Major depressive disorders in patients with inflammatory bowel disease and rheumatoid arthritis

BACKGROUND

Various immune-mediated inflammatory diseases consisting of inflammatory bowel disease (IBD) and rheumatoid arthritis (RA), are found to have a substantial societal burden, increased healthcare costs, and progressive disability. Studies suggest that patients with vs without comorbid depression have a more significant disability, a lower likelihood of remission, and reduced adherence to therapy. Elevated interleukin (IL)-1β, tumor necrosis factor-α, and IL-6 contribute to developing depression by the impaired physiological responses to stress, resulting in increased pain, fever, fatigue, and lack thereof of interest, and thus poor long-term outcomes. This study emphasizes the timely recognition of the prevalence of major depressive disorder (MDD) in patients with RA and IBD combined, thus preventing disability.

AIM

To identify the prevalence level and temporal trends of depression in hospitalized IBD-RA patients.

METHODS

All adult hospitalized patients from January 2000 to December 2019 in the nationwide inpatient sample (NIS) were captured. The study population included all patients with a primary or secondary IBD-RA overlap disease using corresponding international classification of diseases (ICD)-9 and ICD-10 codes. IBD includes Crohn’s disease and ulcerative colitis. The study population was divided into IBD-RA without MDD (controls) and IBD-RA with MDD (cases). For group comparison between MDD vs no MDD, we used Student's t-test for continuous variables and Rao-Scott Chi-square tests for categorical variables. For univariate analyses, we used logistic regression, and for multivariate analysis, we used a weighted multi-level mixed-effects model. We attested all hypotheses with two-tailed significance level of 0.05 (P < 0.05 was considered significant). The outcome is to examine the temporal trends and prevalence of depression in patients with IBD-RA by gender, race, and age.

RESULTS

A total of 133315 records were identified with IBD-RA overlap, of which 26155 patients (19.62%) had MDD. Among the IBD-RA patients, those who had MDD were younger [mean age of 56 years (SD ± 15)] to IBD-RA without MDD patients with a P < 0.0001, more females (80% among cases vs 73% among controls) than males with a P < 0.0001, frequent in the white race (79% among cases vs 73% among controls) than black race. Over the 19 years, the number of patients with MDD in IBD-RA increased from 153 (the year 2000) to 2880 (the year 2019) in weighted NIS, representing a 1782% increase compared to the year 2000 with a P < 0.001. Factors associated with higher MDD included younger age, female gender, white race, alcohol, opioids, esophageal disorders, peptic ulcer disease, chronic pancreatitis, paralysis, dementia, menopausal disorders, obesity, nutritional deficiencies, diabetes mellitus with chronic complications, and osteoarthritis.

CONCLUSION

There is a rise in the prevalence of depression in younger patients with IBD-RA combined compared to their counterparts. These patients are also at higher risk for the increased cost of care and poor treatment compliance. It is crucial to educate the involved clinicians to identify the early signs and symptoms of depression in patients with IBD or RA or IBD-RA combined and treat them to have a better overall prognosis.

Hereditary hemochromatosis: Temporal trends, sociodemographic characteristics, and independent risk factor of hepatocellular cancer – nationwide population-based study

BACKGROUND

Hereditary hemochromatosis (HH) has an increased risk of hepatocellular cancer (HCC) both due to genetic risks and iron overload as iron overload can be carcinogenic; HH impacts the increasing risk of HCC, not only through the development of cirrhosis but concerning hepatic iron deposition, which has been studied further recently.

AIM

To evaluate HH yearly trends, patient demographics, symptoms, comorbidities, and hospital outcomes. The secondary aim sheds light on the risk of iron overload for developing HCC in HH patients, independent of liver cirrhosis complications. The study investigated HH (without cirrhosis) as an independent risk factor for HCC.

METHODS

We analyzed data from National Inpatient Sample (NIS) Database, the largest national inpatient data collection in the United States, and selected HH and HCC cohorts. HH was first defined in 2011 International Classification of Disease - 9^th edition (ICD-9) as a separate diagnosis; the HH cohort is extracted from January 2011 to December 2019 using 275.01 (ICD-9) and E83.110 (ICD-10) diagnosis codes of HH. Patients were excluded from the HH cohort if they had a primary or secondary diagnostic code of cirrhosis (alcoholic, non-alcoholic, and biliary), viral hepatitis, alcoholic liver disease, non-alcoholic fatty liver disease (NAFLD), and non-alcoholic steatohepatitis (NASH). We removed these patients from the HH cohort to rule out bias or ICD-10 diagnostic errors. The HCC cohort is selected from January 2011 to December 2019 using the ICD-9 and ICD-10 codes of HCC. We selected a non-HCC cohort with the 1:1 fixed ratio nearest neighbor (greedy) propensity score method using the patients' age, gender, and race. We performed multivariate analysis for the risk factors of HCC in the HCC and non-HCC matched cohort. We further analyzed HH without cirrhosis (removing HH patients with a diagnosis of cirrhosis) as an independent risk factor of HCC after adjusting all known risk factors of HCC in the multivariate model.

RESULTS

During the 2011-2019 period, a total of 18031 hospitalizations with a primary or secondary diagnosis of HH (excluding liver diseases) were recorded in the NIS database. We analyzed different patients’ characteristics, and we found increments in inpatient population trend with a Ptrend < 0.001 and total hospital cost of care trend from $42957 in 2011 to $66152 in 2019 with a Ptrend < 0.001 despite no change in Length of Stay over the last decade. The multivariate analyses showed that HH without cirrhosis (aOR, 28.8; 95%CI, 10.4–80.1; P < 0.0001), biliary cirrhosis (aOR, 19.3; 95%CI, 13.4–27.6; P < 0.0001), non-alcoholic cirrhosis (aOR, 17.4; 95%CI, 16.5–18.4; P < 0.0001), alcoholic cirrhosis (aOR, 16.9; 95%CI, 15.9–17.9; P < 0.0001), hepatitis B (aOR, 12.1; 95%CI, 10.85–13.60; P < 0.0001), hepatitis C (aOR, 8.58; 95%CI, 8.20–8.98; P < 0.0001), Wilson disease (aOR, 4.27; 95%CI, 1.18–15.41; P < 0.0001), NAFLD or NASH (aOR, 2.96; 95%CI, 2.73–3.20; P < 0.0001), alpha1-antitrypsin deficiency (aOR, 2.10; 95%CI, 1.21–3.64; P < 0.0001), diabetes mellitus without chronic complications (aOR, 1.17; 95%CI, 1.13–1.21; P < 0.0001), and blood transfusion (aOR, 1.80; 95%CI, 1.69–1.92; P < 0.0001) are independent risk factor for liver cancer.

CONCLUSION

Our study showed an increasing trend of in-hospital admissions of HH patients in the last decade. These trends were likely related to advances in diagnostic approach, which can lead to increased hospital utilization and cost increments. Still, the length of stay remained the same, likely due to a big part of management being done in outpatient settings. Another vital part of our study is the significant result that HH without cirrhosis is an independent risk factor for HCC with adjusting all known risk factors. More prospective and retrospective large studies are needed to re-evaluate the HH independent risk in developing HCC.

Atezolizumab, a PD-L1 Inhibitor: An Association of Bleeding Gastric Ulcer With Its Use

Atezolizumab is a programmed death-ligand 1 inhibitor, an immune checkpoint inhibitor (ICI), useful in various advanced solid malignancies. As atezolizumab is more commonly used nowadays, physicians should be aware of the rare associated adverse events (AEs). Most of the AEs associated with the ICIs are immune-related, and the common gastrointestinal (GI) manifestations are colitis and diarrhea. Upper GI manifestations are rare with atezolizumab, and bleeding gastric ulcer is even rarer. We report here a case of a 62-year-old male with hepatocellular carcinoma who presented with upper GI bleed after atezolizumab therapy. Esophagogastroduodenoscopy showed multiple gastric ulcers, which are likely the cause of his bleeding.

Herpes Simplex Virus Esophagitis in the Setting of Acute Use of Corticosteroids for COPD Exacerbation in an Immunocompetent Middle-Aged Woman

Herpes simplex (HSV) esophagitis is usually identified in patients with significant immunosuppressive conditions such as AIDS. Short course of immunosuppressive therapy is an uncommon risk factor for this condition. We present a case of acute gastrointestinal bleeding secondary to HSV type 1-induced esophageal ulcers. A 63-year-old woman developed acute hypoxic hypercapnic respiratory failure. Past medical history was significant for COPD for which the patient was taking short-acting bronchodilator inhalers. The patient was intubated and started on mechanical ventilation. Intravenous Solu-Medrol 40 mg Q6 was started. Hospital course was complicated by sepsis of unknown source. Empiric broad-spectrum antibiotic therapy was started. On the 11th hospital day, the patient experienced multiple episodes of coffee ground emesis. There was abdominal tenderness on physical examination. Significant laboratory results were lipase 1,911 U/L and lymphopenia (ALC = 300/mm3). Endoscopy revealed severe erosive esophagitis and multiple punched-out ulcerations of the esophagus. Empiric treatment with valacyclovir 500 mg OD was started. The patient required PEG tube insertion for dysphagia. Complete resolution of esophagitis was noted then. Immunohistochemical staining for HSV was strongly positive in the cells with inclusions. Short course of intravenous corticosteroids is an uncommon cause of HSV-1 esophagitis. Corticosteroid-induced lymphopenia impedes underlying cellular immunity, which might explain the reactivation of latent herpes and esophageal ulcer formation. Given the rarity of the disease, evidence of treatment is available from case reports only. We found complete resolution of esophageal ulcers after the patient received valacyclovir therapy for 10 days.

Band gap engineering of zinc selenide thin films through alloying with cadmium telluride

This work investigates band gap engineering of zinc selenide (ZnSe) thin films. This was achieved by mixing ZnSe with cadmium telluride (CdTe). The mass ratio (x) of CdTe in the starting material was varied in the range x = 0-0.333. The films were prepared using thermal evaporation. The chemical composition of the films was investigated through energy dispersive spectroscopy and Rutherford backscattering spectrometry. Structural analysis was carried out using X-ray diffraction and atomic force microscopy. Normal incidence transmittance and reflectance were measured over the wavelength range 300-1300 nm. The absorption coefficients and band gaps were determined from these spectrophotometric measurements. The band gap monotonically decreased from 2.58 eV (for x = 0) to 1.75 eV (for x = 0.333). Photocurrent measurements indicated that the maximum current density was obtained for films with x = 0.286. A figure of merit, based on crystallinity, band gap, and photocurrent, was defined. The optimum characteristics were obtained for the films with x = 0.231, for which the band gap was 2.14 eV.