Publications by authors named "Pavani Garlapati"

28 Publications

  • Page 1 of 1

Outcomes of diverticulitis in patients with tobacco smoking: a propensity-matched analysis of nationwide inpatient sample.

Int J Colorectal Dis 2021 May 7;36(5):1033-1042. Epub 2021 Jan 7.

Department of Gastroenterology, SUNY Upstate Medical University, Syracuse, NY, USA.

Background: Recent data shows a significantly increased risk of diverticulosis among smokers. There is limited data on the association between tobacco smoking and diverticulitis. We aim to determine in-hospital outcomes, length of hospital stay, and resource utilization in a contemporary cohort of diverticulitis patients based on tobacco smoking status.

Methods: A retrospective analysis was performed by utilizing the National Inpatient Sample database (2016 and 2017) and the International Classification of Diseases, Tenth Revision codes to identify the patients with the principal diagnosis of diverticulitis and smoking. We assessed all-cause in-hospital mortality, morbidity, length of hospital stay (LOS), and total costs between propensity-matched groups of tobacco smokers vs. nonsmokers with diverticulitis.

Results: We identified 442,273 diverticulitis patients, of whom 96,864 were tobacco smokers, and 345,409 were nonsmokers. Between the two groups, in-hospital mortality was not significant (OR 1.09, 95% CI 0.38-2.6; P = 0.98). Tobacco smokers with diverticulitis have higher odds of lower gastrointestinal bleeding (LGIB) (OR 1.6, 95% CI 1.4-3.8; P = 0.01), peritonitis (OR 1.5, 95% CI 1.9-3.3; P = 0.00), intestinal obstruction (OR 1.6, 95% CI 2.8-7.6; P = 0.00), sepsis (OR 2.1, 95% CI 1.05-4.4; P = 0.03), and shock requiring vasopressor (OR 1.5, 95% CI 1.2-2.2; P = 0.00). In tobacco smokers with complicated diverticulitis, there were higher odds of LGIB (OR 1.4, 95% CI 1.2-1.6; P = 0.00), sepsis (OR 2.1, 95% CI 1.05-4.4; P = 0.03), and colectomy (OR 1.2, 95% CI 1.1-1.2; P = 0.00). In-hospital mortality was not significant in smokers with complicated diverticulitis (OR 1.2, 95% CI 0.78-1.9; P = 0.3).

Conclusions: In this propensity-matched analysis, there was no difference in in-hospital mortality between tobacco smokers vs. nonsmokers with diverticulitis. Smoking has been associated with an increased incidence of complications in diverticulitis with a higher length of hospital stay and resource utilization.
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http://dx.doi.org/10.1007/s00384-020-03805-6DOI Listing
May 2021

Outcomes of oesophageal variceal bleeding among patients with atrial fibrillation: a propensity-matched analysis of a nationwide inpatient sample.

Arch Med Sci Atheroscler Dis 2020 14;5:e255-e262. Epub 2020 Sep 14.

Westchester Medical Centre and New York Medical College, Valhalla, NY, USA.

Introduction: We aimed to determine the influence of atrial fibrillation (AF) on mortality, morbidity, length of hospital stay, and resource utilisation in patients with oesophageal variceal bleeding (OVB).

Material And Methods: The National Inpatient Sample database (2016 and 2017) was used for data analysis using the International Classification of Diseases, Tenth Revision codes to identify patients with the principal diagnosis of OVB and AF. We assessed the all-cause in-hospital mortality, morbidity, predictors of mortality, length of hospital stay (LOS), and total costs between propensity-matched groups of OVB with AF vs. OVB alone.

Results: We identified 80,325 patients with OVB, of whom 4285 had OVB with AF, and 76,040 had OVB only. The in-hospital mortality was higher in OVB with AF (OR = 1.4, 95% CI: 1.09-1.83; < 0.001). OVB with AF had higher odds of sepsis (OR = 1.4, 95% CI: 1.1-1.8; = 0.007), acute kidney injury (OR = 1.2, 95% CI: 1.12-1.32; < 0.001), and mechanical ventilation (OR = 1.2, 95% CI: 1.12-1.32; < 0.001). Advanced age (OR = 1.06, 95% CI: 1.05-1.07; < 0.001), congestive heart failure (OR = 1.7, 95% CI: 1.3-2.3; < 0.001), coronary artery disease (OR = 1.4, 95% CI: 1.03-1.92; = 0.02), and sepsis (OR = 1.3, 95% CI: 1.06-1.70; = 0.01) were identified as predictors of mortality in OVB with AF. Mean LOS (7.5 ±7.4 vs. 6.0 ±7.2, < 0.001) and mean total costs ($25,452 vs. $21,109, < 0.001) were also higher.

Conclusions: In this propensity-matched analysis, OVB with AF was associated with higher odds of in-hospital mortality, sepsis, acute kidney injury, and mechanical ventilation.
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http://dx.doi.org/10.5114/amsad.2020.98949DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7717439PMC
September 2020

Outcomes of in Patients with Vitamin D Deficiency: A Propensity-Matched National Inpatient Sample Analysis.

South Med J 2020 Nov;113(11):593-599

From the Department of Internal Medicine, Interfaith Medical Center, Brooklyn, New York, the Department of Internal Medicine, Division of Medical Oncology, Ashland Bellefonte Cancer Center, Ashland, Kentucky, the Division of Nephrology, The Nephrology Group, Fresno, California, and the Department of Internal Medicine, Division of Rheumatology, Adventist Medical Center, Hanford, California.

Objectives: We aimed to determine in-hospital outcomes, length of hospital stay, and resource utilization in a contemporary cohort of infection (CDI) and vitamin D deficiency (VDD).

Methods: The National Inpatient Sample database for 2016 and 2017 was used for data analysis using () codes to identify the patients with the principal diagnosis of CDI and VDD. We assessed the all-cause in-hospital mortality, morbidity, length of hospital stay (LOS), and total costs between propensity-matched groups of CDI without VDD versus CDI with VDD.

Results: We identified 202,234 patients with CDI, 4515 of whom were patients with VDD and 197,719 of whom were without VDD. After propensity matching, there was no difference in the in-hospital mortality between the two groups (odds ratio [OR] 1.5, 95% confidence interval [CI] 0.58-4.3; = 0.90). CDI with VDD has a higher odds of sepsis (OR 1.6, 95% CI 1.3-1.9; = 0.0), and peritonitis (OR 1.6, 95% CI 1.4-3.8; = 0.01). Mean LOS (5.9 ± 1.8 vs 5.4 ± 2, < 0.01) and mean total charges ($11,500 vs $9971, < 0.04) were higher in CDI with VDD. The factors affecting the LOS were acute coronary syndrome ( = 0.04), mechanical ventilation ( = 0.03), obesity ( = 0.004), acute kidney injury ( = 0.04), and sepsis ( = 0.05).

Conclusions: In this large cohort in a propensity-matched analysis, VDD does not increase the in-hospital mortality in CDI. VDD increases the odds of complications with a higher LOS and resource utilization. These findings may be clinically relevant to guide clinicians to routinely monitor vitamin D status and supplement in patients at risk of CDI.
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http://dx.doi.org/10.14423/SMJ.0000000000001168DOI Listing
November 2020

End-stage renal disease and lower gastrointestinal bleeding-A propensity-matched analysis of nationwide inpatient sample.

Int J Clin Pract 2021 Feb 4;75(2):e13633. Epub 2020 Dec 4.

Department of Medicine, Interfaith Medical Center, Brooklyn, NY, USA.

Aims: We aim to determine the influence of lower gastrointestinal bleeding (LGIB) on mortality, morbidity, length of hospital stay and resource utilisation in end-stage renal disease (ESRD) patients.

Material And Methods: The National Inpatient Sample database (2016 &2017) was used for data analysis using the International Classification of Diseases, Tenth Revision codes to identify the patients with the principal diagnosis of ESRD and LGIB. We assessed the all-cause in-hospital mortality, morbidity, predictors of mortality, length of hospital stay (LOS) and total costs between propensity-matched groups of ESRD patients with LGIB versus ESRD patients.

Results: We identified 2 187 954 ESRD patients, of whom 242 075 has LGIB, and 1 945 879 were ESRD patients. The in-hospital mortality was higher in ESRD with LGIB (OR 2.5, 95% CI 1.5-2.2; P = .00). ESRD with LGIB has higher odds of mechanical ventilation (OR 1.4, 95% CI 6.4-16.4; P = .00), and shock requiring vasopressor (OR 1.2, 95% CI 4.9-5.4; P = .002). Advanced age (OR 1.02 CI 1.02-1.03 P = .00), anaemia (OR 1.04 CI 1.59-1.91 P = .006), acute coronary syndrome (OR 1.8 CI 1.6-2.1, P = .00), acute respiratory failure (OR 1.29 CI 2.0-2.6, P = .00), mechanical ventilation (OR 1.9, CI 3.5-4.4, P = .00) and sepsis (OR 1.5, CI 4.1-5.08, P = .00) were identified as predictors of mortality in ESRD with LGIB. Mean LOS (10.8 ± 14.9 vs 6.3 ± 8.5, P < .01) and mean total charges (37 054 $ vs 18 080 $, P < .01) were also higher.

Conclusions: In this propensity-matched analysis, ESRD with LGIB was associated with higher odds of in-hospital mortality, mechanical ventilation and shock requiring vasopressor. Mean LOS and resource utilisation were also higher.
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http://dx.doi.org/10.1111/ijcp.13633DOI Listing
February 2021

Clinical characteristics and predictors of mortality in African-Americans with COVID-19 from an inner-city community teaching hospital in New York.

J Med Virol 2021 02 5;93(2):812-819. Epub 2020 Oct 5.

Department of Medicine, Interfaith Medical Center, Brooklyn, New York.

There is limited data on the clinical presentation and predictors of mortality in the African-American (AA) patients hospitalized with coronavirus disease 2019 (COVID-19) despite the disproportionately higher burden and mortality. The aim of this study is to report on the clinical characteristics and the predictors of mortality in hospitalized AA patients with COVID-19 infection. In this retrospective cohort review, we included all AA patients with confirmed COVID-19 infection admitted to an inner-city teaching community hospital in New York city. Demographics, clinical presentation, baseline co-morbidities, and laboratory data were compared between survivors and non-survivors. The predictors of mortality were assessed using multivariate logistic regression analysis. Of the 408 (median age, 67 years) patients included, 276 (66.65%, median age 63 years) survived while 132 (33.35%, median age 71 years) died. The most common presenting symptoms were cough, myalgia, fever/chills, shortness of breath, and gastrointestinal symptoms (nausea, vomiting, diarrhea, and abdominal pain), with a prevalence of 62.50%, 43.87%, 53.68%, and 27.21%, respectively. Age (odds ratio [OR], 1.06; confidence interval [CI], 1.04-1.08; P < .001), body mass index (OR, 1.07; CI, 1.04-1.11; P < .001), elevated serum ferritin (OR, 1.99; CI, 1.08-3.66; P < .02), C-reactive protein (OR, 2.42; CI, 1.36-4.33; P < .01), and D-dimers (OR, 3.79; CI, 2.21-6.50; P < .001) at the time of presentation were identified as the independent predictors of mortality. Cough, shortness of breath, fever/chills, gastrointestinal symptoms, and myalgia were the predominant presentation among AAs hospitalized with COVID-19 infection. Advanced age, higher body mass index, elevated serum ferritin, C-reactive protein, and D-dimers are independent predictors of mortality among hospitalized AAs with COVID-19 infection.
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http://dx.doi.org/10.1002/jmv.26306DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7405133PMC
February 2021

A Case Series of Patients Coinfected With Influenza and COVID-19.

J Investig Med High Impact Case Rep 2020 Jan-Dec;8:2324709620934674

Interfaith Medical Center, Brooklyn, NY, USA.

Coronavirus disease 2019, also called COVID-19, is a global pandemic resulting in significant morbidity and mortality worldwide. In the United States, influenza infection occurs mainly during winter and several factors influence the burden of the disease, including circulating virus characteristics, vaccine effectiveness that season, and the duration of the season. We present a case series of 3 patients with coinfection of COVID-19 and influenza, with 2 of them treated successfully and discharged home. We reviewed the literature of patients coinfected with both viruses and discussed the characteristics, as well as treatment options.
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http://dx.doi.org/10.1177/2324709620934674DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7290261PMC
June 2020

Presenting characteristics, comorbidities, and outcomes of patients coinfected with COVID-19 and Mycoplasma pneumoniae in the USA.

J Med Virol 2020 10 25;92(10):2181-2187. Epub 2020 May 25.

Division of Nephrology, Department of Internal Medicine, Adventist Medical Center, Hanford, California.

Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) is spreading at a rapid pace, and the World Health Organization declared it as pandemic on 11 March 2020. Mycoplasma pneumoniae is an "atypical" bacterial pathogen commonly known to cause respiratory illness in humans. The coinfection from SARS-CoV-2 and mycoplasma pneumonia is rarely reported in the literature to the best of our knowledge. We present a study in which 6 of 350 patients confirmed with COVID-19 were also diagnosed with M. pneumoniae infection. In this study, we described the clinical characteristics of patients with coinfection. Common symptoms at the onset of illness included fever (six [100%] patients); five (83.3%) patients had a cough, shortness of breath, and fatigue. The other symptoms were myalgia (66.6%), gastrointestinal symptoms (33.3%-50%), and altered mental status (16.7%). The laboratory parameters include lymphopenia, elevated erythrocyte sedimentation rate, C-reactive protein, lactate dehydrogenase, interleukin-6, serum ferritin, and D-dimer in all six (100%) patients. The chest X-ray at presentation showed bilateral infiltrates in all the patients (100%). We also described electrocardiogram findings, complications, and treatment during hospitalization in detail. One patient died during the hospital course.
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http://dx.doi.org/10.1002/jmv.26026DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7280653PMC
October 2020

Efficacy of Direct-Acting Antivirals for Chronic Hepatitis C in a Large Cohort of Older Adults in the United States.

J Am Geriatr Soc 2020 02 24;68(2):379-387. Epub 2019 Oct 24.

Interfaith Medical Center, SUNY Downstate University Hospital, Brooklyn, New York.

Objectives: Data on the virologic response and tolerability of direct-acting antivirals (DAAs) are lacking in older people because these individuals are underrepresented in clinical trials. This study aimed to assess the effectiveness and tolerability of DAA regimens in older individuals in a large cohort of real-life clinical practice.

Methods: In this retrospective study, patients with chronic hepatitis C infection between 2017 and 2018 were divided into patients aged 65 years and older and those younger than 65 years. We evaluated the sustained virologic response rates (SVRs) in both groups. Further subgroup analyses on the SVRs for patients aged 65 to 74, 75 to 84, and 85 years and older were performed. We also analyzed the predictors of treatment response in older individuals.

Results: Among 1151 eligible patients, 516 were in the older group and 635 were in the younger group. The overall treatment response in the entire cohort was 97.7%. A significantly higher percentage of patients presented with advanced stages of fibrosis in the older group (53.1% vs 39.5%; P = <.001). The SVR rates were similar between the two groups (98.3% vs 97.7%; P = .18). In multivariate models, age was not predictive of SVR after adjusting for confounders. Subgroup analyses in the age groups of 65 to 74, 75 to 84, and older than 85 years showed similar treatment response rates (97.4%, 97.2%, and 86.7, respectively; P = .06) and advanced fibrosis (50.8%, 61.5%, and 53.3%, respectively; P = .14).

Conclusion: Although older people exhibit a significantly higher frequency of fibrosis, DAAs produce high rates of SVR in all age groups, and the age of the patient does not seem to have a significant impact on the efficacy of DAAs including patients in the oldest age category (≥75 y). Treatment should not be withheld in older individuals. J Am Geriatr Soc 68:379-387, 2020.
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http://dx.doi.org/10.1111/jgs.16206DOI Listing
February 2020

National Trends and Hospitalizations Related to Pancreatic Cancer in Acute Pancreatitis Patients: A Nationwide Inpatient Sample Study.

Cureus 2019 Jul 17;11(7):e5155. Epub 2019 Jul 17.

Internal Medicine, St. Barnabas Hospital Health System, Bronx, USA.

Background Pancreatic cancer (PC) is one of the common cancers in the United States (U.S.) and is associated with high mortality and morbidity. In spite of the modest improvement in survival, cancer care costs including PC continue to rise and inpatient costs contribute a significant chunk to cancer care, which is often ignored. Acute pancreatitis (AP) is a rare manifestation of PC. This study aims to determine the national trends and associated health care utilization of PC patients hospitalized with AP in the U.S. Methods We used National Inpatient Sample (NIS) to extract data for patients hospitalized with a primary diagnosis of PC in AP in 2016 using International Classification of Diseases, 10th revision, and Clinical Modification (ICD-10-CM) codes. The analysis included disease etiologies, age, race, sex, hospital region, hospital size, institution type, mortality, length of hospital stay (LOS), and commonly associated comorbidities were correlated. Results There were 250 patients with a discharge diagnosis of PC in patients admitted with AP. Most of the patients were whites (76.6%) with the mean age of 39.42 ± 2.51 years, had Medicare (63.26%) as primary insurance, were from Southern region (46%) and had higher Charlson comorbidity index (CCI) (76.00% with CCI > = 3). The mean hospital charges were $48,462.13, and mean LOS was 5.24 days. The LOS was significantly impacted by race, hospital region, endoscopic retrograde cholangiopancreatography (ERCP), and comorbidities such as dementia, smoking, and seizure. Out of the 250 patients admitted with PC, 245 patients (98%) were discharged alive. Conclusions Our study shows a downward trend in LOS, hospital charges, and in-hospital mortality as compared to other studies despite PC and AP presenting together versus PC with or without other etiologies.
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http://dx.doi.org/10.7759/cureus.5155DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6741367PMC
July 2019

Outcomes of Direct-Acting Antiviral Treatment of Psychiatric Patients with Comorbid Hepatitis C Virus Infection.

Dig Dis 2020 6;38(3):232-239. Epub 2019 Sep 6.

Department of Medicine and Gastroenterology, Interfaith Medical Center, Brooklyn, New York, USA.

Background: The highest burden of hepatitis C virus (HCV) infection is seen in patients with psychiatric disorders who have been excluded from traditional treatments with Interferon due to treatment-emergent neuropsychiatric adverse effects. The goal of this study is to determine the tolerability, treatment retention, and efficacy of direct-acting antivirals with psychiatric disorders and comorbid substance use disorders in real-life settings.

Methods: This is a retrospective cohort observational study of HCV patients treated with direct-acting antivirals between January 2016 and December 2018. Patients were stratified and sub-stratified based on their psychiatric diagnosis and substance use. The primary assessment was the sustained virologic response at 12 weeks post-treatment (SVR12).

Results: Among the 291 patients analyzed, patients with psychiatric diagnosis and non-psychiatric patients made up 51.2% (n = 149) and 48.8% (n = 142) respectively. Majority of the patients included in the study were African-Americans (68.7%, n = 200). Overall, 95.3% (142/149) and 94.4% (134/142) of psychiatric and non-psychiatric patients, respectively, achieved SVR12 and treatment response was similar between the groups (p = 0.72). Among psychiatric patients, only the prior treatment status was identified as a predictor of treatment response (OR 0.153, 95% CI 0.03-0.79; p = 0.05). No statistical difference was observed among the patients with SVR12 based on their primary psychiatric diagnoses or by comorbid substance abuse.

Conclusion: The results of our study show that direct-acting antiviral treatments are well tolerated in psychiatric patients, and an overwhelming majority of patients achieved SVR12. Our study highlights the need to integrate HCV screening with treatment linkage in psychiatry and primary care practice.
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http://dx.doi.org/10.1159/000502514DOI Listing
July 2020

Real-world study of hepatitis C treatment with direct-acting antivirals in patients with drug abuse and opioid agonist therapy.

Scand J Gastroenterol 2019 May 23;54(5):646-655. Epub 2019 May 23.

c Department of Medicine and Division of Gastroenterology and Hepatology , New York-Presbyterian Brooklyn Methodist Hospital , Brooklyn , NY , USA.

Limited data exist evaluating the treatment outcomes with direct-acting antivirals (DAAs) in patients with drug use in the community setting. We aim to assess the treatment response of DAAs in this subset of patients with or without the opioid agonist therapy (OAT). All the hepatitis C virus (HCV) infected patients treated with DAAs were retrospectively analyzed. Patients were stratified into two groups by the presence or absence of abusing alcohol, cocaine and heroin. All the patients who were assigned to the abuser group had positive urine toxicology with one of the drugs during the DAA treatment. The primary assessment was the sustained virologic response (SVR12) at 12 weeks post-treatment (SVR12). Among the 314 patients, 152, 128 and 58 were patients with drug use, non-drug use and receiving OAT. Among the patients with injectable or non-injectable drug use treatment, completion rate was 99% (151/152) and SVR12 was 93.4%. Among the patients with no drug use treatment, completion rate was 95% (122/128) and SVR12 was 88.3%. Among patients receiving OAT alone, SVR12 was 100%, and in patients with OAT + other drug use, SVR12 was 96.5%. None of the patients included in this study discontinued the treatment due to adverse events associated with treatment medications. In this community-based study, DAAs are safe, effective with high overall SVR12 in patients with active drug use (injectable and non-injectable) and OAT enrolled patients. These results support the removal of drug use as a barrier to DAA therapy.
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http://dx.doi.org/10.1080/00365521.2019.1617893DOI Listing
May 2019

Clozapine-Induced Cardiotoxicity Presenting as Sepsis: A Case Report and Literature Review.

Case Rep Med 2019 31;2019:3435108. Epub 2019 Mar 31.

Department of Cardiology, Interfaith Medical Centre, Brooklyn, NY, USA.

Clozapine is an atypical antipsychotic agent indicated in the treatment of medication-resistant schizophrenia. It is often reserved as a last line of treatment owing to the potential for serious and potentially life-threatening side effects, the most serious being agranulocytosis requiring close hematological monitoring and possible discontinuation of the medication from further use in the patient even when the agranulocytosis resolves. Other complications of clozapine include sedation, weight gain, elevated triglyceride levels, postural hypotension, and tachycardia. However, the potentially serious complication of myocarditis, though rare (with an incidence of 3%), may lead to cardiomyopathy as described in our present case. We present a 21-year-old patient who was started on clozapine for management of schizophrenia. He developed fever and tachycardia and was admitted to the medical unit on intravenous antibiotics for management of sepsis as he met the criteria for systemic inflammatory response syndrome. His labs revealed an elevated troponin and trending eosinophilia, which, in the context of clozapine use, raises the suspicion of clozapine cardiotoxicity. Echocardiogram showed reduced systolic function (45%). Clozapine was immediately discontinued, and his repeat echocardiogram showed normalization of his systolic function. In view of the increased prevalence of psychiatric illnesses, internists should be aware of rare but potentially life-threatening side effects.
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http://dx.doi.org/10.1155/2019/3435108DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6462315PMC
March 2019

Rectourethral Fistula Secondary to Transurethral Resection of the Prostate.

Cureus 2018 Oct 22;10(10):e3476. Epub 2018 Oct 22.

Internal Medicine, Interfaith Medical Center, Brooklyn, USA.

An 82-year-old male with benign prostatic hyperplasia (BPH) who underwent transurethral resection of the prostate (TURP) presented to the hospital with suprapubic pain, abdominal distension, and diarrhea. The physical examination was remarkable for an indwelling Foley's catheter. Diagnostic imaging confirmed the diagnosis of a rectourethral fistula (RUF). The most common presenting symptoms of RUF are pneumaturia, fecaluria, and urine leakage from the rectum, which may present similarly to diarrhea. He lacked the common features of RUF such as pneumaturia and fecaluria, which may be explained by a blockage of the catheter with fecal material. This case represents a rare outcome following a TURP, and it is significant due to the high morbidity associated with RUF. As such, clinicians must suspect a RUF in a post-TURP patient with diarrhea and no other obvious etiology due to the morbidity associated with RUF.
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http://dx.doi.org/10.7759/cureus.3476DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6318087PMC
October 2018

Valproic acid induced acute liver injury resulting in hepatic encephalopathy- a case report and literature review.

J Community Hosp Intern Med Perspect 2018 15;8(5):311-314. Epub 2018 Oct 15.

Department of Medicine, Wayne State University/Detroit Medical center, Detroit, MI, USA.

Valproic acid (VPA) is a commonly used agent in the management of seizures and psychiatric disorders. Hyperammonemia is a common complication of VPA with 27.8% of patients having elevated levels - that is unrelated to hepatotoxicity and normal transaminases. Common side effects include obesity, insulin resistance, metabolic disorder and severe forms of hepatotoxicity. Other rare and idiosyncratic reactions have been reported, one of which is presented in our case. A 27-year old patient presented with hyperammonemia and encephalopathy as a consequence of idiosyncratic VPA reaction causing drug-induced liver injury (DILI) with severely elevated transaminases. DILI is commonly overlooked when investigating encephalopathy in the setting of VPA. Physicians should consider DILI in the context of hyperammonemia and transaminitis.
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http://dx.doi.org/10.1080/20009666.2018.1514933DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6197012PMC
October 2018

Moderate Hypertriglyceridemia Causing Recurrent Pancreatitis: A Case Report and the Literature Review.

Case Rep Gastrointest Med 2018 24;2018:8714390. Epub 2018 Sep 24.

Department of Medicine, Wayne State University/Detroit Medical Center, Detroit, MI, USA.

Recurrent acute pancreatitis secondary to hypertriglyceridemia (HTG) with levels below 1000 mg/dL has been rarely reported in the literature. HTG is the third most common cause of acute pancreatitis and has been established in the literature as a risk factor when levels are greater than 1000 mg/dL. A 43-year-old patient presented to the hospital with severe epigastric abdominal pain. Initial laboratory investigations were significant for a lipase level of 4143 U/L and a triglyceride level of 600 mg/dL. Computed tomography (CT) of the abdomen showed diffuse enlargement of the pancreas consistent with pancreatitis. A diagnosis of severe acute pancreatitis secondary to high triglycerides was made based on the revised Atlanta classification 2012. The patient was initially managed with intravenous boluses of normal saline followed by continuous insulin infusion. Diabetic Ketoacidosis (DKA) was ruled out due to a past medical history of diabetes. Her clinical course was complicated by acute respiratory distress syndrome requiring intubation and mechanical ventilation. During the course, she improved symptomatically and was extubated. She was started on nasogastric feeding initially and subsequently switched to oral diet as tolerated. After initial management of HTG with insulin infusion, oral gemfibrozil was started for long-term treatment of HTG. Emerging literature implicates HTG as an independent indicator of poor prognosis in acute pancreatitis (AP). Despite the paucity of data, the risk of developing AP must be considered even at triglyceride levels lower than 1000 mg/dL.
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http://dx.doi.org/10.1155/2018/8714390DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6174808PMC
September 2018

A Rare Case of Acute Pancreatitis Due to Very Severe Hypertriglyceridemia (>10 000 mg/dL) Successfully Resolved With Insulin Therapy Alone: A Case Report and Literature Review.

J Investig Med High Impact Case Rep 2018 Jan-Dec;6:2324709618798399. Epub 2018 Sep 1.

Interfaith Medical Center, New York, NY, USA.

A 48-year-old male presented to the psychiatric emergency room for dysmorphic mood. He was admitted to medical service for the management of hyponatremia, which was discovered in his initial laboratory workup. After the first day of admission, he developed abdominal pain and fever, and subsequent laboratory work revealed a triglyceride level of 10 612 mg/dL (reference range = 0-194 mg/dL). Computed tomography scan of the abdomen and pelvis revealed a hypodense lesion in the pancreas surrounded by a moderate amount of peripancreatic fluid suggestive of hemorrhagic pancreatitis. Based on the laboratory findings and imaging, we diagnosed acute pancreatitis (AP) secondary to hypertriglyceridemia. The patient was initiated on intravenous fluids and insulin to help decrease the triglyceride level with the plan to initiate apheresis. However, the patient improved on insulin therapy alone, which negated the need for apheresis, and the patient was discharged with fenofibrate with no further complications. While elevated triglycerides are a well-known cause of AP, we sought to assess various treatment options in management, especially considering a severely elevated triglyceride level of >10 000 mg/dL. Along with supportive care in AP, there are additional options in hypertriglyceridemia AP, including heparin, insulin, apheresis, antioxidants, and fibrates. Currently, there are no clear guidelines favoring one therapeutic option over the other.
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http://dx.doi.org/10.1177/2324709618798399DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6120174PMC
September 2018

Sofosbuvir Based Regimens in the Treatment of Chronic Hepatitis C with Compensated Liver Cirrhosis in Community Care Setting.

Int J Hepatol 2018 1;2018:4136253. Epub 2018 Aug 1.

Department of Medicine and Gastroenterology, Interfaith Medical Center, 1545 Atlantic Avenue, Brooklyn, NY 11213, USA.

Background: Direct-acting antiviral (DAA) drugs have been highly effective in the treatment of chronic hepatitis C (CHC) infection. We aim to evaluate the treatment response of Sofosbuvir based DAA in CHC patients with compensated liver cirrhosis as limited data exists in the real-world community setting.

Methods: All the CHC patients with compensated liver cirrhosis treated with Sofosbuvir based DAAs between January 2014 and December 2017 in a community clinic setting were retrospectively analyzed. Pretreatment baseline patient characteristics, treatment efficacy with the sustained virologic response at 12 weeks posttreatment (SVR12), and adverse reactions were assessed.

Results: One hundred and twelve patients with CHC infection and concurrent compensated cirrhosis were included in the study. Black patients represented the majority of the study population (64%). Eighty-seven patients were treated with Ledipasvir/Sofosbuvir (LDV/SOF) ±Ribavirin and 25 patients were treated with Sofosbuvir/Velpatasvir (SOF/VEL). Overall, SVR 12 after treatment was achieved in 90% in patients who received one of the two DAA regimens (89.7% in LDV/SOF group and 92% in SOF/VEL group). SVR 12 did not vary based on age, sex, body mass index, baseline HCV viral load, HCV/HIV coinfection, type of genotype, and prior treatment status. Apart from a low platelet count, there were no other factors associated with a statistical difference in SVR 12(0.002) between the two regimens. Fatigue (35%) was the most common adverse effect and no patients discontinued treatment due to adverse effects.

Conclusion: In the community care setting, Sofosbuvir based DAAs are safe, effective with high overall SVR, and well tolerated in patients with CHC patients with compensated liver cirrhosis.
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http://dx.doi.org/10.1155/2018/4136253DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6093047PMC
August 2018

A Rare Case of Systemic Lupus Erythematosus with Gastric Ulcer and Acute Pancreatitis: A Case Report and Literature Review.

Gastroenterology Res 2018 Aug 8;11(4):321-325. Epub 2018 Feb 8.

Department of Medicine, Interfaith Medical Center, Brooklyn, NY, USA.

Systemic lupus erythematosus (SLE) is a chronic inflammatory disease which can manifest in many different organ systems. Gastrointestinal (GI) involvement is common in SLE, but the symptoms are usually mild. More severe GI complications including acute pancreatitis and peptic ulcer bleeding are rare but represent a significant risk of morbidity and mortality. We present a case of a 25-year-old Hispanic female with a severe SLE flare. The initial presentation included symptoms of hematemesis and epigastric abdominal pain secondary to both gastric ulceration and acute pancreatitis, an atypical presentation of an SLE flare. The non-specific symptom of abdominal pain makes both acute pancreatitis and gastric ulcer disease a clinical challenge; however, clinicians need to have a high suspicion for these conditions co-existing at the same time due to higher mortality rates.
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http://dx.doi.org/10.14740/gr1048wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6089583PMC
August 2018

Metachronous Granular Cell Tumor of the Descending Colon.

Gastroenterology Res 2018 Aug 8;11(4):317-320. Epub 2018 Feb 8.

Department of Medicine, Interfaith Medical Center, Brooklyn, NY, USA.

Granular cell tumors (GCTs) are uncommon tumors. They are believed to be neuronal in origin and are usually found in the head and/or neck area of the body. They have also been reported in various locations of the gastrointestinal (GI) system, usually discovered during routine screening colonoscopy. We report a case of GCT in a 58-year-old asymptomatic African American female as a metachronous tumor of a well-differentiated adenocarcinoma of the sigmoid colon, which was an incidental finding in screening colonoscopy. To our knowledge, this is the first case with GCT identified as a metachronous tumor following an adenocarcinoma of the colon.
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http://dx.doi.org/10.14740/gr1045wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6089591PMC
August 2018

Association Between Vitamin D Levels and Treatment Response to Direct-Acting Antivirals in Chronic Hepatitis C: A Real-World Study.

Gastroenterology Res 2018 Aug 8;11(4):309-316. Epub 2018 Feb 8.

Department of Medicine and Division of Gastroenterology and Hepatology, New York-Presbyterian Brooklyn Methodist Hospital, 506, 6th St, Brooklyn, NY 11215, USA.

Background: Low serum vitamin D levels in chronic hepatitis C (CHC) is associated with advanced liver fibrosis; and there remains an imprecise relationship with the treatment response based on the vitamin D levels. Previous studies have shown conflicting results on the vitamin D levels, and association with treatment response in CHC treated with interferon-based regimens.

Methods: Patients with CHC treated with direct-acting antivirals (DAAs) between January 2016 and December 2017 in the community clinic setting were retrospectively analyzed. Pretreatment baseline patient characteristics, treatment efficacy with the sustained virologic response at 12 weeks post-treatment (SVR 12) were assessed in CHC patients with deficient, insufficient, and normal levels of vitamin D measured before the initiation of DAA therapy.

Results: Two hundred and ninety-one patients were included in the study. Direct-acting antivirals included in the study were ledipasvir/sofosbuvir ± ribavirin, ombitasvir + paritaprevir + ritonavir + dasabuvir ± ribavirin, and sofosbuvir/velpatasvir. An overall sustained virologic response was achieved in 95% (n = 276) of patients. SVR 12 rates among patients with vitamin D deficiency, vitamin D insufficiency and normal vitamin D levels were 92%, 96.2%, and 97.2% respectively and was not statically significant (P = 0.214). A total of 71 patients were cirrhotic. The prevalence of vitamin D insufficiency (20 - 29.9 ng/mL) and deficiency (< 20 ng/mL) was significantly higher in cirrhotic patients (P = 0.01). Despite this, pretreatment vitamin D levels did not show any impact on the virologic response. The most common adverse effect observed was fatigue. None of the patients had to discontinue the treatment due to adverse events.

Conclusions: DAAs are safe and effective with a high overall SVR 12 in CHC and treatment response does not depend on the pretreatment vitamin D levels. The prevalence of both vitamin D insufficiency and deficiency was observed to be higher in cirrhotic cohorts compared to non-cirrhotic counterparts.
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http://dx.doi.org/10.14740/gr1072wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6089592PMC
August 2018

Sofosbuvir based regimens in the treatment of chronic hepatitis C genotype 1 infection in African-American patients: a community-based retrospective cohort study.

Eur J Gastroenterol Hepatol 2018 10;30(10):1200-1207

Department of Medicine and Division of Gastroenterology and Hepatology, New York-Presbyterian Brooklyn Methodist Hospital, Brooklyn, New York.

Background: Direct-acting antiviral (DAA) drugs have been highly effective in the treatment of chronic hepatitis C (HCV) infection. Limited data exist comparing the safety, tolerability, and efficacy of DAAs in African-American (AA) patients with chronic hepatitis C genotype 1 (HCV GT-1) in the community practice setting. We aim to evaluate treatment response of DAAs in these patients.

Patients And Methods: All the HCV GT-1 patients treated with DAAs between January 2014 and January 2018 in a community clinic setting were retrospectively analyzed. Pretreatment baseline patient characteristics, treatment efficacy with a sustained virologic response at 12 weeks post-treatment (SVR12), and adverse reactions were assessed.

Results: Two-hundred seventy-eight patients of AA descent were included in the study. One-hundred sixty-two patients were treated with ledipasvir/sofosbuvir (SOF)±ribavirin, 38 were treated with simeprevir/SOF±ribavirin, and 38 patients were treated with SOF/velpatasvir. Overall, SVR at 12 weeks was achieved in 94.6% in patients who received one of the three DAA regimens (93.8% in ledipasvir/SOF group, 92.1% in simeprevir/SOF group, and 97.4% in SOF/velpatasvir group). Previous treatment experience, HCV RNA levels and HIV status had no statistical significance on overall SVR achievement (P=0.905, 0.680, and 0.425, respectively). Compensated cirrhosis in each of the treatment groups did not influence overall SVR of 12. The most common adverse effect was fatigue (27%). None of the patients discontinued the treatment because of adverse events.

Conclusion: In the real-world setting, DAAs are safe, effective, and well tolerated in African-American patients with chronic HCV GT-1 infection with a high overall SVR rate of 94.6%. Treatment rates did not differ on the basis of previous treatment and compensated cirrhosis status.
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http://dx.doi.org/10.1097/MEG.0000000000001233DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6133221PMC
October 2018

Hyperacute liver injury following intravenous fluconazole: A rare case of dose-independent hepatotoxicity.

J Family Med Prim Care 2018 Mar-Apr;7(2):451-454

Department of Medicine, Interfaith Medical Center, Brooklyn, NY, USA.

Fluconazole is a triazole antifungal medication used in the treatment of various fungal infections. It is available in both oral and parenteral formulations. Liver damage has been reported with fluconazole use, but most commonly it is benign elevated liver transaminases. Acute liver failure (ALF) in fluconazole use is rare, with cases being reported sporadically in literature and large cohorts describing incidence rates of acute liver injury ranging from 0.0 to 31.6/10,000 patients. We present a case of a 45-year-old African-American male with no history of liver disease who presented with superficial candidiasis and superimposed bacterial cellulitis. He was subsequently started on intravenous fluconazole and clindamycin. Shortly after he developed ALF and a drug-induced liver injury (DILI) was suspected. Fluconazole was stopped, and the clinical picture improved shortly afterward, leading to a diagnosis of fluconazole-induced ALF. Patient underwent laboratory and clinical evaluation to exclude competing etiologies of liver injury as well as a standardized assessment for causality and disease severity such as Roussel Uclaf Causality Assessment Method/Council for International Organizations of Medical Sciences score, which concluded a "Highly Probable" DILI, and a Naranjo score identifying adverse drug reaction (ADR) which concluded a "Definite ADR." Due to the severity of ALF and the routine use of fluconazole in clinical practice, clinicians should be aware that fluconazole can be a causative agent of ALF, even in low-risk populations.
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http://dx.doi.org/10.4103/jfmpc.jfmpc_330_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6060922PMC
August 2018

Real-World Clinical Efficacy and Tolerability of Direct-Acting Antivirals in Hepatitis C Monoinfection Compared to Hepatitis C/Human Immunodeficiency Virus Coinfection in a Community Care Setting.

Gut Liver 2018 11;12(6):694-703

Division of Gastroenterology and Hepatology, Department of Medicine, New York-Presbyterian Brooklyn Methodist Hospital, New York, NY, USA.

Background/aims: Limited data exist comparing the safety and efficacy of direct-acting antivirals (DAAs) in hepatitis C virus (HCV) monoinfected and HCV/human immunodeficiency virus (HIV) coinfected patients in the real-world clinic practice setting.

Methods: All HCV monoinfected and HCV/HIV coinfected patients treated with DAAs between January 2014 and October 2017 in community clinic settings were retrospectively analyzed. Pretreatment baseline patient characteristics, treatment efficacy, factors affecting sustained virologic response at 12 weeks (SVR12) after treatment, and adverse reactions were compared between the groups.

Results: A total of 327 patients were included in the study, of which 253 were HCV monoinfected, and 74 were HCV/HIV coinfected. There was a statistically significant difference observed in SVR12 when comparing HCV monoinfection and HCV/HIV coinfection (94% and 84%, respectively, p=0.005). However, there were no significant factors identified as a predictor of a reduced response. The most common adverse effect was fatigue (27%). No significant drug interaction was observed between DAA and antiretroviral therapy. None of the patients discontinued the treatment due to adverse events.

Conclusions: In a real-world setting, DAA regimens have lower SVR12 in HCV/HIV coinfection than in HCV monoinfection. Further studies involving a higher number of HCV/HIV coinfected patients are needed to identify real predictors of a reduced response.
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http://dx.doi.org/10.5009/gnl18004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6254621PMC
November 2018

Direct-Acting Antivirals in Chronic Hepatitis C Genotype 4 Infection in Community Care Setting.

Gastroenterology Res 2018 Apr 7;11(2):130-137. Epub 2018 Apr 7.

Department of Medicine and Division of Gastroenterology and Hepatology, New York-Presbyterian Brooklyn Methodist Hospital, 506 6th St., Brooklyn, NY 11215, USA.

Background: Limited data exists comparing the safety, tolerability, and efficacy of direct-acting antivirals (DAAs) in patients with chronic hepatitis C genotype 4 (HCV GT-4) in the community practice setting. We aim to evaluate the treatment response of DAAs in these patients.

Methods: All the HCV GT-4 patients treated with DAAs between January 2014 and October 2017 in a community clinic setting were retrospectively analyzed. Pretreatment baseline patient characteristics, treatment efficacy with sustained virologic response (SVR) at 12 weeks post treatment (SVR12), and adverse reactions were assessed.

Results: Fifty-two patients of Middle Eastern (primarily Egyptian) descent were included in the study. Thirty-two patients were treated with ledipasvir/sofosbuvir (Harvoni) ± ribavirin, 12 patients were treated with ombitasvir/paritaprevir/ritonavir/dasabuvir (ViekiraPak) ± ribavirin, and eight patients were treated with sofosbuvir/Velpatasvir (Epclusa). Ten patients (19.2%) had compensated cirrhosis. Overall, SVR at 12 weeks was achieved in 94% in patients who received one of the three DAA regimens (93.8% in Harvoni group, 91.7 % in ViekiraPak group and 100% in Epclusa group). Prior treatment status and type of regimen used in the presence of compensated cirrhosis had no statistical significance on overall SVR achievement (P value = 0.442 and P value = 0.091, respectively). The most common adverse effect was fatigue (27%).

Conclusions: In the real-world setting, DAAs are effective and well tolerated in patients with chronic HCV GT-4 infection with a high overall SVR rate of 94%. Large-scale studies are needed to further assess this SVR in these groups.
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http://dx.doi.org/10.14740/gr999wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5916637PMC
April 2018

Drug-Induced Liver Injury: An Institutional Case Series and Review of Literature.

J Investig Med High Impact Case Rep 2018 Jan-Dec;6:2324709618761754. Epub 2018 Mar 14.

Interfaith Medical Center, Brooklyn, NY, USA.

Drug-induced liver injury (DILI) is the most common cause of acute liver failure in the USA. DILI can be broadly classified as Intrinsic and Idiosyncratic. Identifying predictors and at-risk patients are challenging but can have a substantial clinical implication. This case report series demonstrates the importance of valproic acid, fluconazole, and amiodarone as potential hepatoxic agents of drug-induced liver injury leading to acute hepatic failure. The causality in all cases was established by Roussel Uclaf Causality Assessment Method/Council for International Organizations of Medical Sciences score and Naranjo Algorithm. Obesity, hypo-perfusion state, and concurrent hepatotoxic agent might identify at-risk patients. Further studies are required to understand the risk factors.
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http://dx.doi.org/10.1177/2324709618761754DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5858623PMC
March 2018

Fatal Acute Liver Failure With Intravenous Amiodarone: A Case Report and Literature Review.

Gastroenterology Res 2018 Feb 23;11(1):62-63. Epub 2018 Feb 23.

Interfaith Medical Center, 1545 Atlantic Ave, Brooklyn, NY 11213, USA.

Amiodarone is a drug which frequently causes elevated transaminases. However, acute liver failure has been rarely reported. Here, we present a case of fatal acute liver failure following the administration of intravenous amiodarone. It is important to be aware of this rare but potentially fatal complication of intravenous amiodarone so that it can be withdrawn immediately at the first sign of hepatic impairment.
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http://dx.doi.org/10.14740/gr911wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5827905PMC
February 2018

Assessment of Knowledge, Attitudes, and Practices Regarding Chronic Hepatitis C Treatment and Its Challenges: A Survey of Internal Medicine Residents in a Community Hospital.

Gastroenterology Res 2018 Feb 23;11(1):31-35. Epub 2018 Feb 23.

Department of Gastroenterology, Interfaith Medical Center, Brooklyn, NY, USA.

Background: Despite recent advances in chronic hepatitis C (CHC) treatment, only a small proportion of patients are connected with care and receive treatment. Internal medicine (IM) residents spend nearly one-third of their training in primary care settings and play a crucial role in diagnosing and counseling patients as well as linking patients with care and following up.

Methods: IM residents in a community hospital completed an anonymous questionnaire regarding their knowledge, attitude, and practice associated with CHC treatment and its challenges.

Results: Descriptive analysis of the survey showed that there is a substantial gap in knowledge regarding the newer treatment of CHC between IM residents' perceptions of patient awareness and IM residents.

Conclusion: Updated education regarding CHC that is geared towards medical residents and focused on new modalities of treatment can narrow the gap and lead to considerable increases in the rates of diagnosis and treatment and decreases in morbidity and mortality.
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http://dx.doi.org/10.14740/gr963wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5827899PMC
February 2018