Cancer and Cardiovascular Disease: The Conjoined Twins

Cancer and cardiovascular disease are the two most common causes of death worldwide. As the fields of cardiovascular medicine and oncology continue to expand, the area of overlap is becoming more prominent demanding dedicated attention and individualized patient care. We have come to realize that both fields are inextricably intertwined in several aspects, so much so that the mere presence of one, with its resultant downstream implications, has an impact on the other. Nonetheless, cardiovascular disease and cancer are generally approached independently. The focus that is granted to the predominant pathological entity (either cardiovascular disease or cancer), does not allow for optimal medical care for the other. As a result, ample opportunities for improvement in overall health care are being overlooked. Herein, we hope to shed light on the interconnected relationship between cardiovascular disease and cancer and uncover some of the unintentionally neglected intricacies of common cardiovascular therapeutics from an oncologic standpoint.

Fluid loading during the hemodynamic evaluation of pulmonary hypertension: a cross-sectional study

Background

Compensated pulmonary hypertension due to left heart disease (PH-LHD) may be difficult to identify based on resting hemodynamics. Fluid challenge is commonly used to unmask occult PH-LHD. We sought to determine the hemodynamic effect of fluid loading and its association with the clinical pretest probability of PH-LHD.

Methods

We included consecutive patients evaluated for PH who underwent right heart catheterization (RHC) with fluid challenge at Cleveland Clinic between April 2013 and January 2019. We obtained hemodynamic measurements at rest and after intravenous rapid fluid challenge (500 mL of normal saline). We calculated the pretest probability of PH-LHD based on the 6th World Symposium on PH proceedings. For statistical analyses we used t-test, analysis of variance (ANOVA), Chi-square, paired t-test, Wilcoxon signed-rank test and linear regression as indicated.

Results

We included 174 patients with mean ± standard deviation (SD) age of 63.7±13.0 years and 123 (71%) of female sex. Baseline pulmonary artery wedge pressure (PAWP) was 11±5 mmHg, with a PAWP/cardiac output (CO) ratio of 2.1±1.1 Wood units (WU). The absolute increase in PAWP and PAWP/CO was 6.9±3.6 mmHg and 1.06±0.91 WU, respectively. The change in PAWP was inversely associated with baseline PAWP (P<0.001). The PAWP with fluids was >18 mmHg in 81% of the patients with baseline PAWP 13-15 mmHg. We found no strong associations between the change in PAWP, PAWP/CO or right atrial pressure to pulmonary arterial wedge pressure ratio (RAP/PAWP) and the pretest probability of PH-LHD.

Conclusions

The absolute change in PAWP, PAWP/CO, or achieving a PAWP >18 mmHg with rapid fluid loading was not robustly associated with the pretest probability of PH-LHD. Patients with PAWP between 13-15 mmHg commonly had a positive fluid challenge, questioning the utility of this intervention in these patients.

Prevalence Rates of Pneumococcal Vaccination in IBD and 30-Day Clinical Outcomes in Patients With IBD and Pneumococcal Disease Stratified by Receipt of Pneumococcal Vaccination: A Multi-Network Study

This study sought to assess outcomes associated with pneumococcal vaccination in adult inflammatory bowel disease patients. Results found unvaccinated patients had higher adverse outcomes, including greater risk of hospitalization, ICU admission, ventilation, and mortality. These findings underscore the importance of pneumococcal vaccination.

The global burden of cancer attributable to risk factors, 2010-19: a systematic analysis for the Global Burden of Disease Study 2019

BACKGROUND

Understanding the magnitude of cancer burden attributable to potentially modifiable risk factors is crucial for development of effective prevention and mitigation strategies. We analysed results from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 to inform cancer control planning efforts globally.

METHODS

The GBD 2019 comparative risk assessment framework was used to estimate cancer burden attributable to behavioural, environmental and occupational, and metabolic risk factors. A total of 82 risk-outcome pairs were included on the basis of the World Cancer Research Fund criteria. Estimated cancer deaths and disability-adjusted life-years (DALYs) in 2019 and change in these measures between 2010 and 2019 are presented.

FINDINGS

Globally, in 2019, the risk factors included in this analysis accounted for 4·45 million (95% uncertainty interval 4·01-4·94) deaths and 105 million (95·0-116) DALYs for both sexes combined, representing 44·4% (41·3-48·4) of all cancer deaths and 42·0% (39·1-45·6) of all DALYs. There were 2·88 million (2·60-3·18) risk-attributable cancer deaths in males (50·6% [47·8-54·1] of all male cancer deaths) and 1·58 million (1·36-1·84) risk-attributable cancer deaths in females (36·3% [32·5-41·3] of all female cancer deaths). The leading risk factors at the most detailed level globally for risk-attributable cancer deaths and DALYs in 2019 for both sexes combined were smoking, followed by alcohol use and high BMI. Risk-attributable cancer burden varied by world region and Socio-demographic Index (SDI), with smoking, unsafe sex, and alcohol use being the three leading risk factors for risk-attributable cancer DALYs in low SDI locations in 2019, whereas DALYs in high SDI locations mirrored the top three global risk factor rankings. From 2010 to 2019, global risk-attributable cancer deaths increased by 20·4% (12·6-28·4) and DALYs by 16·8% (8·8-25·0), with the greatest percentage increase in metabolic risks (34·7% [27·9-42·8] and 33·3% [25·8-42·0]).

INTERPRETATION

The leading risk factors contributing to global cancer burden in 2019 were behavioural, whereas metabolic risk factors saw the largest increases between 2010 and 2019. Reducing exposure to these modifiable risk factors would decrease cancer mortality and DALY rates worldwide, and policies should be tailored appropriately to local cancer risk factor burden.

FUNDING

Bill & Melinda Gates Foundation.

The Natural Course of Pancreatic Cysts in Inflammatory Bowel Disease: Results of a Long-term Follow-up

OBJECTIVES

The natural course of pancreatic cysts in inflammatory bowel disease (IBD) is unknown. We aim to describe the natural course of pancreatic cysts in IBD and evaluate long-term outcomes.

METHODS

A database of patients with abdominal imaging diagnosis of pancreatic cysts (2008-2019) was reviewed. Patients with IBD and pancreatic cysts (study group) and pancreatic cysts without IBD (controls) were selected. Outcomes were measured at 1, 3, 5, and 10 years. Several logistic regression models were used for analysis.

RESULTS

Of the 1789 patients evaluated, 1690 had pancreatic cysts without IBD, and 78 had IBD and pancreatic cysts. Majority of cysts were intraductal papillary mucinous neoplasms. Patients with IBD and pancreatic cysts were more likely to be diagnosed with pancreatic cysts at a younger age (P < 0.001) and were more likely to undergo surgical intervention at a younger age (P < 0.001).

CONCLUSIONS

This is the first study to evaluate the natural course of pancreatic cysts in IBD patients. Patients with IBD were more likely to have pancreatic cysts detected at a younger age. Despite the early presentation, there were no differences in long-term outcomes. Patients with IBD with pancreatic cysts should be managed similarly to those without IBD.

Global, regional, and national burden of colorectal cancer and its risk factors, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019

BACKGROUND

Colorectal cancer is the third leading cause of cancer deaths worldwide. Given the recent increasing trends in colorectal cancer incidence globally, up-to-date information on the colorectal cancer burden could guide screening, early detection, and treatment strategies, and help effectively allocate resources. We examined the temporal patterns of the global, regional, and national burden of colorectal cancer and its risk factors in 204 countries and territories across the past three decades.

METHODS

Estimates of incidence, mortality, and disability-adjusted life years (DALYs) for colorectal cancer were generated as a part of the Global Burden of Diseases, Injuries and Risk Factors Study (GBD) 2019 by age, sex, and geographical location for the period 1990-2019. Mortality estimates were produced using the cause of death ensemble model. We also calculated DALYs attributable to risk factors that had evidence of causation with colorectal cancer.

FINDINGS

Globally, between 1990 and 2019, colorectal cancer incident cases more than doubled, from 842 098 (95% uncertainty interval [UI] 810 408-868 574) to 2·17 million (2·00-2·34), and deaths increased from 518 126 (493 682-537 877) to 1·09 million (1·02-1·15). The global age-standardised incidence rate increased from 22·2 (95% UI 21·3-23·0) per 100 000 to 26·7 (24·6-28·9) per 100 000, whereas the age-standardised mortality rate decreased from 14·3 (13·5-14·9) per 100 000 to 13·7 (12·6-14·5) per 100 000 and the age-standardised DALY rate decreased from 308·5 (294·7-320·7) per 100 000 to 295·5 (275·2-313·0) per 100 000 from 1990 through 2019. Taiwan (province of China; 62·0 [48·9-80·0] per 100 000), Monaco (60·7 [48·5-73·6] per 100 000), and Andorra (56·6 [42·8-71·9] per 100 000) had the highest age-standardised incidence rates, while Greenland (31·4 [26·0-37·1] per 100 000), Brunei (30·3 [26·6-34·1] per 100 000), and Hungary (28·6 [23·6-34·0] per 100 000) had the highest age-standardised mortality rates. From 1990 through 2019, a substantial rise in incidence rates was observed in younger adults (age <50 years), particularly in high Socio-demographic Index (SDI) countries. Globally, a diet low in milk (15·6%), smoking (13·3%), a diet low in calcium (12·9%), and alcohol use (9·9%) were the main contributors to colorectal cancer DALYs in 2019.

INTERPRETATION

The increase in incidence rates in people younger than 50 years requires vigilance from researchers, clinicians, and policy makers and a possible reconsideration of screening guidelines. The fast-rising burden in low SDI and middle SDI countries in Asia and Africa calls for colorectal cancer prevention approaches, greater awareness, and cost-effective screening and therapeutic options in these regions.

FUNDING

Bill & Melinda Gates Foundation.

Global, regional, and national burden of hepatitis B, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019

Background

Combating viral hepatitis is part of the UN Sustainable Development Goals (SDGs), and WHO has put forth hepatitis B elimination targets in its Global Health Sector Strategy on Viral Hepatitis (WHO-GHSS) and Interim Guidance for Country Validation of Viral Hepatitis Elimination (WHO Interim Guidance). We estimated the global, regional, and national prevalence of hepatitis B virus (HBV), as well as mortality and disability-adjusted life-years (DALYs) due to HBV, as part of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019. This included estimates for 194 WHO member states, for which we compared our estimates to WHO elimination targets.

Methods

The primary data sources were population-based serosurveys, claims and hospital discharges, cancer registries, vital registration systems, and published case series. We estimated chronic HBV infection and the burden of HBV-related diseases, defined as an aggregate of cirrhosis due to hepatitis B, liver cancer due to hepatitis B, and acute hepatitis B. We used DisMod-MR 2.1, a Bayesian mixed-effects meta-regression tool, to estimate the prevalence of chronic HBV infection, cirrhosis, and aetiological proportions of cirrhosis. We used mortality-to-incidence ratios modelled with spatiotemporal Gaussian process regression to estimate the incidence of liver cancer. We used the Cause of Death Ensemble modelling (CODEm) model, a tool that selects models and covariates on the basis of out-of-sample performance, to estimate mortality due to cirrhosis, liver cancer, and acute hepatitis B.

Findings

In 2019, the estimated global, all-age prevalence of chronic HBV infection was 4·1% (95% uncertainty interval [UI] 3·7 to 4·5), corresponding to 316 million (284 to 351) infected people. There was a 31·3% (29·0 to 33·9) decline in all-age prevalence between 1990 and 2019, with a more marked decline of 76·8% (76·2 to 77·5) in prevalence in children younger than 5 years. HBV-related diseases resulted in 555 000 global deaths (487 000 to 630 000) in 2019. The number of HBV-related deaths increased between 1990 and 2019 (by 5·9% [–5·6 to 19·2]) and between 2015 and 2019 (by 2·9% [–5·9 to 11·3]). By contrast, all-age and age-standardised death rates due to HBV-related diseases decreased during these periods. We compared estimates for 2019 in 194 WHO locations to WHO-GHSS 2020 targets, and found that four countries achieved a 10% reduction in deaths, 15 countries achieved a 30% reduction in new cases, and 147 countries achieved a 1% prevalence in children younger than 5 years. As of 2019, 68 of 194 countries had already achieved the 2030 target proposed in WHO Interim Guidance of an all-age HBV-related death rate of four per 100 000.

Interpretation

The prevalence of chronic HBV infection declined over time, particularly in children younger than 5 years, since the introduction of hepatitis B vaccination. HBV-related death rates also decreased, but HBV-related death counts increased as a result of population growth, ageing, and cohort effects. By 2019, many countries had met the interim seroprevalence target for children younger than 5 years, but few countries had met the WHO-GHSS interim targets for deaths and new cases. Progress according to all indicators must be accelerated to meet 2030 targets, and there are marked disparities in burden and progress across the world. HBV interventions, such as vaccination, testing, and treatment, must be strategically supported and scaled up to achieve elimination.

Funding

Bill & Melinda Gates Foundation.

Rates of Intestinal Resection and Colectomy in Inflammatory Bowel Disease Patients After Initiation of Biologics: A Cohort Study

BACKGROUND & AIMS

50% to 80% Crohn's disease (CD) and 10% to 30% ulcerative colitis (UC) patients require surgery over their lifetime. Biologic therapies may alter this natural history, but data on the effect of biologics on surgery rates in this patient population are mixed. We sought to investigate the influence of biologics on surgery prevalence in CD and UC.

METHODS

We used a commercial database (Explorys Inc, Cleveland, OH), which includes electronic health record data from 26 major integrated US healthcare systems. We identified all patients who were diagnosed with CD or UC that were treated with any biologics between 2015 and 2020. The primary outcome was to examine the association between biologics therapy and the prevalence of bowel resection. Also, we identified the factors associated with surgery in IBD patients on biologics.

RESULTS

Of 32,904,480 patients in the database, we identified 140,540 patients with CD and 115,260 patients with UC, of whom 25,840 (18%) and 9,050 (7.8%) patients received biologics, respectively. The prevalence of intestinal resection was significantly lower in biologics-treated CD patients (9.3%) compared to those who did not receive biologics (12.1%) (p < .001). Similarly, biologic-treated UC patients were significantly less likely to undergo colectomy (7.3%) compared to UC patients who did not receive biologic therapy (11.0%) (p < .001). Tobacco use, Clostridium difficile infection, and perianal disease were associated with intestinal resection in CD. Colon neoplasm and Clostridium difficile infection were associated with colectomy in UC.

CONCLUSIONS

In this study of a large healthcare administrative database, inflammatory bowel disease (IBD) patients treated with biologics were significantly less likely to undergo bowel resection when compared to those who never received biologics. This data suggests that biologics may impact surgical rates in IBD.

Prevalence of hypothyroidism and effect of thyroid hormone replacement therapy in patients with non-alcoholic fatty liver disease: A population-based study

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is currently considered as the most common cause of chronic liver disease worldwide. Risk factors for NAFLD have been well-described, including obesity, type 2 diabetes mellites (T2DM), dyslipidemia (DLP) and metabolic syndrome. Hypothyroidism has been identified as an independent risk factor for the development of NAFLD, although the literature is inconsistent

AIM

To evaluate the prevalence of hypothyroidism in patients with NAFLD, assess if it is an independent risk factor and explore the effect of thyroxine replacement therapy.

METHODS

Our cohort’s data was obtained using a validated, large, multicenter database (Explorys Inc, Cleveland, OH, United States) aggregated from pooled outpatient and inpatient records of 26 different healthcare systems, consisting of a total of 360 hospitals in the United States, and utilizing Systematized Nomenclature of Medicine-Clinical Terms for coding. We evaluated a cohort of patients with hypothyroidism and NAFLD. Multivariate analysis was performed to adjust for confounding risk factors including hypertension (HTN), T2DM, DLP, obesity and metabolic syndrome. SPSS version 25, IBM Corp was used for statistical analysis, and for all analyses, a 2-sided P value of < 0.05 was considered statistically significant. Exclusion criteria were limited to age < 18 years.

RESULTS

Among the 37648180 included individuals in this database who are above the age of 18 years, there were a total of 2320 patients with NAFLD (6.16 per 100000) in the last five years (2015-2020), amongst which 520 patients (22.4%) had hypothyroidism. Baseline characteristics of patients in this database are described in Table 1. Patients with NAFLD were also more likely to have obesity, T2DM, DLP, HTN, and metabolic syndrome (Table 2). While males and females were equally affected, patients in the age group 18-65 years as well as Caucasians seem to be at a higher risk. There was an increased risk of NAFLD among patients with hypothyroidism (OR = 1.587). Furthermore, thyroid hormone replacement was not associated with a decreased risk for developing NAFLD (OR = 1.106, C = 0.952-1.285, P = 0.303).

CONCLUSION

Hypothyroidism seems to be an independent risk factor for the development of NAFLD. Thyroid hormone replacement did not provide a statistically significant risk reduction. Further studies are needed to evaluate the effect of thyroid hormone replacement and assess if being euthyroid while on thyroid replacement therapy affects development and/or progression of NAFLD.

Patients With Inflammatory Bowel Disease on Treatment Have Lower Rates of Celiac Disease

BACKGROUND

The association between celiac disease and inflammatory bowel disease (IBD) has been studied; however, the impact of IBD therapy on celiac disease is not known. Using a large database, we sought to describe the association of celiac disease and IBD and the impact of IBD treatment.

METHODS

We queried a large multicenter database (Explorys Inc.), an electronic health record data aggregate from 26 American health care systems. We identified a cohort of patients with celiac disease and IBD between 1999 and 2020 and conducted a statistical analysis using a multivariate model.

RESULTS

Of the 72,965,940 individuals in the database, 133,400 had celiac disease (0.18%), 191,570 (0.26%) had ulcerative colitis (UC), and 230,670 (0.32%) had Crohn disease (CD). Patients with IBD were more likely to have a diagnosis of celiac disease (odds ratio [OR], 13.680), with a greater association with CD. Treated patients with UC and with CD, respectively, had a lower risk association with celiac disease compared to those not undergoing IBD treatment, specifically corticosteroids (OR, 0.407 and 0.585), 5-aminosalicylates (OR, 0.124 and 0.127), immunomodulators (OR, 0.385 and 0.425), and anti-tumor necrosis factor drugs (OR, 0.215 and 0.242). There was no lower risk association in the vedolizumab group, but there was a higher risk association among the ustekinumab group.

CONCLUSIONS

In this large dataset, we showed a bidirectional association between celiac disease and IBD that was stronger with CD. Patients with IBD treated using corticosteroids, 5-aminosalicylates, immunomodulators, or anti-tumor necrosis factor drugs had a lower association with celiac disease. Additional studies are required to determine the underlying mechanisms for IBD therapy-related modification of celiac disease incidence.

Cancer Incidence, Mortality, Years of Life Lost, Years Lived With Disability, and Disability-Adjusted Life Years for 29 Cancer Groups From 2010 to 2019: A Systematic Analysis for the Global Burden of Disease Study 2019

IMPORTANCE

The Global Burden of Diseases, Injuries, and Risk Factors Study 2019 (GBD 2019) provided systematic estimates of incidence, morbidity, and mortality to inform local and international efforts toward reducing cancer burden.

OBJECTIVE

To estimate cancer burden and trends globally for 204 countries and territories and by Sociodemographic Index (SDI) quintiles from 2010 to 2019.

EVIDENCE REVIEW

The GBD 2019 estimation methods were used to describe cancer incidence, mortality, years lived with disability, years of life lost, and disability-adjusted life years (DALYs) in 2019 and over the past decade. Estimates are also provided by quintiles of the SDI, a composite measure of educational attainment, income per capita, and total fertility rate for those younger than 25 years. Estimates include 95% uncertainty intervals (UIs).

FINDINGS

In 2019, there were an estimated 23.6 million (95% UI, 22.2-24.9 million) new cancer cases (17.2 million when excluding nonmelanoma skin cancer) and 10.0 million (95% UI, 9.36-10.6 million) cancer deaths globally, with an estimated 250 million (235-264 million) DALYs due to cancer. Since 2010, these represented a 26.3% (95% UI, 20.3%-32.3%) increase in new cases, a 20.9% (95% UI, 14.2%-27.6%) increase in deaths, and a 16.0% (95% UI, 9.3%-22.8%) increase in DALYs. Among 22 groups of diseases and injuries in the GBD 2019 study, cancer was second only to cardiovascular diseases for the number of deaths, years of life lost, and DALYs globally in 2019. Cancer burden differed across SDI quintiles. The proportion of years lived with disability that contributed to DALYs increased with SDI, ranging from 1.4% (1.1%-1.8%) in the low SDI quintile to 5.7% (4.2%-7.1%) in the high SDI quintile. While the high SDI quintile had the highest number of new cases in 2019, the middle SDI quintile had the highest number of cancer deaths and DALYs. From 2010 to 2019, the largest percentage increase in the numbers of cases and deaths occurred in the low and low-middle SDI quintiles.

CONCLUSIONS AND RELEVANCE

The results of this systematic analysis suggest that the global burden of cancer is substantial and growing, with burden differing by SDI. These results provide comprehensive and comparable estimates that can potentially inform efforts toward equitable cancer control around the world.

Takotsubo cardiomyopathy in orthotopic liver transplant recipients: A cohort study using multi-center pooled electronic health record data

BACKGROUND

Takotsubo cardiomyopathy (TCM), or stress-induced cardiomyopathy, is associated with adverse prognosis. Limited data suggest that TCM occurring in orthotopic liver transplant (OLT) recipients is associated with elevated peri-operative risk.

AIM

To characterize the predictors of TCM in OLT recipients, using a large, multi-center pooled electronic health database.

METHODS

A multi-institutional database (Explorys Inc, Cleveland, OH, USA), an aggregate of de-identified electronic health record data from 26 United States healthcare systems was surveyed. A cohort of patients with a Systematized Nomenclature of Medicine-Clinical Terms of “liver transplant” between 09/2015 and 09/2020 was identified. Subsequently, individuals who developed a new diagnosis of TCM following OLT were identified. Furthermore, the risk associations with TCM among this patient population were characterized using linear regression.

RESULTS

Between 09/2015 and 09/2020, of 37718540 patients in the database, 38740 (0.10%) had a history of OLT (60.6% had an age between 18-65 years, 58.1% female). A new diagnosis of TCM was identified in 0.3% of OLT recipients (45.5% had an age between 18-65 years, 72.7% female), compared to 0.04% in non-OLT patients [odds ratio (OR): 7.98, 95% confidence intervals: 6.62-9.63, (P < 0.0001)]. OLT recipients who developed TCM, compared to those who did not, were more likely to be greater than 65 years of age, Caucasian, and female (P < 0.05). There was also a significant association with cardiac arrhythmias, especially ventricular arrhythmias (P < 0.0001).

CONCLUSION

TCM was significantly more likely to occur in LT recipients vs non-recipients. Older age, Caucasian ethnicity, female gender, and presence of arrhythmias were significantly associated with TCM in LT recipients.

Clinical Risk Prediction Model for Neoadjuvant Therapy in Resectable Esophageal Adenocarcinoma

GOALS AND BACKGROUND

Clinical staging with endoscopic ultrasound (EUS) and positron emission tomography (PET) is used to identify esophageal adenocarcinoma (EAC) patients with locally advanced disease and therefore, benefit from neoadjuvant therapy. However, EUS is operator dependent and subject to interobserver variability. Therefore, we aimed to identify clinical predictors of locally advanced EAC and build a predictive model that can be used as an adjunct to current staging methods.

STUDY

This was a cross-sectional study of patients with EAC who underwent preoperative staging with EUS and PET scan followed by definitive therapy at our institution from January 2011 to December 2017. Demographic data, symptoms, endoscopic findings, EUS, and PET scan findings were obtained.

RESULTS

Four hundred and twenty-six patients met the study criteria, of which 86 (20.2%) patients had limited stage EAC and 340 (79.8%) had locally advanced disease. The mean age was 65.4±10.3 years of which 356 (83.6%) were men and 393 (92.3%) were White. On multivariable analysis, age (above 75 or below 65 y), dysphagia [odds ratio (OR): 2.84], weight loss (OR: 2.06), protruding tumor (OR: 2.99), and tumor size >2 cm (OR: 3.3) were predictive of locally advanced disease, while gastrointestinal bleeding (OR: 0.36) and presence of visible Barrett's esophagus (OR: 0.4) were more likely to be associated with limited stage. A nomogram for predicting the risk of locally advanced EAC was constructed and internally validated.

CONCLUSIONS

We constructed a nomogram to facilitate an individualized prediction of the risk of locally advanced EAC. This model can aid in decision making for neoadjuvant therapy in EAC.

The Epidemiology of Annular Pancreas in the United States: A Population-based Study

BACKGROUND AND AIMS

Annular pancreas is a rare congenital condition where the second part of the duodenum is encircled by pancreatic tissue. There is a scarcity of data on its natural history therefore, we aimed to evaluate the epidemiology of annular pancreas and identify underlying associations using a large database.

METHODS

A multi-institutional database (Explorys) was surveyed. A cohort of patients with a Systematized Nomenclature of Medicine-Clinical Terms diagnosis of "MRI, CT, EUS and/or ERCP" between April 2015 and April 2020 was identified. Subsequently a cohort of patients with history of "annular pancreas" was identified.

RESULTS

There were a total of 40,075,980 individuals in the database with 6,162,600 (15.38%) who had an magnetic resonance imaging, computed tomography, endoscopic retrograde cholangiopancreatography, and/or endoscopic ultrasound. There were 210 (3.4/100,000) had a diagnosis of annular pancreas. When compared with the control group, patients with annular pancreas were more likely to have a history of alcohol use, smoking, acute pancreatitis, chronic pancreatitis, gastritis, duodenitis, jaundice, and gastrointestinal outlet obstruction.

CONCLUSIONS

This is the largest study evaluating the epidemiology of annular pancreas. We found the estimated prevalence rate of annular pancreas to be 3.4/100,000 in those who had abdominal imaging. Annular pancreas was more likely to be diagnosed in patients with symptoms pertaining to acute or chronic pancreatitis, biliary, and gastric outlet obstruction.

Epidemiology of Depressive Disorders in Patients With Liver Cirrhosis: A Population-Based Study in the United States

Objective: Major depressive disorder (MDD) is a chronic, debilitating mood disorder associated with poor medical outcomes. MDD has a multifactorial etiology with numerous biopsychosocial factors implicated as risk factors. Functional and psychiatric impairments have been evaluated in patients with liver cirrhosis; however, less is known about the prevalence and risk factors for the development of MDD in those patients. The objective of this study was to evaluate the risk of developing depression among adult patients with liver cirrhosis in the United States.

Methods: Data were collected using a commercial database, an aggregate of electronic health record data from 26 major integrated US health care systems consisting of 360 hospitals in the US from 1999 to 2019.

The study cohort was retrieved by searching the database for a Systematized Nomenclature of Medicine-Clinical Terms diagnosis of "cirrhosis of liver" during the designated period of the study.

The following factors were adjusted for in the analyses: age, sex, race, smoking, alcohol, substance abuse, underlying mental disorders, and comorbidities.

Results: 56,197,690 adults were identified between 1999 and 2019. Of those, 293,150 had a diagnosis of liver cirrhosis. The prevalence of depression among those cirrhotic patients was 23.93% versus 7.61% in the noncirrhotic control group (95% CI, 16.1836%-16.4770%; P < .0001). By applying a multivariate analysis model, cirrhotic patients were found to be more likely to develop depression (odds ratio = 2.172; 95% CI, 2.159-2.185; P < .0001) compared to patients with no prior history of liver cirrhosis.

Conclusions: Liver cirrhosis is associated with increased risk of depression and is likely to be an independent risk factor in its development. Future efforts should focus on the identification and treatment of this debilitating condition in those with liver cirrhosis via an integrated care model.

The global burden of adolescent and young adult cancer in 2019: a systematic analysis for the Global Burden of Disease Study 2019

BACKGROUND

In estimating the global burden of cancer, adolescents and young adults with cancer are often overlooked, despite being a distinct subgroup with unique epidemiology, clinical care needs, and societal impact. Comprehensive estimates of the global cancer burden in adolescents and young adults (aged 15-39 years) are lacking. To address this gap, we analysed results from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019, with a focus on the outcome of disability-adjusted life-years (DALYs), to inform global cancer control measures in adolescents and young adults.

METHODS

Using the GBD 2019 methodology, international mortality data were collected from vital registration systems, verbal autopsies, and population-based cancer registry inputs modelled with mortality-to-incidence ratios (MIRs). Incidence was computed with mortality estimates and corresponding MIRs. Prevalence estimates were calculated using modelled survival and multiplied by disability weights to obtain years lived with disability (YLDs). Years of life lost (YLLs) were calculated as age-specific cancer deaths multiplied by the standard life expectancy at the age of death. The main outcome was DALYs (the sum of YLLs and YLDs). Estimates were presented globally and by Socio-demographic Index (SDI) quintiles (countries ranked and divided into five equal SDI groups), and all estimates were presented with corresponding 95% uncertainty intervals (UIs). For this analysis, we used the age range of 15-39 years to define adolescents and young adults.

FINDINGS

There were 1·19 million (95% UI 1·11-1·28) incident cancer cases and 396 000 (370 000-425 000) deaths due to cancer among people aged 15-39 years worldwide in 2019. The highest age-standardised incidence rates occurred in high SDI (59·6 [54·5-65·7] per 100 000 person-years) and high-middle SDI countries (53·2 [48·8-57·9] per 100 000 person-years), while the highest age-standardised mortality rates were in low-middle SDI (14·2 [12·9-15·6] per 100 000 person-years) and middle SDI (13·6 [12·6-14·8] per 100 000 person-years) countries. In 2019, adolescent and young adult cancers contributed 23·5 million (21·9-25·2) DALYs to the global burden of disease, of which 2·7% (1·9-3·6) came from YLDs and 97·3% (96·4-98·1) from YLLs. Cancer was the fourth leading cause of death and tenth leading cause of DALYs in adolescents and young adults globally.

INTERPRETATION

Adolescent and young adult cancers contributed substantially to the overall adolescent and young adult disease burden globally in 2019. These results provide new insights into the distribution and magnitude of the adolescent and young adult cancer burden around the world. With notable differences observed across SDI settings, these estimates can inform global and country-level cancer control efforts.

FUNDING

Bill & Melinda Gates Foundation, American Lebanese Syrian Associated Charities, St Baldrick's Foundation, and the National Cancer Institute.

Immune checkpoint inhibitor induced colitis: A nationwide population-based study

BACKGROUND

ICIs are used in the management of several malignancies. However, they can result in immune-related adverse events, such as colitis. The aim of this study is to obtain an epidemiological survey of patients who develop immune checkpoint inhibitor (ICI)-induced colitis and identify underlying risk factors.

METHODS

A cohort study was performed using Explorys, a US-based population database. Our cohort included all patients in a five-year interval on an ICI. We further identified those who developed colitis after initiating an ICI. Demographic data and possible risk factors were assessed. Odds ratios were calculated and multivariable statistical analysis was performed.

RESULTS

3.6% of patients developed ICI-induced colitis. Women [OR: 1.2; 95% CI 1.224-1.231, p <0.001], Caucasians [OR: 2.3; 2.284 - 2.299], individuals older than 65 years [OR: 1.3; 1.319 - 1.326], obese patients [OR: 3.3; 3.273 - 3.302], and those with a history of alcohol abuse [OR: 2.5; 2.485 - 2.523] were more likely to develop colitis. Patients who received Nivolumab [OR: 2.8; 2.563 - 3.022], Ipilimumab [OR: 4.9; 3.937 - 6.061], Pembrolizumab [OR 2.7; 2.463 - 2.868], and Atezolizumab [OR 2.9; 2.430 - 3.388] had an increased odds of developing colitis. The majority of cases were diagnosed in the first 6 months of therapy.

CONCLUSIONS

This is the largest study to describe the epidemiology of ICI-induced colitis and it is the first to identify underlying risk factors. Ipilimumab poses the greatest risk for ICI-induced colitis. The risk of colitis should be discussed with all patients prior to initiating an ICI, as it may be a factor in choosing among ICIs.

Epidemiology of neuroendocrine tumors of the appendix in the USA: a population-based national study (2014-2019)

Background

The appendix is the third most common place for neuroendocrine tumors (NETs) along the digestive tract and NETs are the most common neoplasms of the appendix. However, there are limited population-based data on the epidemiology of this disease. Using a large database, we sought to describe the epidemiology and risk association of NETs of the appendix.

Method

We queried a multi-institutional database (Explorys Inc., Cleveland, OH, USA), comprising 360 hospitals in the United States (US), for patients with a diagnosis of NETs of the appendix from 2014-2019.

Results

Of the 30,324,050 individuals in the database, 2020 patients had an appendiceal NET diagnosis (0.007%). The most common presenting symptoms included abdominal pain, nausea, vomiting and diarrhea. Patients with appendiceal NETs were more likely to be female (odds ratio [OR] 1.36, 95% confidence interval [CI] 1.24-1.49), Caucasian (OR 2.71, 95%CI 2.40-3.07), with a history of smoking (OR 1.82, 95%CI 1.65-2.01), family history of primary gastrointestinal malignancy (OR 7.26, 95%CI 6.31-8.33), diagnosis of multiple endocrine tumor type 1 (OR 52.31, 95%CI 23.15-118.23), or neurofibromatosis type 1 (OR 16.37, 95%CI 7.24-37.01).

Conclusions

In a population-based study in the US, using the Explorys database, we found the overall prevalence of NETs of the appendix to be 7 per 100,000 persons. The incidence in the year January 2019-January 2020 was 0.4 per 100,000 individuals. These rates are higher than previously reported and may be more accurate, given the more comprehensive nature of the Explorys database.

Clostridioides difficile infection in liver cirrhosis patients: A population-based study in United States

BACKGROUND

Clostridioides (formerly Clostridium) difficile infection (CDI) is an increasingly frequent cause of morbidity and mortality in hospitalized patients. Multiple risk factors are documented in the literature that includes, but are not limited to, antibiotics use, advanced age, and gastric acid suppression. Several epidemiological studies have reported an increased incidence of CDI in advanced liver disease patients. Some have also demonstrated a higher prevalence of nosocomial infections in cirrhotic patients.

AIM

To use a large nationwide database, we sought to determine CDI’s risk among liver cirrhosis patients in the United States.

METHODS

We queried a commercial database (Explorys Inc^TM, Cleveland, OH, United States), and obtained an aggregate of electronic health record data from 26 major integrated United States healthcare systems comprising 360 hospitals in the United States from 2018 to 2021. Diagnoses were organized into the Systematized Nomenclature of Medicine Clinical Terms (SNOMED–CT) hierarchy. Statistical analysis for the multivariable model was performed using Statistical Package for Social Sciences (SPSS version 25, IBM Corp^TM). For all analyses, a two-sided P value of < 0.05 was considered statistically significant.

RESULTS

There were a total of 19387760 patients in the database who were above 20 years of age between the years 2018-2021. Of those, 133400 were diagnosed with liver cirrhosis. The prevalence of CDI amongst the liver cirrhosis population was 134.93 per 100.000 vs 19.06 per 100.000 in non-cirrhotic patients (P < 0.0001). The multivariate analysis model uncovered that cirrhotic patients were more likely to develop CDI (OR: 1.857; 95%CI: 1.665-2.113, P < 0.0001) compared to those without any prior history of liver cirrhosis.

CONCLUSION

In this large database study, we uncovered that cirrhotic patients have a significantly higher CDI prevalence than those without cirrhosis. Liver cirrhosis may be an independent risk factor for CDI. Further prospective studies are needed to clarify this possible risk association that may lead to the implementation of screening methods in this high-risk population.

Chemoprevention in Barrett's esophagus and esophageal adenocarcinoma

There has been a dramatic increase in the incidence of Barrett's esophagus and esophageal adenocarcinoma over the past several decades with a continued rise expected in the future. Several strategies have been developed for screening and surveillance of patients with Barrett's esophagus and endoscopic treatment of Barrett's associated dysplasia and early esophageal cancer; however, they have not made a substantial impact on the incidence of cancer. Herein, chemoprevention becomes an attractive idea for reducing the incidence of cancer in Barrett's patients. Several agents appear promising in preclinical and observational studies but very few have been evaluated in randomized controlled trials. Strongest evidence to date is available for proton-pump inhibitors and Aspirin that have been evaluated in a large randomized controlled trial. Other agents such as statins, metformin, ursodeoxycholic acid, and dietary supplements have insufficient evidence for chemoprevention in Barrett's patients.

The Risk of Acute and Chronic Pancreatitis in Celiac Disease

BACKGROUND AND AIMS

Celiac disease (CD) is a chronic immune-mediated enteropathy that is precipitated by dietary gluten in genetically predisposed individuals. A few studies reported a higher incidence of pancreatitis in the CD population. Using a large US database, we sought to describe the epidemiology, risk, and outcomes of acute pancreatitis (AP) and chronic pancreatitis (CP) in CD patients.

METHODS

We queried a multiple health system data analytics and research platform (Explorys Inc, Cleveland, OH, USA). A cohort of patients with a diagnosis of CD was identified. Subsequently, individuals who developed a new diagnosis of AP and CP after at least 30 days of being diagnosed with CD were identified. A multivariate regression model was performed to adjust for multiple confounding factors.

RESULTS

Of the 72,965,940 individuals in the database, 133,400 (0.18%), 362,050 (0.50%), and 95,190 (0.13%) had CD, AP, and CP, respectively. New diagnosis of AP and CP after at least 30 days of CD diagnosis was 1.06%, 0.52%, respectively, compared to non-CD patients with 0.49% for AP and 0.13% for CP, P < .0001. In multivariate regression analysis, patients with CD were at higher risk of developing AP [OR 2.66; 95% CI 2.55-2.77] and CP [OR 2.18; 95% CI 2.04-2.34]. Idiopathic AP was the most common etiology among CD patients [OR 1.54; 95% CI 1.34-1.77].

CONCLUSIONS

In this largest US population database and after adjusting for several confounders, patients with CD were at increased risk of developing AP and CP. Celiac disease patients had worse outcomes and higher medical burden compared to non-CD patients. Recurrent abdominal pain that suggests pancreatic etiology, idiopathic pancreatitis, or elevation of pancreatic enzymes should warrant investigation for CD as a potential cause of pancreatic disease.

Epidemiology and risk of psychiatric disorders among patients with celiac disease: A population-based national study

BACKGROUND AND AIM

Celiac disease (CD) is a chronic disorder resulting from an immune reaction to gluten in genetically predisposed individuals. Although several studies have linked CD to psychiatric diseases, there are limited data on this topic. Using a large database, we sought to describe the epidemiology of several psychiatric disorders in CD.

METHODS

We queried a multicenter database (Explorys Inc), an aggregate of electronic health record data from 26 major integrated healthcare systems from 2016 to 2020 consisting of 360 hospitals in the USA. A cohort of patients with a Systematized Nomenclature Of Medicine - Clinical Terms diagnosis of CD was identified. Multivariate analysis was performed using Statistical Package for Social Sciences version 25.

RESULTS

Of the 37 465 810 patients in the database between 2016 and 2020, there were 112 340 (0.30%) individuals with CD. When compared with patients with no history of CD, patients with CD were more likely to have a history of anxiety (odds ratio [OR]: 1.385; 95% confidence interval [CI]: 1.364-1.407), depression (OR: 1.918; 95% CI: 1.888-1.947), bipolar (OR: 1.321; 95% CI: 1.289-1.354), attention-deficit hyperactivity disorder (OR: 1.753; 95% CI: 1.714-1.792), eating disorder (OR: 15.84; 95% CI: 15.533-16.154), and childhood autistic disorder (OR: 4.858; 95% CI: 3.626-6.508). Patients with CD and psychiatric conditions were more likely to be smokers, with history of alcohol and substance abuse as well as a history of personality disorder.

CONCLUSIONS

In this large database, patients with CD are at increased risk of having multiple psychiatric diseases including anxiety, depression, bipolar, attention-deficit hyperactivity disorder, eating disorder, and childhood autism. Individual care and referral to psychiatry when appropriate are warranted while taking care of this group of patients.

Implications of artificial intelligence in inflammatory bowel disease: Diagnosis, prognosis and treatment follow up

Driven by the tremendous availability of data, artificial intelligence (AI) using deep learning has emerged as a breakthrough computer technology in the last few decades and has recently been acknowledged by the Task Force on AI as a golden opportunity for research. With its ability to understand, learn from and build on non-linear relationships, AI aims to individualize medical care in an attempt to save time, cost, effort and improve patient’s safety. AI has been applied in multiple medical fields with substantial progress made in gastroenterology mainly to facilitate accurate detection of pathology in different disease processes, among which inflammatory bowel disease (IBD) seems to drag significant attention, specifically by interpreting imaging studies, endoscopic images and videos and -to a lesser extent- disease genomics. Moreover, models have been built to predict IBD occurrence, flare ups, persistence of histological inflammation, disease-related structural abnormalities as well as disease remission. In this article, we will review the applications of AI in IBD in the present medical literature at multiple points of IBD timeline, starting from disease prediction via genomic assessment, diagnostic phase via interpretation of radiological studies and AI-assisted endoscopy, and the role of AI in the evaluation of therapy response and prognosis of IBD patients.

Pancreatic manifestations in rheumatoid arthritis: a national population-based study

OBJECTIVES

RA is a systemic autoimmune disease characterized by persistent joint inflammation. Extra-articular manifestations of RA can involve different organs including the gastrointestinal (GI) system. Using a large database, we sought to describe the epidemiology of pancreas involvement in RA.

METHODS

We queried a multicentre database (Explorys Inc, Cleveland, OH, USA), an aggregate of electronic health record data from 26 major integrated US healthcare systems in the US from 1999 to 2019. After excluding patients younger than 18, a cohort of individuals with Systematized Nomenclature of Medicine - Clinical Terms (SNOMED-CT) diagnosis of RA was identified. Within this cohort, patients who developed a SNOMED-CT diagnosis of acute pancreatitis (AP), chronic pancreatitis (CP) and primary pancreatic cancer (PaCa) after at least 30 days of RA diagnosis were identified. Statistical analysis for multivariate model was performed using Statistical Package for Social Sciences (SPSS version 25, IBM Corp) to adjust for several factors.

RESULTS

Of the 56 183 720 individuals in the database, 518 280 patients had a diagnosis of RA (0.92%). Using a multivariate regression model, patients with RA were more likely to develop AP [odds ratio (OR): 2.51; 95% CI: 2.41, 2.60], CP (OR: 2.97; 95% CI: 2.70, 3.26) and PaC (OR: 1.79; 95% CI: 1.52, 2.10).

CONCLUSION

In this large database, we found a modest increased risk of AP and CP among patients with RA after adjusting for the common causes of pancreatitis. Further studies are required to better understand this association and the effect of medications used for RA.

Lower Rates of Colorectal Cancer in Patients With Inflammatory Bowel Disease Using Anti-TNF Therapy

BACKGROUND

Chronic inflammation is a key factor for the development of colorectal cancer (CRC) among patients with inflammatory bowel disease (IBD). Despite the increased use of biologic agents in patients with IBD, their impact on colorectal carcinogenesis remains unclear. With the use of a large database, we sought to describe the effect of biologics on CRC among patients with IBD.

METHODS

We evaluated a multicenter database (Explorys) consisting of electronic medical records from several U.S. hospitals between 1999 and 2020. A cohort of patients with a diagnosis of IBD was identified. We performed a multivariate analysis to adjust for multiple factors including medical and surgical therapies.

RESULTS

There were a total of 62,007,510 patients in the database between 1999 and 2020. Amongst those, 225,090 (0.36%) individuals had Crohn's disease and 188,420 (0.30%) had ulcerative colitis. After adjusting for confounding factors using multivariate analysis, patients with IBD were more likely to develop CRC. Among the IBD cohort, patients treated with anti-TNF agents were less likely to develop CRC; patients with Crohn's disease: odds ratio, 0.69; 95% confidence interval, 0.66-0.73; P < 0.0001 vs patients with ulcerative colitis: odds ratio, 0.78; 95% confidence interval, 0.73-0.83; P < 0.0001.

CONCLUSIONS

Patients with IBD who were treated with anti-tumor necrosis factor agents were less likely to develop CRC. Prospective studies are needed to evaluate whether anti-tumor necrosis factor drugs provide a chemoprotective effect in patients with IBD by inflammation control and mucosal healing.

Epidemiology of gallbladder cancer in the Unites States: a population-based study

BACKGROUND

Gallbladder cancer (GBC) is the most common neoplasm of the biliary tract with the lowest rates of survival. Most GBCs are adenocarcinomas that arise from the epithelial lining of the gallbladder. There are limited data in the literature regarding the epidemiology of GBC. Using a large database, we aim to describe the epidemiology using a US population database.

METHODS

A multi-institutional database (Explorys Inc., Cleveland, OH, USA) was surveyed. A cohort of patients with a primary malignant neoplasm of gallbladder between 1999-2019 was identified. The prevalence rate was calculated and age-, race-, and sex-based distributions were described. Multivariate analysis was done to evaluate underlying associations.

RESULTS

Of the 56,197,690 individuals in the database, 4,790 individuals with GBC were identified with a prevalence rate of 8.5 per 100,000. Asian race has the highest prevalence of GBC (13.6/100,000). Patients with GBC were also more likely to be smokers, have a history of alcohol abuse, obesity, diabetes, cholelithiasis, chronic cholecystitis, primary sclerosing cholangitis (PSC), and chronic viral hepatitis.

CONCLUSIONS

This is one of the largest US population studies to date evaluating the epidemiology of GBC. The 20-year period prevalence rate of GBC was 8.5 per 100,000. Patients with GBC were more likely to be elderly, females, obese, diabetic, and have chronic hepatobiliary disorders.

Increasing Prevalence of Anxiety and Depression Disorders After Diagnosis of Chronic Pancreatitis: A 5-Year Population-Based Study

OBJECTIVES

Chronic pancreatitis (CP) is often associated with poor quality of life. Only a few small associative studies have reported the prevalence of mood disorders in CP. Using a large database, we sought to describe the epidemiology and risk association of anxiety and depression in CP and evaluate their outcomes.

METHODS

A multicenter database (Explorys), an aggregate of electronic health record data from 26 US healthcare systems, was surveyed. A cohort of patients with a diagnosis of CP between 2014 and 2019 was identified. Within this cohort, rates of anxiety and depression were calculated. Demographics, comorbidities, and outcomes were described.

RESULTS

Of the 30,276,810 individuals in the database (2014-2019), 67,260 patients had a CP diagnosis (0.22%). When compared with patients with no history of CP, patients with CP were more likely to develop anxiety (odds ratio, 6.94; 95% confidence interval, 6.85-7.04) and depression (odds ratio, 5.09; 95% confidence interval, 5.01-5.17). Chronic pancreatitis patients with depression had an increased risk of suicidal ideation compared with controls.

CONCLUSIONS

Patients with CP are at a higher risk of developing anxiety and depression compared with those without CP, with overall worse outcomes. Clinicians should screen CP patients and make appropriate referral to psychiatry when indicated.

Prevalence of Myocardial Infarction in Patients With Chronic Pancreatitis

OBJECTIVE

We conducted this study to ascertain whether chronic inflammation secondary to chronic pancreatitis (CP) has any association with myocardial infarction(MI).

METHODS

Data were collected from a commercial database (Explorys, Inc, IBM Watson, Ohio). Adults with the diagnosis of "chronic pancreatitis," based on Systematized Nomenclature of Medicine-Clinical Terms, were included in the CP group, and the rest of the patients were included in the non-CP group. The prevalence of MI was compared in both groups, and statistical multivariate model was performed.

RESULTS

A total of 28,842,210 patients were included in the study. The overall prevalence of MI was 14.22% in the CP group as compared with 3.23% in the non-CP group (P < 0.0001). In the multivariate analysis, the odds ratio (OR) for MI in CP group was 1.453 (95% confidence interval, 1.418-1.488, P < 0.0001). Hypertension was a strong predictor for MI in the CP group with an OR of 3.2 (95% confidence interval, 3.0-3.5), followed by chronic kidney disease, older than 65 years, dyslipidemia, diabetes mellitus, obesity, alcohol abuse, smoking, White race, and male sex.

CONCLUSIONS

This study showed that CP is associated with comorbidities, which can increase the prevalence and OR of MI.

Pyloroplasty and the risk of Barrett's esophagus in patients with gastroparesis

Barrett's esophagus (BE), a consequence of gastroesophageal reflux disease (GERD), is a premalignant condition for esophageal adenocarcinoma. Impaired gastric emptying leads to increased gastric volume and therefore more severe reflux. We seek to investigate the association between gastroparesis and BE and the predictors of BE among patients with gastroparesis. This is a retrospective review of patients seen at Cleveland Clinic between 2011 and 2016 who had an upper endoscopy and a gastric emptying study. Demographics, symptoms, medications, endoscopic and histological findings, and therapeutic interventions were abstracted. Risk of BE among gastroparesis group and control group was assessed, and logistic regression analysis was performed to identify predictors of BE among gastroparesis patients. Of the 4,154 patients, 864 (20.8%) had gastroparesis and 3, 290 (79.2%) had normal gastric emptying. The mean age was 51.4 ± 16.4 years, 72% were women and 80% were Caucasians. Among the gastroparesis group, 18 (2.1%) patients had BE compared to 71 (2.2%) cases of BE in the control group, P = 0.89. There were no differences in gender, race, reflux symptoms, or esophageal findings between the two groups. Among gastroparesis group, predictors of developing BE were a history of alcohol use (odds ratio [OR] 6.76; 95% confidence intervals [CI]: 1.65-27.67, P = 0.008), history of pyloroplasty (OR: 8.228; CI: 2.114-32.016, P = 0.002), and hiatal hernia (OR: 8.014; CI: 2.053-31.277, P = 0.003). Though gastroparesis is a known contributing factor for GERD, there was no increased prevalence of BE in gastroparesis. Among patients with gastroparesis, predictors of BE are history of alcohol use, hiatal hernia, and pyloroplasty.

Successful liver transplantation for acute sickle cell intrahepatic cholestasis: A case report and review of the literature

BACKGROUND

Sickle cell hepatopathy (SCH) is an inclusive term referring to any liver dysfunction among patients with sickle cell disease. Acute sickle cell intrahepatic cholestasis is one of the rarest and most fatal presentations of SCH. We present the 23rd reported case of liver transplantation (LT) for SCH; a rare case of acute sickle cell intrahepatic cholestasis managed with LT from a hepatitis C virus (HCV) nucleic acid amplification test positive donor.

CASE SUMMARY

A 29-year-old male with a past medical history of sickle cell disease presented with vaso-occlusive pain crisis. On examination, he had jaundice and a soft, non-tender abdomen. Initially he was alert and fully oriented; within 24 h he developed new-onset confusion. Laboratory evaluation was notable for hyperbilirubinemia, leukocytosis, anemia, thrombocytopenia, acute kidney injury and elevated international normalized ratio (INR). Imaging by ultrasound and computed tomography scan suggested a cirrhotic liver morphology with no evidence of biliary ductal dilatation. The patient was diagnosed with acute sickle cell intrahepatic cholestasis after excluding competing etiologies of acute liver injury. He underwent LT from an HCV nucleic acid amplification test positive donor 9 d after initial presentation. The liver explant was notable for widespread sinusoidal dilatation with innumerable clusters of sickled red blood cells and cholestasis. On postoperative day 3, HCV RNA was detectable in the patient's peripheral blood and anti-HCV therapy with glecaprevir/pibrentasvir was initiated on postoperative day 23. He subsequently achieved sustained virologic response after completing 3 mo of therapy and has been followed clinically for 12 mo post-transplant.

CONCLUSION

This case highlights the utility of LT as a viable treatment option for acute sickle cell intrahepatic cholestasis.

Distribution of D1S80 alleles in the Bahrainian population

This study demonstrates that the locus D1S80 is highly polymorphic in the Bahrainian population. There were 24 different D1S80 alleles and 51 distinct genotypes observed in 198 Bahrainians. There was one allele observed that was smaller than the 14 repeat allele. This data set meets the Hardy-Weinberg expectations (HWE) and could be a useful marker for parentage testing and forensic applications.