - William A Faubion
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Laura E Raffals
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Edward V Loftus
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Badr Al-Bawardy
- Section of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut, USA
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10
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Hung KW, Freedberg DE. Reply. Clin Gastroenterol Hepatol 2021; 19:1298. [PMID: 33249021 DOI: 10.1016/j.cgh.2020.07.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Accepted: 07/21/2020] [Indexed: 02/07/2023]
Affiliation(s)
- Kenneth W Hung
- Division of Digestive Diseases, Department of Internal Medicine, Yale University, New Haven, Connecticut
| | - Daniel E Freedberg
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University, Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York
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Faye AS, Hung KW, Cheng K, Blackett JW, Mckenney AS, Pont AR, Li J, Lawlor G, Lebwohl B, Freedberg DE. Minor Hematochezia Decreases Use of Venous Thromboembolism Prophylaxis in Patients with Inflammatory Bowel Disease. Inflamm Bowel Dis 2020; 26:1394-1400. [PMID: 31689354 PMCID: PMC7534414 DOI: 10.1093/ibd/izz269] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Despite increased risk of venous thromboembolism (VTE) among hospitalized patients with inflammatory bowel disease (IBD), pharmacologic prophylaxis rates remain low. We sought to understand the reasons for this by assessing factors associated with VTE prophylaxis in patients with IBD and the safety of its use. METHODS This was a retrospective cohort study conducted among patients hospitalized between January 2013 and August 2018. The primary outcome was VTE prophylaxis, and exposures of interest included acute and chronic bleeding. Medical records were parsed electronically for covariables, and logistic regression was used to assess factors associated with VTE prophylaxis. RESULTS There were 22,499 patients studied, including 474 (2%) with IBD. Patients with IBD were less likely to be placed on VTE prophylaxis (79% with IBD, 87% without IBD), particularly if hematochezia was present (57% with hematochezia, 86% without hematochezia). Among patients with IBD, admission to a medical service and hematochezia (adjusted odds ratio 0.27; 95% CI, 0.16-0.46) were among the strongest independent predictors of decreased VTE prophylaxis use. Neither hematochezia nor VTE prophylaxis was associated with increased blood transfusion rates or with a clinically significant decline in hemoglobin level during hospitalization. CONCLUSION Hospitalized patients are less likely to be placed on VTE prophylaxis if they have IBD, and hematochezia may drive this. Hematochezia appeared to be minor and was unaffected by VTE prophylaxis. Education related to the safety of VTE prophylaxis in the setting of minor hematochezia may be a high-yield way to increase VTE prophylaxis rates in patients with IBD.
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Affiliation(s)
- Adam S Faye
- Department of Medicine, Division of Digestive and Liver Diseases, New York Presbyterian Columbia University Medical Center, New York, NY, USA,Address correspondence to: Adam S. Faye, Department of Medicine, New York Presbyterian Columbia University Medical Center, 630 West 168th Street, Room P&S 3-401, New York, NY 10032, USA. E-mail:
| | - Kenneth W Hung
- Department of Medicine, Division of Digestive and Liver Diseases, New York Presbyterian Columbia University Medical Center, New York, NY, USA
| | - Kimberly Cheng
- Department of Medicine, Division of Digestive and Liver Diseases, New York Presbyterian Columbia University Medical Center, New York, NY, USA
| | - John W Blackett
- Department of Medicine, Division of Digestive and Liver Diseases, New York Presbyterian Columbia University Medical Center, New York, NY, USA
| | - Anna Sophia Mckenney
- Department of Radiology, New York Presbyterian Weill Cornell Medical College, New York, NY, USA
| | - Adam R Pont
- Department of Medicine, Division of Digestive and Liver Diseases, New York Presbyterian Columbia University Medical Center, New York, NY, USA
| | - Jianhua Li
- Department of Biomedical Informatics, New York Presbyterian Columbia University Medical Center, New York, NY, USA
| | - Garrett Lawlor
- Department of Medicine, Division of Digestive and Liver Diseases, New York Presbyterian Columbia University Medical Center, New York, NY, USA
| | - Benjamin Lebwohl
- Department of Medicine, Division of Digestive and Liver Diseases, New York Presbyterian Columbia University Medical Center, New York, NY, USA
| | - Daniel E Freedberg
- Department of Medicine, Division of Digestive and Liver Diseases, New York Presbyterian Columbia University Medical Center, New York, NY, USA
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Hung KW, Knotts RM, Faye AS, Pont AR, Lebwohl B, Abrams JA, Freedberg DE. Factors Associated With Adherence to Helicobacter pylori Testing During Hospitalization for Bleeding Peptic Ulcer Disease. Clin Gastroenterol Hepatol 2020; 18:1091-1098.e1. [PMID: 31352090 DOI: 10.1016/j.cgh.2019.07.037] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 07/09/2019] [Accepted: 07/19/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Guidelines recommend testing patients with peptic ulcer disease for Helicobacter pylori infection. We sought to identify factors associated with adherence to testing for H pylori in patients hospitalized for bleeding ulcers and to evaluate whether performing these tests affect risk for rebleeding. METHODS We performed a retrospective study of 830 inpatients who underwent endoscopy from 2011 through 2016 for gastrointestinal bleeding from gastric or duodenal ulcers. We searched electronic medical records for evidence of tests to detect H pylori by biopsy, serologic, or stool antigen analyses. We used multivariable models to identify clinical, demographic, and endoscopic factors associated with testing for H pylori. Kaplan-Meier analysis was performed to determine whether H pylori testing altered risk for the composite outcome of rebleeding or death within 1 year of admission. RESULTS Among the patients hospitalized for bleeding peptic ulcer disease during the 6-year period, 19% were not tested for H pylori within 60 days of index endoscopy. Hospitalization in the intensive care unit (ICU) was the factor most frequently associated with nonadherence to H pylori testing guidelines (only 66% of patients in the ICU were tested vs 90% of patients not in the ICU; P < .01), even after we adjusted for ulcer severity, coagulation status, extent of blood loss, and additional factors (adjusted odds ratio, 0.42; 95% CI, 0.27-0.66). Testing for H pylori was associated with a 51% decreased risk of rebleeding or death during the year after admission (adjusted hazard ratio 0.49; 95% CI, 0.36-0.67). CONCLUSIONS In an analysis of hospitalized patients who underwent endoscopy for gastrointestinal bleeding from gastric or duodenal ulcers, we found admission to the ICU to be associated with failure to test for H pylori infection. Failure to test for H pylori was independently associated with increased risk of rebleeding or death within 1 year of hospital admission. We need strategies to increase testing for H pylori among inpatients with bleeding ulcers.
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Affiliation(s)
- Kenneth W Hung
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University, New York, New York; Section of Digestive Diseases, Department of Medicine, Yale University, New Haven, Connecticut.
| | - Rita M Knotts
- Division of Gastroenterology and Hepatology, Department of Medicine, New York University, New York, New York
| | - Adam S Faye
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University, New York, New York
| | - Adam R Pont
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University, New York, New York
| | - Benjamin Lebwohl
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University, New York, New York; Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York
| | - Julian A Abrams
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University, New York, New York; Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York
| | - Daniel E Freedberg
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University, New York, New York; Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York
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Laskey HL, Schomaker N, Hung KW, Asrani SK, Jennings L, Nydam TL, Gralla J, Wiseman A, Rosen HR, Biggins SW. Predicting renal recovery after liver transplant with severe pretransplant subacute kidney injury: The impact of warm ischemia time. Liver Transpl 2016; 22:1085-91. [PMID: 27302834 DOI: 10.1002/lt.24488] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Revised: 05/06/2016] [Accepted: 05/12/2016] [Indexed: 01/13/2023]
Abstract
Identifying which liver transplantation (LT) candidates with severe kidney injury will have a full recovery of renal function after liver transplantation alone (LTA) is difficult. Avoiding unnecessary simultaneous liver-kidney transplantation (SLKT) can optimize the use of scarce kidney grafts. Incorrect predictions of spontaneous renal recovery after LTA can lead to increased morbidity and mortality. We retrospectively analyzed all LTA patients at our institution from February 2002 to February 2013 (n = 583) and identified a cohort with severe subacute renal injury (n = 40; creatinine <2 mg/dL in the 14-89 days prior to LTA and not on renal replacement therapy [RRT] yet, ≥2 mg/dL within 14 days of LTA and/or on RRT). Of 40 LTA recipients, 26 (65%) had renal recovery and 14 (35%) did not. The median (interquartile range) warm ischemia time (WIT) in recipients with and without renal recovery after LTA was 31 minutes (24-46 minutes) and 39 minutes (34-49 minutes; P = 0.02), respectively. Adjusting for the severity of the subacute kidney injury with either Acute Kidney Injury Network or Risk, Injury, Failure, Loss, and End-Stage Kidney Disease criteria, increasing WIT was associated with lack of renal recovery (serum creatinine <2 mg/dL after LTA, not on RRT), with an odds ratio (OR) of 1.08 (1.01-1.16; P = 0.03) and 1.09 (1.01-1.17; P = 0.02), respectively. For each minute of increased WIT, there was an 8%-9% increase in the risk of lack of renal recovery after LTA. In a separate cohort of 98 LTA recipients with subacute kidney injury, we confirmed the association of WIT and lack of renal recovery (OR, 1.04; P = 0.04). In LT candidates with severe subacute renal injury, operative measures to minimize WIT may improve renal recovery potentially avoiding RRT and the need for subsequent kidney transplant. Liver Transplantation 22 1085-1091 2016 AASLD.
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Affiliation(s)
- Heather L Laskey
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Nathan Schomaker
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Kenneth W Hung
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Sumeet K Asrani
- Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Linda Jennings
- Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Trevor L Nydam
- Department of Surgery, University of Colorado Denver, Denver, CO
| | - Jane Gralla
- Department of Pediatrics and Biostatistics and Informatics, University of Colorado Denver, Denver, CO
| | - Alex Wiseman
- Division of Nephrology, University of Colorado Denver, Denver, CO
| | - Hugo R Rosen
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Scott W Biggins
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO
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Dirchwolf M, Dodge JL, Gralla J, Bambha KM, Nydam T, Hung KW, Rosen HR, Feng S, Terrault NA, Biggins SW. The corrected donor age for hepatitis C virus-infected liver transplant recipients. Liver Transpl 2015; 21:1022-30. [PMID: 26074140 PMCID: PMC4809736 DOI: 10.1002/lt.24194] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Revised: 05/13/2015] [Accepted: 05/21/2015] [Indexed: 12/11/2022]
Abstract
Donor age has become the dominant donor factor used to predict graft failure (GF) after liver transplantation (LT) in hepatitis C virus (HCV) recipients. The purpose of this study was to develop and validate a model of corrected donor age (CDA) for HCV LT recipients that transforms the risk of other donor factors into the scale of donor age. We analyzed all first LT recipients with HCV in the United Network for Organ Sharing (UNOS) registry from January 1998 to December 2007 (development cohort, n = 14,538) and January 2008 to December 2011 (validation cohort, n = 7502) using Cox regression, excluding early GF (<90 days from LT). Accuracy in predicting 1 year GF (death or repeat LT) was assessed with the net reclassification index (NRI). In the development cohort, after controlling for pre-LT recipient factors and geotemporal trends (UNOS region, LT year), the following donor factors were independent predictors of GF, all P < 0.05: donor age (hazard ratio [HR], 1.02/year), donation after cardiac death (DCD; HR, 1.31), diabetes (HR, 1.23), height < 160 cm (HR, 1.13), aspartate aminotransferase (AST) ≥ 120 U/L (HR, 1.10), female (HR, 0.94), cold ischemia time (CIT; HR, 1.02/hour), and non-African American (non-AA) donor-African American (AA) recipient (HR, 1.65). Transforming these risk factors into the donor age scale yielded the following: DCD = +16 years; diabetes = +12 years; height < 160 cm = +7 years; AST ≥ 120 U/L = +5 years; female = -4 years; and CIT = +1 year/hour > 8 hours and -1 year/hour < 8 hours. There was a large effect of donor-recipient race combinations: +29 years for non-AA donor and an AA recipient but only +5 years for an AA donor and an AA recipient, and -2 years for an AA donor and a non-AA recipient. In a validation cohort, CDA better classified risk of 1-year GF versus actual age (NRI, 4.9%; P = 0.009) and versus the donor risk index (9.0%, P < 0.001). The CDA, compared to actual donor age, provides an intuitive and superior estimation of graft quality for HCV-positive LT recipients because it incorporates additional factors that impact LT GF rates.
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Affiliation(s)
- Melisa Dirchwolf
- Hepatopatías Infecciosas, Hospital Francisco J. Muñiz, Buenos Aires, Argentina
| | | | | | | | | | | | | | - Sandy Feng
- University of California, San Francisco, CA
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15
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Hung KW, Blaine J, Faubel S. Dual therapy difficulties in angiotensin blockade for proteinuria: a teachable moment. JAMA Intern Med 2014; 174:1429-30. [PMID: 25089763 DOI: 10.1001/jamainternmed.2014.3460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
| | - Judith Blaine
- Division of Renal Diseases and Hypertension, Department of Medicine, University of Colorado, Aurora
| | - Sarah Faubel
- Division of Renal Diseases and Hypertension, Department of Medicine, University of Colorado, Aurora
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16
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Stotts MJ, Hung KW, Benson A, Biggins SW. Rate and predictors of successful cardiopulmonary resuscitation in end-stage liver disease. Dig Dis Sci 2014; 59:1983-6. [PMID: 24599771 DOI: 10.1007/s10620-014-3084-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2013] [Accepted: 02/18/2014] [Indexed: 12/09/2022]
Abstract
BACKGROUND Cardiopulmonary resuscitation (CPR) after cardiac arrest in terminally ill patients is controversial. End-stage liver disease (ESLD) patients are unique from other terminally ill as they are generally younger and may be candidates for curative liver transplantation, but multiple studies have suggested poor outcomes when these patients require CPR. Predictors of success of CPR in ESLD have not been fully investigated, limiting end-of-life discussions. AIM The aim of this study was to quantify the rate and predictors of successful CPR in ESLD. METHODS We performed a retrospective chart review of patients with ESLD who received CPR from 2/2002 to 12/2013 at a single institution. Pre-cardiac arrest variables were collected for analysis as predictors of survival. Our primary outcome was survival to hospital discharge. RESULTS Of the 38 patients who underwent CPR, six survived to hospital discharge. When comparing those who survived to discharge with those who did not, we found no significant difference in age (p = 0.34), gender (p = 0.85), presence of ascites (p = 0.67), location at time of arrest (p = 0.39), concurrent GI bleeding (p = 0.48), and multiple individual lab values. Significant predictors of not surviving to hospital discharge were a model for end-stage liver disease (MELD) ≥ 20 (OR 6.0, p = 0.044) and presentation with a non-shockable rhythm (PEA/asystole) (OR 29, p < 0.001). CONCLUSION ESLD patients requiring CPR have worse outcomes as their MELD score increases. CPR in ESLD when MELD is <20 or with a shockable rhythm has a greater likelihood of success.
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Affiliation(s)
- Matthew J Stotts
- Division of Gastroenterology, Saint Louis University Hospital, St. Louis, MO, USA
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Sivaraman T, Kumar TK, Hung KW, Yu C. Comparison of the structural stability of two homologous toxins isolated from the Taiwan cobra (Naja naja atra) venom. Biochemistry 2000; 39:8705-10. [PMID: 10913281 DOI: 10.1021/bi992867j] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Cardiotoxin analogue III (CTX III) and cobrotoxin (CBTX) isolated from the Taiwan cobra venom (Naja naja atra) are structurally homologous, small molecular weight, all-beta-sheet proteins, cross-linked by four disulfide bonds at identical positions. The conformational stabilities of these toxins are compared based on temperature-dependent chemical shifts and amide proton exchange kinetics using two-dimensional NMR spectroscopy. The structure of CTX III is found to be significantly more stable than that of CBTX. In both the toxins, beta-strand III appears to constitute the stability core. In CTX III, the stability of the triple-stranded beta-sheet domain is observed to be markedly higher than the double-stranded beta-sheet segment. In contrast, in CBTX, both structural domains (double- and triple-stranded beta-sheet domains) appear to contribute equally to the stability of the protein. Estimation of the free energy of exchange (Delta G(ex)) of residues in CBTX and CTX III reveals that the enhanced stability of the structure of CTX III stems from the strong interactions among the beta-strands constituting the triple-stranded beta-sheet domain and also the molecular forces bridging the residues at the N- and C-terminal ends of the molecule.
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Affiliation(s)
- T Sivaraman
- Department of Chemistry, National Tsing Hua University, Hsinchu, Taiwan (R.O.C.), China
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18
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Abstract
The effect(s) of TFE (2,2,2-trifluoroethanol) on three different conformational states (native, denatured, and carboxymethylated) of CTX III and RNase A has been examined. Contrary to the general belief, the results of the present study reveal that TFE can induce helical conformation in a protein which has no sequence propensity to form a helix. It is found that the helix induction in TFE is intricately related to the destabilization of the tertiary structural conformation in proteins. More importantly, the disulfide bonds in proteins are found to have significant influence on the TFE-mediated helix induction. The results obtained in this study strongly suggest that information pertaining to the influence of disulfide bonds on helix induction need to be considered to improve the accuracy of secondary structure prediction algorithms.
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Affiliation(s)
- T Sivaraman
- Department of Chemistry, National Tsing Hua University, Hsinchu, Taiwan
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