Depression and the Aberrant Intestinal Microbiome

Depression is one of the most common mental health disorders affecting adults in the United States. The current treatment is the combination of pharmacotherapy and psychotherapy. Recently, the evidence linking gut microbiome dysregulation to the development of depression has grown. The pathophysiology is currently poorly understood, although leading hypotheses include involvement of the hypothalamic-pituitary-adrenal axis, a bidirectional relationship between the gut microbiome and the central nervous system, and production of signaling molecules by the gut microbiome. Available and emerging treatments of the aberrant microbiome include antidepressants, antibiotics, diet modification, probiotics, and fecal microbiota transplant. This article explores the interconnectivity of gut microbiota and depression and treatments targeted toward the gut, reviews the gastroenterologist's potential role in managing gut dysbiosis in patients with depression, and highlights research topics to be addressed to create evidence-based guidelines.

Cannabis Use in Patients with Gastroparesis

Aim: The primary aim was to determine the prevalence of cannabis use among patients hospitalized for gastroparesis. The secondary aim was to identify independent variables associated with cannabis use compared with noncannabis-related gastroparesis hospitalization. Methods: We use the nationwide inpatient sample database from January 2012 to December 2014. The patients included in this study were the ones with primary diagnosis of gastroparesis and cannabis use. The analysis was performed using the Statistical Package for the Social Sciences 27 (SPSS) and a multivariable regression was conducted to identify independent variables. Results: We found 50,170 patients with a primary diagnosis of gastroparesis. The prevalence of cannabis use among patients hospitalized for gastroparesis was 4.2%. Multivariate regression analysis was performed, adjusting for confounders. The variables found to increase the odds of cannabis use in gastroparesis populations independently were age interval of 18-35 and 36-50 years, male, Black and Asian, median household income 1-25th percentile, Medicaid insurance, no charge hospitalization, and smoking. Cannabis use was associated with lower odds of vomiting. Conclusion: Patients who used cannabis were younger and of African American, Asian, or Pacific Islander descent. They had Medicaid insurance and a lower median household income.

Rare Association of Autoimmune Limbic Encephalitis and Stiff Person Syndrome

Antibodies to Glutamic Acid Decarboxylase (GAD) have been implicated in the pathogenesis of both autoimmune Limbic Encephalitis (LE) and Stiff Person Syndrome (SPS). However, their association is quite rare. We present a case of a 48-year-old Caucasian female who presented with symptoms of recurrent severe headaches, behavioral and cognitive dysfunction, and an episode of seizure. She was found to have high titers of anti-GAD65 antibodies in both cerebrospinal fluid and serum. She was diagnosed with LE and SPS, and was started on immunosuppressive therapy with steroids and intravenous immunoglobulins (IVIG). The patient responded well to treatment with improvement in her symptoms.

Gastrointestinal hemorrhage in the setting of gastrointestinal cancer: Anatomical prevalence, predictors, and interventions

BACKGROUND

Gastrointestinal hemorrhage (GIH) is a common complication with gastrointestinal cancers (GIC). There is no comprehensive research that examines GIH in different types of GIC.

AIM

To study the prevalence, predictors, and interventions of GIH based on the anatomical location of GIC.

METHODS

This is a retrospective analysis of the 2016-2018 National Inpatient Sample database, the largest inpatient care database in the United States. All adult inpatients (≥ 18-year-old) were included. ICD-10-CM codes were used to identify patients with GIH and GIC. Prevalence of GIH was obtained based on the anatomical location of GIC. Predictors of GIH in the GIC population were studied using multivariate analysis. Interventions including endoscopy were compared to the non-intervention group to determine the differences in inpatient mortality.

RESULTS

Out of a total of 18173885 inpatients, 321622 (1.77%) cases had a diagnosis of GIC. Within GIC patients, 30507 (9.5%) inpatients had GIH, which was significantly (P < 0.001) more than the prevalence of GIH in patients without GIC (3.4%). The highest to lowest GIH rates are listed in the following order: Stomach cancer (15.7%), liver cancer (13.0%), small bowel cancer (12.7%), esophageal cancer (9.1%), colorectal cancer (9.1%), pancreatic cancer (7.2%), bile duct cancer (6.0%), and gallbladder cancer (5.1%). Within gastric cancer, the GIH rate ranged from 14.8% in cardia cancer to 25.5% in fundus cancer. Within small bowel cancers, duodenal cancers had a higher GIH rate (15.6%) than jejunal (11.1%) and ileal cancers (5.7%). Within esophageal cancers, lower third cancers had higher GIH (10.7%) than the middle third (8.0%) or upper third cancers (6.2%). When studying the predictors of GIH in GIC, socioeconomic factors such as minority race and less favorable insurances (Medicaid and self-pay) were associated with significantly higher GIH on multivariate analysis (P < 0.01). Chemotherapy and immunotherapy were also identified to have a lower risk for GIH [odds ratios (OR) = 0.74 (0.72-0.77), P < 0.001]. Out of 30507 GIC inpatients who also had GIH, 16267 (53.3%) underwent an endoscopic procedure, i.e., upper endoscopy or colonoscopy. Inpatient mortality was significantly lower in patients who underwent endoscopy compared to no endoscopy [5.5% vs 14.9%, OR = 0.42 (0.38-0.46), P < 0.001].

CONCLUSION

The prevalence of GIH in patients with GIC varies significantly based on the tumor’s anatomical location. Endoscopy, which appears to be associated with a substantial reduction in inpatient mortality, should be offered to GIC patients with GIH. Nevertheless, the decision on intervention in the GIC population should be tailored to individual patient's goals of care, the benefit on overall care, and long-term survival.

Chronic Hypotension Due to Thrombosis of an Inferior Vena Cava Filter

Inferior vena cava filters (IVCF) are associated with many long-term complications. Often, these complications manifest as acute events, such as shock. However, we report a case of a patient who presented with chronic hypotension and dizziness due to a thrombosed IVCF filter.

Safety and efficacy of dual versus triple antithrombotic therapy in Patients with atrial fibrillation undergoing percutaneous coronary intervention: A meta-analysis

BACKGROUND

Patients with atrial fibrillation undergoing percutaneous coronary intervention have indications for oral anticoagulation and dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 receptor inhibitor. The concurrent use of all three agents, termed triple oral antithrombotic therapy (TAT), increases the risk of bleeding. A number of prospective trials showed that the omission of aspirin mitigates the risk of bleeding without affecting major adverse cardiovascular event (MACE).

MATERIALS AND METHODS

The databases of PubMed, Embase, and Cochrane Central databases were searched from inception to October 2019. Relevant randomized control trials comparing dual antithrombotic therapy (DAT) versus TAT were identified and a metanalysis was performed using random-effect model. The safety endpoints of interest were thrombolysis in myocardial infarction criteria (TIMI) major and minor bleeding, TIMI major bleeding, and intracranial bleeding. The efficacy endpoints of interest were MACE and individual components of MACE.

RESULTS

Six trials with 11,722 patients were included. For safety endpoint, DAT was associated with significantly lower incidence of TIMI major and minor bleeding [RR: 0.58, 95% CI 0.44-0.77, P = 0.0001], TIMI major bleeding [RR: 0.55, 95% CI 0.42-0.73, P < 0.0001] as well as intracranial bleeding [RR: 0.35, 95% CI 0.16-0.73, P = 0.006] compared with TAT. No significant difference was observed for MACE [RR: 0.96 (0.79-1.17) P = 0.71] or any of the individual components of MACE between the two groups.

CONCLUSION

Omission of aspirin from TAT in patients with Atrial Fibrillation (AF) after percutaneous coronary intervention is associated with lower risk of bleeding without compromising the efficacy in terms of mortality and cardiovascular thrombotic events.

Efficacy and Safety of Intragastric Balloon Placements in 1600 Case, an Experience from the Middle East

BACKGROUND AND PURPOSE

Intragastric balloons are used as a treatment for obesity. Much of the data collected on balloons had been in the context of clinical trials in academic medical centers or as a bridge to bariatric surgery in obesity centers. The aim of this study was to investigate the efficacy and safety of balloon treatment in private practice.

STUDY DESIGN

This is an interventional study.

SUBJECTS

The study included 1600 patients.

PLACE

The study was conducted at the ElKatib Hospital.

METHOD

This was a retrospective analysis of 6-month weight loss data and balloon-related complications of patients referred to a private center for obesity treatment.

ASSESSMENT

The assessment was carried out by obtaining full patients' history (personal history, present illness, and previous drug history and operations). Laboratory work was done in the form of CBC, blood sugar, and viral markers. Bioenterics Intragastric Balloon (BIB) silicone balloon was used, filled with saline plus methylene blue dye with a volume ranging from 400 to 700 ml. The gained measures were analyzed by using SPSS program, and paired t test and chi-square test were used to compare between groups.

RESULTS

A total of 1600 patients were included (368 male (23%) and 1232 female (77%)) with mean age 34.1 ± 10.354, mean body weight 112.45 ± 26.24, and mean body mass index (BMI) 40.32 ± 8.17. There were 46 patients younger than 18 years and 12 patients older than 60 years. There were 109 patients with a BMI ranging from 25 to < 35 and 737 patients with a BMI ≥ 40 kg/m². A total of 1567 patients who attended weight consultation had a mean weight loss 17.35 ± 11.07 from intragastric balloon implantation. Thirty-three patients from the total sample were not weighted after the removal of the balloon (dropped out). Percentage excess weight loss (% EWL) = 100% × (baseline absolute weight (AW)-last weight)/(baseline AW-initial body weight (IBW)) was found, and weight loss of more than 10% was considered significant. About 49.3% of patients showed significant weight loss > 10%, 24.7% of patients showed weight loss > 20%, while 26% of patients showed no significant weight loss < 10%.

CONCLUSION

Intragastric balloons on their own, with an intensive lifestyle program and supportive consultations, resulted in safe and short-term substantial weight loss, and may fill the therapeutic gap between pharmacotherapy and surgery.

Nonmetastatic renal cell carcinoma presenting with persistent cough: Case report with literature review

Renal cell carcinomas (RCC), constitute 80– 85% of primary renal neoplasms. The classic triad of RCC (flank pain, hematuria, and a palpable abdominal renal mass) occurs in approximately 9% of patients; it strongly suggests locally advanced disease. RCC may also be associated with a number of paraneoplastic syndromes. These are typically due to ectopic production of various hormones. We present a 69-year-old male patient previously healthy presented to the emergency department with recurrent persistent cough. A non-metastatic RCC was incidentally discovered. Eventually, he underwent left radical nephrectomy. One year has passed with no cough. This is a rare and unusual presentation of RCC that falls under the category of paraneoplastic syndrome with review of similar reported cases and summary of all paraneoplastic syndromes associated with RCC in literature.

Retrospective Analysis Confirms Tetracycline Quadruple as Best Helicobacter pylori Regimen in the USA

BACKGROUND

Declining Helicobacter pylori (H. pylori) eradication rates have prompted a switch in first-line therapy from standard triple (PPI, clarithromycin, and amoxicillin) to bismuth-based quadruple therapy. A caveat of the ACG 2017 H. pylori treatment guidelines was a paucity of recent US eradication data.

AIM

To determine Rhode Island H. pylori eradication data, in the largest US study from the last two decades.

METHODS

Electronic records were queried for patients with H. pylori infection diagnosed by pathology, urea breath test, or stool antigen from 2015 to 2017. Demographics, diagnostic test, treatment regimen, and test of cure were extracted. Eradication rates were calculated, and treatment regimens were compared.

RESULTS

A total of 1710 patients were identified (64% female): 825 (46%) diagnosed by breath test, 755 (42%) by biopsy, and 191 (12%) by stool antigen. Full data were obtained on 1101 patients. Seven regimens were used: quadruple (64%), triple (25%), doxycycline quadruple (5%), and miscellaneous (6%). Quadruple was superior to triple: (85% vs. 75%, P = 0.002), quadruple 14 days versus triple 14 days (87% vs. 79%, P = 0.0052), quadruple 10 days versus triple 10 days (77% vs. 67%, P = 0.33). Increased therapy length improved eradication (quadruple 14 days  vs. 10 days, 87% vs. 77%, P = 0.002; triple 14 days  versus 10 days 79% vs. 67%, P = 0.13). Finally, substituting doxycycline for tetracycline yielded lower eradication (85% vs. 67%, P = 0.006).

CONCLUSION

Quadruple therapy is superior to triple therapy within the Rhode Island population. Fourteen-day therapy achieves superior eradication compared to 10-day therapy, and doxycycline is inferior to tetracycline for quadruple therapy. Our findings support adherence to ACG and international guidelines advising 14-day quadruple therapy.

Computed Tomography Scan Overestimates the Size of Pericardial Effusion Compared to Echocardiography

Objective: Pericardial effusion is not an uncommon finding in hospitalized patients. Many pericardial effusions are found incidentally through computed tomography (CT) performed for other indications. Echocardiography is usually ordered when an incidentally discovered pericardial effusion is found on the CT to examine the effect of the effusion on hemodynamics and to detect early signs of tamponade. However, in clinical practice, the discrepancy between CT and echocardiography regarding the size of pericardial effusions is common. The accuracy of CT in the evaluation of the size of pericardial effusions is not well-studied. Our study aims to evaluate the accuracy of CT in assessing the size of a pericardial effusion compared with the gold standard echocardiography.

Methods: This is a retrospective study examining patients presenting to the University of Toledo Medical Center (UTMC) with pericardial effusions. One hundred and forty-one patient charts were reviewed and 45 subjects were excluded. Ninety-six patients in whom both CT and echocardiography were performed were enrolled in the final analysis. The time interval between both imaging modalities was limited to less than 14 days and no interventions on the effusion (e.g., pericardiocentesis) occurred in the time interval between the two imaging modalities.

Results: The size of the pericardial effusion was assessed similarly between CT and echocardiography in 50% of the cases (48/96). In the other half of the study population, the results were discrepant; CT was found to overestimate the size of pericardial effusion in 44% of the cases (42/96). The agreement rate between the two modalities is significantly low kappa = 0.111, P = 0.028.

The independent variables age, gender, body mass index (BMI), use of anticoagulants, and renal function had no effect on the agreement between CT and echocardiography.

Conclusion: Computerized tomography tends to overestimate the size of the pericardial effusion compared to echocardiography. Based on an incidental finding of pericardial effusion on CT scan, this discrepancy should be recognized prior to ordering an echocardiogram. Echocardiography can be considered in relevant clinical settings.

Critical Care Utilization in Patients with Diabetic Ketoacidosis, Stroke, and Gastrointestinal Bleed: Two Hospitals Experience

Introduction: Intensive Care Units (ICUs) are among the most expensive components of hospital care. Experts believe that ICUs are overused; however, hospitals vary in their ICU admission rate. Our hypothesis is based on clinical observations that many patients with diabetic ketoacidosis (DKA), stroke, and gastrointestinal (GI) bleeding admitted to the ICU don’t really need it and could be managed safely in a non-ICU level of care. Reducing inappropriate admissions would reduce healthcare costs and improve outcomes. Our primary objective was to determine the frequency of inappropriate ICU admissions. Secondary objectives were to evaluate which diagnoses were more unnecessarily admitted to the ICU, evaluate different variables and comorbidities, and determine the mortality rates during ICU admissions.

Methods: Patients admitted to the ICU, from the Emergency Department (ED) or transferred from the floor, during a one-year period were evaluated in this retrospective study. Patients 18-years old and above who had an admitting diagnosis of DKA, GI bleed, ischemic stroke, or hemorrhagic stroke were included. Patients in a comatose state, intubated, on vasopressors, hemodynamically unstable or had an unstable comorbid disease, subarachnoid hemorrhage, surgery during hospitalization prior to the ICU admission were excluded. Patients were categorized as having an appropriate or inappropriate ICU admission based on our institutional ICU admission criteria and data from available literature and guidelines.

Results: A total of 95 patients were included in our cohort. Seventy-two out of 95 (76%) were considered as inappropriate ICU admissions. When comparing each of the four admitting diagnoses, a significantly higher proportion of DKA patients were considered inappropriate ICU admissions when compared to the other diagnoses (P = 0.001). The overall mortality rate of ICU admissions was 16%, 15 patients out of 95 study population. When comparing each of the four admitting diagnoses, there was a significant difference in mortality rate with DKA having the lowest mortality (3%) and GI bleed having the highest mortality (43%). Out of the 15 patients who died, only 1 patient was categorized as an inappropriate ICU admission.

Conclusions: More than three-quarters of our study population was admitted to the ICU inappropriately. Incorporating severity scores in ICU admission criteria could improve the appropriateness of ICU admission and financial feasibility.

This article is based on a poster: Alsamman S, Alsamman MA, Castro M, Koselka H, Steinbrunner J: ICU admission patterns in patients with DKA, stroke and GI bleed: do they all need ICU? J Hosp Med. March 2015.