Publications by authors named "Prabin Sharma"

30 Publications

  • Page 1 of 1

Efficient -mediated stable genetic transformation of green microalgae, .

3 Biotech 2021 Apr 26;11(4):196. Epub 2021 Mar 26.

Centre for Energy, Indian Institute of Technology Guwahati, Guwahati, Assam 781039 India.

The green oleaginous microalgae, , is a highly productive species and a potential host for the production of biofuel, nutraceuticals, and recombinant therapeutic proteins. The lack of a stable and efficient genetic transformation system is the major bottleneck in improving this species. We report an efficient and stable -mediated transformation system for the first time in . Cocultivation of cells (optical density at  = 1.0) with at a cell density of OD = 0.6, on BG11 agar medium (pH 5.6) supplemented with 100 μM of acetosyringone, for three days at 25 ± 2 °C in the dark, resulted in significantly higher transformation efficiency (220 ± 5 hygromycin-resistant colonies per 10 cells). Transformed cells primarily selected on BG11 liquid medium with 30 mg/L hygromycin followed by selecting homogenous transformants on BG11 agar medium with 75 mg/L hygromycin. PCR analysis confirmed the presence of , and the absence of amplification ruled out the contamination in transformed microalgal cells. Southern hybridization confirmed the integration of the gene into the genome of . The qRT-PCR and Western blot analyses confirmed and GUS gene expression in the transgenic cell lines. The specific growth rate, biomass doubling time, PSII activity, and fatty-acid profile of transformed cells were found similar to wild-type untransformed cells, clearly indicating the growth and basic metabolic processes not compromised by transgene expression. This protocol can facilitate opportunities for future production of biofuel, carotenoids, nutraceuticals, and therapeutic proteins.

Supplementary Information: The online version contains supplementary material available at 10.1007/s13205-021-02750-7.
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http://dx.doi.org/10.1007/s13205-021-02750-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7997936PMC
April 2021

Healthcare Disparities in the Management of Acute Cholecystitis: Impact of Race, Gender, and Socioeconomic Factors on Cholecystectomy vs Percutaneous Cholecystostomy.

J Gastrointest Surg 2021 04 24;25(4):880-886. Epub 2021 Feb 24.

Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.

Background: While percutaneous cholecystostomy (PC) is a recommended treatment strategy in lieu of cholecystectomy (CCY) for acute cholecystitis among patients who may not be considered good surgical candidates, reports on disparities in treatment utilization remain limited. The aim of this study was to investigate the role of demographic, clinical, and socioeconomic factors in treatment of acute cholecystitis.

Methods: Patients with a diagnosis of acute cholecystitis who underwent CCY versus PC were reviewed from the U.S. Nationwide Inpatient Sample (NIS) database between 2008-2014. Measured variables including age, race/ethnicity, Charlson comorbidity index (CCI), hospital type/region, insurance payer, household income, length of stay (LOS), hospital cost, and mortality were compared using chi-square and ANOVA. Multivariable logistic regression was performed to identify specific predictors of cholecystitis treatment.

Results: A total of 1,492,877 patients (CCY:n=1,435,255 versus PC:n=57,622) were analyzed. The majority of patients that received PC were at urban teaching hospitals (65.2%). LOS was significantly longer with higher associated costs for PC [(11.1±11.0 versus 4.5±5.3 days; P<0.001) and ($99577±138850 versus $48399±58330; P<0.001)]. Mortality was also increased for patients that received PC compared to CCY (8.8% versus 0.6%; P<0.001). Multivariable regression demonstrated multiple socioeconomic and healthcare-related factors influencing the utilization of PC including male gender, Black or Asian race/ethnicity, Medicare payer status, urban hospital location, and household income (all P<0.001).

Conclusion: Although patients receiving PC had higher CCI scores, multiple socioeconomic and healthcare related factors appeared to also influence this treatment decision. Additional studies to investigate these disparities are indicated to improve outcomes for all individuals with this condition.
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http://dx.doi.org/10.1007/s11605-021-04959-6DOI Listing
April 2021

Evaluation of socioeconomic and healthcare disparities on same admission cholecystectomy after endoscopic retrograde cholangiopancreatography among patients with acute gallstone pancreatitis.

Surg Endosc 2021 Jan 22. Epub 2021 Jan 22.

Section of Digestive Diseases, Yale University School of Medicine, New Haven, CT, USA.

Background: Despite literature and guidelines recommending same admission cholecystectomy (CCY) after endoscopic retrograde cholangiopancreatography (ERCP) for patients with acute gallstone pancreatitis, clinical practice remains variable. The aim of this study was to investigate the role of clinical and socio-demographic factors in the management of acute gallstone pancreatitis.

Methods: Patients with acute gallstone pancreatitis who underwent ERCP during hospitalization were reviewed from the U.S. Nationwide Inpatient Sample database between 2008 and 2014. Patients were classified by treatment strategy: ERCP + same admission CCY (ERCP + CCY) versus ERCP alone. Measured variables including age, race/ethnicity, Charlson Comorbidity Index (CCI), hospital type/region, insurance payer, household income, length of hospital stay (LOS), hospitalization cost, and in-hospital mortality were compared between cohorts using χ and ANOVA. Multivariable logistic regression was performed to identify specific predictors of same admission CCY.

Results: A total of 205,012 patients (ERCP + CCY: n = 118,318 versus ERCP alone: n = 86,694) were analyzed. A majority (53.4%) of patients that did not receive same admission CCY were at urban-teaching hospitals. LOS was longer with higher associated costs for patients with same admission CCY [(6.8 ± 5.6 versus 6.4 ± 6.5 days; P < 0.001) and ($69,135 ± 65,913 versus $52,739 ± 66,681; P < 0.001)]. Mortality was decreased significantly for patients who underwent ERCP + CCY versus ERCP alone (0.4% vs 1.1%; P < 0.001). Multivariable regression demonstrated female gender, Black race, higher CCI, Medicare payer status, urban-teaching hospital location, and household income decreased the odds of undergoing same admission CCY + ERCP (all P < 0.001).

Conclusion: Based upon this analysis, multiple socioeconomic and healthcare-related disparities influenced the surgical management of acute gallstone pancreatitis. Further studies to investigate these disparities are indicated.
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http://dx.doi.org/10.1007/s00464-020-08272-2DOI Listing
January 2021

Chylous ascites in cirrhosis from retroperitoneal lymphoma.

Proc (Bayl Univ Med Cent) 2020 Oct 1;34(1):138-140. Epub 2020 Oct 1.

Department of Radiology, Yale New Haven Health Bridgeport Hospital, Bridgeport, Connecticut.

Chylous ascites occurs due to processes that elevate pressures within or obstruct the lymphatics in the retroperitoneum. In cirrhosis, spontaneous chylous ascites can occur but is uncommon. We describe a case of a 74-year-old man with cirrhosis from nonalcoholic steatohepatitis who presented with worsening abdominal distension and chylous ascites on paracentesis; an infiltrating retroperitoneal lymphoma was subsequently detected on computed tomography imaging.
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http://dx.doi.org/10.1080/08998280.2020.1814597DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7785197PMC
October 2020

Safety of Bariatric Surgery in Morbidly Obese Patients with Human Immunodeficiency Virus: A Nationwide Inpatient Sample Analysis, 2004-2014.

Bariatr Surg Pract Patient Care 2020 Sep 14;15(3):116-123. Epub 2020 Sep 14.

Section of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut, USA.

Despite rising rates of obesity among human immunodeficiency virus (HIV)-positive individuals, the safety and tolerability of surgery in this population have not been established. The primary aim of this study was to examine the safety of bariatric surgery and rate of in-hospital postoperative complications in morbidly obese patients with HIV. The U.S. Nationwide Inpatient Sample database was queried between 2004 and 2014 for discharges with codiagnoses of morbid obesity and bariatric surgery. The primary outcome was in-hospital mortality. Secondary outcomes included length of stay, hospitalization costs, and multiple categories of complications, including systemic complications, surgical complications, and nutritional and behavioral complications. Among 267,082 patients with discharge diagnoses of morbid obesity and bariatric surgery, 346 (0.13%) were diagnosed with HIV. On multivariable analysis, HIV did not influence in-hospital mortality ( = 0.530). HIV was not associated with increased risk of renal failure ( = 0.274), thromboembolism ( = 0.713), myocardial infarction ( = 0.635), sepsis ( = 0.757), hemorrhage ( = 0.303), or wound infection ( = 0.229). Other measured surgical complications were not significantly different ( > 0.05). Notably, HIV-positive patients had an increased risk for postoperative pneumonia ( = 0.002), pancreatitis ( = 0.049), and thiamine deficiency ( = 0.016). Bariatric surgery among HIV-positive patients appears to be acceptably safe with the risk of postoperative complications comparable with non-HIV patients.
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http://dx.doi.org/10.1089/bari.2019.0065DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7488204PMC
September 2020

Alternative uses of lumen apposing metal stents.

World J Gastroenterol 2020 Jun;26(21):2715-2728

Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, United States.

The advent of lumen apposing metal stents (LAMS) has revolutionized the management of many complex gastroenterological conditions that previously required surgical or radiological interventions. These procedures have garnered popularity due to their minimally invasive nature, higher technical and clinical success rate and lower rate of adverse events. By virtue of their unique design, LAMS provide more efficient drainage, serve as conduit for endoscopic access, are associated with lower rates of leakage and are easy to be removed. Initially used for drainage of pancreatic fluid collections, the use of LAMS has been extended to gallbladder and biliary drainage, treatment of luminal strictures, creation of gastrointestinal fistulae, pancreaticobiliary drainage, improved access for surgically altered anatomy, and drainage of intra-abdominal and pelvic abscesses as well as post-surgical fluid collections. As new indications of endosonographic techniques and LAMS continue to evolve, this review summarizes the current role of LAMS in the management of these various complex conditions and also highlights clinical pearls to guide successful placement of LAMS.
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http://dx.doi.org/10.3748/wjg.v26.i21.2715DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7284179PMC
June 2020

Comparative effectiveness of pharmacologic and endoscopic interventions for prevention of post-ERCP pancreatitis: a network meta-analysis.

Endosc Int Open 2020 Jan 8;8(1):E29-E40. Epub 2020 Jan 8.

Center for Interventional Endoscopy, Florida Hospital, University of Central Florida College of Medicine, Orlando, Florida, United States.

 While several interventions may decrease risk of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis, it remains unclear whether one strategy is superior to others. The purpose of this study was to compare the effectiveness of pharmacologic and endoscopic interventions to prevent post-ERCP pancreatitis among high-risk patients. A systematic review was performed to identify randomized controlled trials from PubMed, Embase, Web of Science, and Cochrane database through May 2017. Interventions included: rectal non-steroidal anti-inflammatory drugs (NSAIDs), aggressive hydration with lactated ringer's (LR) solution, and pancreatic stent placement compared to placebo. Only studies with patients at high-risk for post-ERCP pancreatitis were included. Bayesian network meta-analysis was performed and relative ranking of treatments was assessed using surface under the cumulative ranking (SUCRA) probabilities.  We identified 29 trials, comprising 7,862 participants comparing four preventive strategies. On network meta-analysis, compared with placebo, rectal NSAIDs (B = - 0.69, 95 % CI [-1.18; - 0.21]), pancreatic stent (B = - 1.25, 95 % CI [-1.81 to -0.69]), LR (B = - 0.67, 95 % CI [-1.20 to -0.13]), and combination of LR plus rectal NSAIDs (B = - 1.58; 95 % CI [-3.0 to -0.17]), were all associated with a reduced risk of post-ERCP pancreatitis. Pancreatic stent placement had the highest SUCRA probability (0.81, 95 % CI [0.83 to 0.80]) of being ranked the best prophylactic treatment.  Based on this network meta-analysis, pancreatic stent placement appears to be the most effective preventive strategy for post-ERCP pancreatitis in high-risk patients.
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http://dx.doi.org/10.1055/a-1005-6366DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6949176PMC
January 2020

Response to Letter to the Editor: Impact of Bariatric Surgery on Outcomes of Patients with Sickle Cell Disease: a Nationwide Inpatient Sample Analysis, 2004-2014.

Obes Surg 2019 08;29(8):2624

Section of Digestive Diseases, Yale University School of Medicine, 333 Cedar St, New Haven, CT, 06520, USA.

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http://dx.doi.org/10.1007/s11695-019-03956-8DOI Listing
August 2019

Neoadjuvant vs. adjuvant chemotherapy for cholangiocarcinoma: A propensity score matched analysis.

Eur J Surg Oncol 2019 Aug 21;45(8):1432-1438. Epub 2019 Mar 21.

Department of Oncology, Mayo Clinic, Rochester, MN, 55905, USA. Electronic address:

Background: Chemotherapy is frequently used in cholangiocarcinoma as an adjunct to surgical resection, but the appropriate sequence of chemotherapy with surgery is unclear.

Patients And Methods: Using the National Cancer Database, we identified patients who underwent surgery and chemotherapy for stage I-III cholangiocarcinoma between 2006 and 2014. The propensity score reflecting the probability of receiving neoadjuvant chemotherapy was estimated by multivariate logistic regression method. Patients in the neoadjuvant and adjuvant chemotherapy study arms were then propensity-matched in 1:3 ratios using the nearest neighbor method. Overall Survival (OS) in the matched data set was estimated using the Kaplan-Meier method. Hazard ratios (HRs) were calculated using Cox proportional hazard regression model.

Results: Of the 1450 patients who met our inclusion criteria, 299 (20.6%) received neoadjuvant chemotherapy while 1151 (79.3%) received adjuvant chemotherapy. The median age at diagnosis was 63 years. 278 patients in the neoadjuvant group were matched to 700 patients in the adjuvant group. In the matched cohort, patients who received neoadjuvant chemotherapy had a superior OS compared to those who received adjuvant chemotherapy (Median OS: 40.3 vs. 32.8 months; HR: 0.78; 95% CI: 0.64-0.94, p = 0.01). The 1- and 5-year OS rates for the neoadjuvant chemotherapy group were 85.8% and 42.5% respectively compared to 84.6% and 31.7% for the adjuvant chemotherapy group.

Conclusion: In this large national database study, neoadjuvant chemotherapy was associated with a longer OS in a select group of patients with cholangiocarcinoma compared to those who underwent upfront surgical resection followed by adjuvant chemotherapy.
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http://dx.doi.org/10.1016/j.ejso.2019.03.023DOI Listing
August 2019

Impact of Bariatric Surgery on Outcomes of Patients with Sickle Cell Disease: a Nationwide Inpatient Sample Analysis, 2004-2014.

Obes Surg 2019 06;29(6):1789-1796

Section of Digestive Diseases, Yale University School of Medicine, 333 Cedar St., New Haven, CT, 06520, USA.

Background: With advances in disease-specific treatments and improved overall survival, obesity rates are rising among patients with sickle cell disease (SCD). The primary aim of this study was to evaluate the role of bariatric surgery on clinical outcomes among hospitalized obese patients with SCD.

Methods: The United States Nationwide Inpatient Sample database was queried between 2004 and 2014 for discharges with co-diagnoses of morbid obesity and SCD. The primary outcome was in-hospital mortality. Secondary outcomes included vaso-occlusive crisis, acute chest syndrome, biliary-pancreatic complications, renal failure, urinary tract infection, malnutrition, sepsis, pneumonia, respiratory failure, thromboembolic events, strictures, wound infection, length of stay, and hospitalization costs. Using Poisson regression, adjusted incidence risk ratios (IRR) were derived for clinical outcomes in patients with prior-bariatric surgery compared to those without bariatric surgery.

Results: Among 2549 patients with a discharge diagnosis of SCD and morbid obesity, only 42 patients (1.7%) had bariatric surgery. On multivariable analysis, bariatric surgery did not influence mortality (P = 0.98). Bariatric surgery was not associated with increased risk for acute chest syndrome, sepsis, multi-organ failure, biliary-pancreatic, or surgery-related complications (all P > 0.05). Interestingly, bariatric surgery decreased risk of vaso-occlusive crises (IRR 0.21; 95% CI, 0.07-0.69; P = 0.01) in these patients and was associated with a shorter length of stay (P < 0.001) but higher hospitalization costs (P < 0.001).

Conclusions: Bariatric surgery may lower rates of vaso-occlusive crises in morbidly obese sickle cell patients without significantly affecting mortality and other adverse outcomes. In spite of this, these weight loss surgeries are underutilized in this select population.
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http://dx.doi.org/10.1007/s11695-019-03780-0DOI Listing
June 2019

Impact of bariatric surgery on outcomes of patients with celiac disease: a nationwide inpatient sample analysis, 2004-2014.

Ann Gastroenterol 2019 Jan-Feb;32(1):73-80. Epub 2018 Nov 2.

Section of Digestive Diseases, Yale University School of Medicine, New Haven, CT (Basile Njei), USA.

Background: While patients with celiac disease have increasingly developed an atypical pattern of weight gain and obesity, the role of bariatric surgery remains unclear. The primary aim of this study was to evaluate the effect of bariatric surgery on clinical outcomes among hospitalized patients with celiac disease.

Methods: The United States Nationwide Inpatient Sample database was queried for discharges with co-diagnoses of morbid obesity and celiac disease between 2004 and 2014. The primary outcome was in-hospital mortality. Secondary outcomes included renal failure, urinary tract infection, malnutrition, sepsis, pneumonia, respiratory failure, thromboembolic events, strictures, micronutrient deficiency, length of stay, and hospitalization costs. Using Poisson regression, adjusted incidence risk ratios (IRR) were derived for clinical outcomes in patients with prior bariatric surgery compared to those without bariatric surgery.

Results: Among 1499 patients with a discharge diagnosis of celiac disease and morbid obesity, 126 patients (8.4%) underwent bariatric surgery. Despite an increase in morbid obesity over the study period, the proportion of morbidly obese patients with celiac disease who had bariatric surgery declined by 18.5% (P<0.05). On multivariable analysis, bariatric surgery did not influence mortality (P=0.98), but was associated with a lower risk of renal failure, pneumonia, sepsis, urinary tract infection and respiratory failure (all P<0.05). Bariatric surgery increased the risk of vitamin D deficiency (IRR 3.5; 95% confidence interval [CI] 1.6-7.7; P=0.002) and post-operative strictures (IRR 3.3; 95%CI 1.5-7.5; P=0.004).

Conclusion: Despite the underutilization of bariatric surgery in morbidly obese celiac disease patients, the procedure is safe and appears to significantly reduce morbidity.
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http://dx.doi.org/10.20524/aog.2018.0323DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6302198PMC
November 2018

Impact of bariatric surgery in patients with HIV infection: a nationwide inpatient sample analysis, 2004-2014.

AIDS 2018 09;32(14):1959-1965

Section of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut, USA.

Objective: Despite rising rates of obesity among patients with HIV, the potential role for weight loss surgery in this population remains less clear. The primary aim of this study was to evaluate the role of bariatric surgery on relevant clinical outcomes among hospitalized obese patients with HIV.

Design: Retrospective analysis using the United States Nationwide Inpatient Sample database from 2004 to 2014. Using Poisson regression, adjusted incidence risk ratios (IRR) were derived for clinical outcomes in patients with prior-bariatric surgery compared with those without bariatric surgery.

Patients: Patients with discharge co-diagnoses of morbid obesity and HIV.

Intervention: Bariatric surgery.

Main Outcome Measures: Primary outcome was in-hospital mortality. Secondary outcomes included renal failure, urinary tract infection, malnutrition, sepsis, pneumonia, respiratory failure, thromboembolic events, gastrointestinal strictures, micronutrient deficiency, length of stay, and hospitalization costs.

Results: Among 7803 patients with discharge diagnoses of HIV and morbid obesity, 346 patients (4.4%) had bariatric surgery. The proportion of bariatric surgery in obese patients with HIV initially declined by -0.10% per year from 2004 to 2009 (Ptrend < 0.05), then increased at an annual rate of +0.33% from 2012 to 2014 (Ptrend < 0.05). On multivariable analysis, bariatric surgery did not influence mortality (P = 0.98). Bariatric surgery was associated with decreased risk for renal failure, respiratory failure, and sepsis (all P < 0.001). However, bariatric surgery increased the risk for postoperative strictures (IRR 2.5; 95% CI 1.5-4.5; P = 0.001).

Conclusion: Though initially underutilized, bariatric surgery in morbidly obese HIV patients is increasing and appears to be well tolerated and effective in significantly reducing life-threatening morbidity.
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http://dx.doi.org/10.1097/QAD.0000000000001915DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6126912PMC
September 2018

Cannabis Use Is Associated With Increased Risk of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis: Analysis of the US Nationwide Inpatient Sample Database, 2004-2014.

Pancreas 2018 10;47(9):1142-1149

From the Section of Digestive Diseases and.

Objective: The aim of this study was to investigate the impact of cannabis on post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP).

Methods: The US Nationwide Inpatient Sample was queried to identify patients who underwent endoscopic retrograde cholangiopancreatography pancreatitis from 2004 to 2014. Cannabis use was identified by International Classification of Diseases, Ninth Edition codes, and patients in remission were excluded. Poisson regression models were used to derive adjusted incidence risk ratios (IRRs) for outcomes.

Results: Among 37,712 patients with PEP, 0.4% had documented cannabis use disorder. From 2004 to 2014, the rate of PEP and cannabis use increased (8.9%-11.0% [P < 0.01] and 0.20%-0.70% [P < 0.01], respectively). Univariate analysis demonstrated cannabis was associated with increased risk of PEP (IRR, 1.70; 95% confidence interval [CI], 1.50-1.90; P < 0.01). On multivariate analysis, cannabis use was an independent predictor of PEP (IRR, 1.2; 95% CI, 1.1-1.4; P = 0.004). Cannabis was not associated with in-hospital death (IRR, 0.15; 95% CI, 0.02-1.04; P = 0.06) but was associated with shorter hospital stay (IRR, 0.96; 95% CI, 0.94-0.98; P < 0.001) and lower costs (IRR, 0.91; 95% CI, 0.91-0.92; P < 0.001).

Conclusions: Cannabis use was associated with an increase in PEP without significant increase in mortality.
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http://dx.doi.org/10.1097/MPA.0000000000001143DOI Listing
October 2018

Bariatric Surgery and Hepatocellular Carcinoma: a Propensity Score-Matched Analysis.

Obes Surg 2018 12;28(12):3880-3889

Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Boston, MA, USA.

Background: The association between obesity and rising incidence of hepatocellular carcinoma (HCC) in the USA has been documented; however, the role of bariatric surgery remains less clear.

Aim: To evaluate the cross-sectional association of prior-bariatric surgery and HCC.

Methods: The United States Nationwide Inpatient Sample (NIS) database was queried from 2004 to 2014 for discharges with a diagnosis of morbid obesity. Primary outcomes of interest were HCC and in-hospital mortality rate. Secondary outcomes were length of stay and cost. Baseline characteristics were balanced using propensity score matching (PSM). Using Poisson and logistic regressions, adjusted HCC prevalence ratio (PR) and mortality odds ratio (OR) were derived in patients with prior-bariatric surgery compared to those without bariatric surgery.

Results: Of the 2,881,414 patients included in our study, 267,082 (9.3%) underwent bariatric surgery. From 2004 to 2014, there was a threefold increase in age-adjusted prevalence of HCC from 27 per 100,000 to 72 per 100,000 (P < 0.001). After PSM, 230,956 patients with prior-bariatric surgery were matched with 230,956 patients without bariatric surgery. Prior-bariatric surgery was associated with lower prevalence of HCC (PR 0.11; 95% CI, 0.03-0.48; P < 0.001). In-hospital mortality was also lower for patients with surgery (OR 0.22; 95% CI, 0.20-0.26; P < 0.001). The occurrence of HCC added $18,840 extra cost, increased mean length of stay by 2 (95% CI; 1-3) days, and increased risk of death by 65% (aOR 1.65; 95% CI 1.18-2.29).

Conclusion: In this nationwide study of morbidly obese patients, prior-bariatric surgery was associated with a lower prevalence of HCC and lower in-patient mortality.
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http://dx.doi.org/10.1007/s11695-018-3431-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6219901PMC
December 2018

Weekend Effect in Acute Pancreatitis-Related Hospital Admissions in the United States: An Analysis of the Nationwide Inpatient Sample.

Pancreas 2018 Apr;47(4):418-424

Objective: This study aimed to assess the difference in overall outcomes between weekend admissions for acute pancreatitis (AP) and weekday admissions.

Methods: Between 2005 and 2012, data were extracted from the Nationwide Inpatient Sample on adult patients with AP. Exclusion criteria were applied for chronic pancreatitis and other pancreatic and biliary malignancies. In-hospital mortality, length of stay, hospitalization costs, comorbidities, complications, and intervention rates were compared between the weekend and weekday admissions.

Results: During the study period, there were a total of 432,303 weekday admissions and 147,435 weekend admissions for AP in the United States hospitals. Weekend AP admissions were more likely to develop alcohol withdrawal (5.9% vs 5.7%, P = 0.001) and ileus (4.1% vs 3.1%, P = 0.04). They were also more likely to develop acute respiratory distress syndrome (4.7% vs 4.4%, P < 0.001) and required more endotracheal intubation (3.9% vs 3.6%, P < 0.001). There was no significant in-hospital mortality difference between the weekend and weekday admissions on both univariate and multivariate analysis.

Conclusions: Weekend AP admissions develop more severe complications requiring intensive care. Despite this, there was no weekend effect for in-hospital mortality for AP-related admissions.
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http://dx.doi.org/10.1097/MPA.0000000000001008DOI Listing
April 2018

Demographics, tumor characteristics, treatment, and survival of patients with Klatskin tumors.

Ann Gastroenterol 2018 Mar-Apr;31(2):231-236. Epub 2018 Feb 8.

Hematology-Oncology Fellowship Program, Mayo Clinic, Rochester, MN (Siddhartha Yadav), USA.

Background: The objective of this study was to investigate the incidence, demographics, tumor characteristics, treatment, and survival of patients with hilar cholangiocarcinoma.

Methods: Data on Klatskin tumors between 2004 and 2013 was extracted from the Surveillance, Epidemiology and End Results Registry. The epidemiology of these tumors was then analyzed.

Results: A total of 254 patients with Klatskin tumors were identified. The overall age-adjusted incidence of Klatskin tumors between 2004 and 2013 was 0.38 per 1,000,000 per year. A gradual decline in the incidence was noted, with the highest (0.44) in 2005 and lowest (0.24) in 2010. Males had a higher incidence of Klatskin tumors compared to females (0.47 vs. 0.25 per 1,000,000 per year). These tumors were more common among Asian and Pacific islanders, who had an age-adjusted incidence rate of 0.48 per 1,000,000. Incidence increased with age, with the peak incidence between the ages of 80 and 84 years. The majority of the tumors were extrahepatic (67.3%). Approximately one-fourth (22.4%) of these patients had metastatic disease at presentation. Only 26.8% of patients had surgically resectable disease at presentation. One- and 5-year cause-specific survival for Klatskin tumors was 41% and 10.4%, respectively, with a median survival of 7 months. On Cox proportional hazard regression analysis, extrahepatic tumors (hazard ratio [HR] 0.54, 95% confidence interval [CI] 0.37-0.80, P=0.02) and those treated surgically (HR 0.47, 95%CI 0.29-0.77, P=0.003) had significantly better outcomes.

Conclusions: Klatskin tumors are rare and have a very poor prognosis with low survival rate. Among these tumors, extrahepatic and surgically treated tumors tend to have better outcomes.
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http://dx.doi.org/10.20524/aog.2018.0233DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5825954PMC
February 2018

Impact of Bariatric Surgery on Outcomes of Patients with Inflammatory Bowel Disease: a Nationwide Inpatient Sample Analysis, 2004-2014.

Obes Surg 2018 04;28(4):1015-1024

Section of Digestive Diseases, Yale University School of Medicine, 333 Cedar St, New Haven, CT, 06520, USA.

Purpose: There is a paucity of data regarding the benefits of bariatric surgery in patients with inflammatory bowel disease (IBD). The primary aim of this study was to evaluate the role of bariatric surgery on clinical outcomes among hospitalized patients with IBD.

Materials And Methods: The United States (US) National Inpatient Sample database was queried between 2004 and 2014 for discharges with co-diagnoses of morbid obesity and IBD. Hospitalizations with a history of prior-bariatric surgery were also identified. The primary outcome was in-hospital mortality. Secondary outcomes included renal failure, under-nutrition, thromboembolic events, strictures, fistulae, length of stay, and hospitalization costs. Using Poisson regression, adjusted incidence risk ratios (IRR) were derived for clinical outcomes in patients with prior-bariatric surgery compared to those without bariatric surgery.

Results: Among 15,319 patients with a discharge diagnosis of IBD and morbid obesity, 493 patients (3.2%) had bariatric surgery. From 2004 to 2014, the proportion of obese IBD patients that underwent bariatric surgery declined (5.2 versus 3.1%). In a multivariable analysis, prior-bariatric surgery was associated with decreased IRR for renal failure, under-nutrition, and fistulae formation in morbidly obese IBD patients [(IRR 0.1; 95% CI 0.02-0.3; P < 0.001), (IRR 0.2; 95% CI 0.05-0.8; P = 0.03), and (IRR 0.1; 95% 0.2-08; P = 0.03), respectively]. Bariatric surgery did not influence mortality (P = 0.99).

Conclusions: Despite a gradual increase in morbid obesity among patients with IBD, there has been a decrease in proportion of overall bariatric surgeries. Bariatric surgery appears to reduce morbidity in obese patients with IBD.
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http://dx.doi.org/10.1007/s11695-017-2959-0DOI Listing
April 2018

Secondary systemic amyloidosis in inflammatory bowel disease: a nationwide analysis.

Ann Gastroenterol 2017 14;30(5):504-511. Epub 2017 Jun 14.

Division of Nephrology and Hypertension, MedStar Georgetown University Hospital, Washington (Mark Abi Nader), USA.

Background: Secondary systemic amyloidosis (SSA) is a rare but severe complication of inflammatory bowel disease (IBD). We aimed to evaluate the clinical characteristics, predictors of complications, and in-hospital mortality of patients with Crohn's disease (CD) and Ulcerative colitis (UC) who develop SSA.

Methods: Using the National Inpatient Sample, we identified patients hospitalized for IBD and SSA between 2004 and 2012. Using multivariate logistic regression, patients with CD were compared with those with UC regarding the presence or absence of SSA. IBD patients without SSA were matched in a 2:1 ratio with those with SSA using propensity matching. We analyzed the hospitalization trends of SSA in CD and UC patients using Pearson's χ test. Analyses were performed using SAS version 9.3.

Results: Among the 302,548 patients with CD and 174,057 patients with UC hospitalized between 2004 and 2012, we identified 47 (0.02%) and 36 (0.02%) cases of SSA, respectively. We noted rising annual hospitalization trends for both CD and UC patients with or without SSA. In-hospital mortality was significantly higher for both the UC+SSA group (16.7% vs. 2.1%, P<0.0001) and the CD+SSA group (6.4% vs. 1.0%, P=0.0001) before propensity matching. However, this difference was not seen for either UC+SSA (17.1% vs. 7.1%, P=0.11) or CD+SSA (6.8% vs. 2.3%, P=0.20) after matching.

Conclusions: SSA rarely affects IBD patients, but when it does, it is associated with increased rates of infection, severe sepsis, and multi-organ system involvement. Despite this, SSA does not affect in-hospital mortality in IBD patients. Further studies are needed to explore this association.
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http://dx.doi.org/10.20524/aog.2017.0168DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5566770PMC
June 2017

Balloon enteroscopy versus spiral enteroscopy for small-bowel disorders: a systematic review and meta-analysis.

Gastrointest Endosc 2017 Dec 23;86(6):997-1005. Epub 2017 Jun 23.

Division of Digestive and Liver Diseases, Cedars-Sinai Medical Center, Los Angeles, California, USA.

Background And Aims: Two novel enteroscopic procedures, balloon enteroscopy and spiral enteroscopy, have revolutionized the diagnostic and therapeutic approach to small-bowel disorders. These disorders that historically required surgical interventions are now investigated and managed nonsurgically. Only a few weakly powered studies have compared the outcomes of spiral enteroscopy and balloon enteroscopy. We conducted a systematic review and meta-analysis to compare the efficacy and safety of these 2 procedures.

Methods: PubMed, Cochrane Library, Scopus, and clinicaltrials.gov databases were searched for all studies published up to January 12, 2017 comparing the efficacy and safety of balloon enteroscopy (single or double) and spiral enteroscopy. Primary outcomes of interest were diagnostic and therapeutic success rates. Other outcomes included procedure length, depth of maximal insertion (DMI), rate of complete enteroscopy, and adverse events. We calculated Odds ratios (ORs) for categorical variables and mean difference (MD) for continuous variables. The Mantel-Haenszel method was used to analyze the data. Fixed and random effect models were used for <50% heterogeneity and >50% heterogeneity, respectively.

Results: Eight studies met the inclusion criteria for this meta-analysis. A total of 615 procedures were analyzed, which included 394 balloon enteroscopy and 221 spiral enteroscopy procedures. There were no significant differences in diagnostic and therapeutic success rates (OR, 1.27; 95% confidence interval [CI], .86-1.88; P = .22; and OR, 1.23; 95% CI, .82-1.84; P = .32, respectively) between the 2 procedures. Similarly, DMI was not significantly different between the 2 groups (MD, 26.29; 95% CI, 20.92-73.49; P = .28). However, the procedure time was significantly shorter for the spiral enteroscopy group compared with the balloon enteroscopy group (MD, 11.26; 95% CI, 2.72-19.79; P = .010). A subgroup analysis comparing double balloon enteroscopy with spiral enteroscopy yielded similar results.

Conclusions: Both procedures achieved similar diagnostic and therapeutic outcomes and with similar depth of insertion. Spiral enteroscopy has the benefit of shorter procedural time.
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http://dx.doi.org/10.1016/j.gie.2017.06.015DOI Listing
December 2017

Burkitt lymphoma as a lead point for jejunojejunal intussusception in a human immunodeficiency virus patient.

Clin J Gastroenterol 2017 Aug 18;10(4):342-350. Epub 2017 May 18.

Section of Digestive Diseases, Yale New Haven Hospital, 40 Temple Street, Suite 1A, New Haven, CT, 06510-2715, USA.

Intussusception is commonly seen in children but is rare in adults and represents only 5% of all intussusceptions causing 1% of intestinal obstructions. More than 50% of these intussusceptions in adults are due to intestinal neoplasms, including malignant lymphoma, e.g., Burkitt lymphoma. These lymphomas are more common in human immunodeficiency virus (HIV)-positive patients than in the general population. We present a case of a young male who was diagnosed with HIV when he developed intestinal obstruction and intussusception secondary to Burkitt lymphoma. He was managed with surgical resection followed by chemotherapy and antiretroviral treatment. HIV patients presenting with acute abdomen pose a diagnostic challenge to clinicians due to a wide range of differential diagnoses including inflammatory, infectious and neoplastic conditions. In a young HIV patient presenting with acute abdomen, intussusception caused by Burkitt lymphoma should be considered in the differential.
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http://dx.doi.org/10.1007/s12328-017-0747-yDOI Listing
August 2017

In-Hospital Mortality in Cirrhotic Patients with End-Stage Renal Disease Treated with Hemodialysis Versus Peritoneal Dialysis: A Nationwide Study.

Perit Dial Int 2017 Jul-Aug;37(4):464-471. Epub 2017 Mar 27.

Department of Nephrology, MedStar Georgetown University, Washington, DC, USA; Kidney Care Consultants, Memphis, TN, USA.

Background: Cirrhotic patients often develop end-stage renal disease (ESRD) requiring renal replacement therapy in the form of hemodialysis (HD) or peritoneal dialysis (PD). Studies comparing the outcomes and difference in in-hospital mortality between these 2 groups, particularly among those with ascites, are sparse. We set our objective to determine the dialysis modality with a better in-hospital survival rate among cirrhotic patients with ESRD (ESRD-cirrhosis).

Methods: Data was extracted from the 2005 to 2012 Nationwide Inpatient Sample (NIS). Using propensity score matching, ESRD-cirrhosis patients on PD were matched with patients on HD at a 1:1 ratio. Another subgroup analysis of ESRD-cirrhosis patients with ascites was performed using the same matching algorithm. Analyses were performed using SAS version 9.3 (SAS Institute, Cary, NC, USA).

Results: Among 26,135 cirrhotic patients with incident ESRD, 25,686 (98.3%) and 449 (1.7%) were initiated on HD and PD, respectively, during the hospitalization. There was a nonsignificant mortality difference between the ESRD-cirrhosis patients treated with PD and those treated with HD. In a subgroup analysis of these patients with ascites, 18 patients underwent PD while 1,878 patients required HD. Also, PD had a significantly lower in-hospital mortality compared with HD in this subgroup (0% vs 26.67%, = 0.03). Mean length of stay for those who received HD was 8.34 days compared with 7.06 days for the PD group ( < 0.0001). Similarly, mean hospital charges were greater for those who had HD compared with PD ($74,501 vs $57,460; < 0.001).

Conclusion: Cirrhotic patients with ESRD and ascites who undergo PD have a significantly lower mortality than those who are started on HD. However PD is rarely initiated for ESRD in cirrhotic patients with ascites during hospitalization in the United States. Due to the potential advantages of PD, nephrologists should encourage PD when selecting dialysis modality in this subgroup of patients whenever possible.
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http://dx.doi.org/10.3747/pdi.2016.00131DOI Listing
May 2018

Sclerosing mesenteritis: a systematic review of 192 cases.

Clin J Gastroenterol 2017 Apr 14;10(2):103-111. Epub 2017 Feb 14.

Gastroenterology Center of Connecticut, Clinical Instructor of Medicine, Yale University School of Medicine, Hamden, 06518, CT, USA.

Introduction: Sclerosing mesenteritis includes a spectrum of inflammatory disorders involving the adipose tissue of the bowel mesentery.

Aim: To perform a systematic review of previously reported cases of sclerosing mesenteritis (SM) to determine the epidemiology, risk factors, methods of diagnosis, treatment patterns and outcomes for this disease.

Methods: Medline, PubMed, Google Scholar and Cochrane database were searched using keywords mesenteric panniculitis, retractile mesenteritis, mesenteric lipodystrophy and sclerosing mesenteritis. Data was collated into a single excel database, transferred into SPSS (Version 21.0) and analyzed.

Results: Patients diagnosed with SM were between ages of 3 and 88 with a mean age of 55 ± 19.2 years. SM was more common in Caucasians (n = 28, 60.8% of those reporting ethnicity) and men (n = 133, 69.3%) with a male to female ratio of 2.3:1. 28.6% (n = 55) of patients reported a prior abdominal surgery or abdominal trauma, 8.9% (n = 17) had a history of malignancy, and 5.7% (n = 11) of autoimmune disease. 85.4% (n = 164) underwent surgical abdominal exploration (open or laparoscopic); 41.7% (n = 80) had surgery with resection of the involved bowel and mesentery. 34.9% (n = 67) of patients received medical treatment with the majority of them receiving steroids (n = 56, 83.5%). Symptom duration of more than a month (66.7% vs 40.4%, p < 0.05), underlying autoimmune disorder (14.3% vs 4.0%, p < 0.05) or low protein (14.3% vs 4.0%, p < 0.05) at presentation were seen more frequently in those with poor treatment response whereas patients with tender abdomen (45.0% vs 19.0%, p < 0.05) or leukocytosis (20.5% vs 0.0%, p < 0.05) at presentation were likely to have good response to therapy. The most common complications included bowel obstruction/ileus/ischemia (n = 10, 23.8%) and obstructive uropathy/renal failure (n = 10, 23.8%). There were a total of 14 deaths, 12 (85.7%) of which were secondary to SM related complications.

Conclusion: SM is a poorly understood chronic inflammatory disease. Our study is the first systematic review of the published cases of SM. Future work is required to better understand this disease and its optimal therapy.
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http://dx.doi.org/10.1007/s12328-017-0716-5DOI Listing
April 2017

Atypical Mycobacterial Infection after Abdominoplasty Overseas: A Case Report and Literature Review.

Case Rep Infect Dis 2016 27;2016:3642567. Epub 2016 Dec 27.

Department of Infectious Diseases, Yale New Haven Health System, Bridgeport Hospital, Bridgeport, CT 06610, USA.

Increasing number of medical tourists travel internationally for cosmetic procedures. is a form of medical tourism becoming popular among patients of developed countries due to the cost efficiency of cosmetic procedures when performed in developing nations. There is a paucity of data on quality, safety, and risks involved with these surgeries. Many cases of infections have been documented in patients following cosmetic surgeries in developing countries. We present a case of a 34-year-old female who underwent abdominoplasty in Dominican Republic that was complicated with development of multiple abdominal wall abscesses due to infection from rapidly growing mycobacteria (RGM). In the absence of clear treatment guidelines, she was treated with a combination of intermittent surgical drainage and prolonged antibiotic course. This case is of interest as more than one species of RGM was isolated from the same patient. Our case highlights the fact that identification of these organisms can be difficult requiring referral of samples to specialized laboratories and treatment duration can last several months, which is determined by clinical and microbiological response.
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http://dx.doi.org/10.1155/2016/3642567DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5223012PMC
December 2016

Ectopic expression of , encoding diacylglycerol -acyltransferase exclusively committed to TAG biosynthesis, enhances oil accumulation in seeds and leaves of Jatropha.

Biotechnol Biofuels 2016 21;9:226. Epub 2016 Oct 21.

Center for Energy, Indian Institute of Technology Guwahati, Guwahati, 781039 India ; Department of Biosciences and Bioengineering, Indian Institute of Technology Guwahati, Guwahati, 781039 India.

Background: is an important biofuel crop due to the presence of high amount of oil in its seeds suitable for biodiesel production. Triacylglycerols (TAGs) are the most abundant form of storage oil in plants. Diacylglycerol -acyltransferase (DGAT1) enzyme is responsible for the last and only committed step in seed TAG biosynthesis. Direct upregulation of TAG biosynthesis in seeds and vegetative tissues through overexpression of the could enhance the energy density of the biomass, making significant impact on biofuel production.

Results: The enzyme diacylglycerol -acyltransferase is the rate-limiting enzyme responsible for the TAG biosynthesis in seeds. We generated transgenic Jatropha ectopically expressing an gene through -mediated transformation. The resulting transgenic plants showed a dramatic increase in lipid content by 1.5- to 2 fold in leaves and 20-30 % in seeds, and an overall increase in TAG and DAG, and lower free fatty acid (FFA) levels compared to the wild-type plants. The increase in oil content in transgenic plants is accompanied with increase in average plant height, seeds per tree, average 100-seed weight, and seed length and breadth. The enhanced TAG accumulation in transgenic plants had no penalty on the growth rates, growth patterns, leaf number, and leaf size of plants.

Conclusions: In this study, we produced transgenic Jatropha ectopically expressing . We successfully increased the oil content by 20-30 % in seeds and 1.5- to 2.0-fold in leaves of Jatropha through genetic engineering. Transgenic plants had reduced FFA content compared with control plants. Our strategy of increasing energy density by enhancing oil accumulation in both seeds and leaves in Jatropha would make it economically more sustainable for biofuel production.
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http://dx.doi.org/10.1186/s13068-016-0642-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5073959PMC
October 2016

Posterior Reversible Encephalopathy Syndrome (PRES) Presenting as Status Epilepticus: A Case Report and Literature Review.

Conn Med 2016 Sep;80(8):475-478

Posterior reversible encephalopathy syndrome (PRES) is one of many causes of status epilepticus (SE). Itis defined classically as a clinical radiographic entity, characterized by presentation of headache, altered mental status, visual disturbances, seizures, and typical neuroradiographic findings of symmetrical white-matter edema. Predisposing conditions include uncontrolled hypertension, eclampsia, and use of chemotherapeu- tic and immunosuppressant agents. Bevacizumab (Avastin), a monoclonal antibody against vascular endothelial growth factor (VEGF), is used in a combination with FOLFOX [FOL - Folinic acid; F - Fluorouracil (5-FU); OX - Oxaliplatin] as a first-line treatment for patients with metastatic colorectal cancer. We present a case of a 52-year-old male on systemic chemotherapy with FOLFOX and bevacizumab who presented with SE and was diagnosed with PRES. His symptoms resolved with intensive control of blood pressure and discontinuation of chemotherapy. Bevacizumab-induced vasospasm, endothelial and blood-brain-barrier dysfunction, in combination with elevated blood pressure, were likely the underlying mechanism of PRES in our patient.
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September 2016

Paget-Schroetter syndrome after a dental procedure in a patient with factor V Leiden (R506Q) heterozygosity.

Authors:
Prabin Sharma

Blood Coagul Fibrinolysis 2017 Apr;28(3):269-271

Department of Internal Medicine, Bridgeport Hospital, Yale New Haven Health System, Bridgeport, Connecticut, USA.

: Paget-Schroetter syndrome or effort thrombosis is characterized by spontaneous thrombosis of the upper extremity venous system, commonly seen in a young healthy patient after repetitive use of the upper extremities. It is rarely associated with coagulopathy and thus, hypercoagulable work-up is not usually a part of the investigation. We present a first case of a young woman, who was diagnosed with left upper extremity effort thrombosis following a dental procedure. Interestingly, she was also noted to be heterozygous for factor V Leiden mutation.
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http://dx.doi.org/10.1097/MBC.0000000000000592DOI Listing
April 2017

Comparison of Demographics, Tumor Characteristics, and Survival Between Pancreatic Adenocarcinomas and Pancreatic Neuroendocrine Tumors: A Population-based Study.

Am J Clin Oncol 2018 05;41(5):485-491

Nancy and James Grosfeld Cancer Genetics Center, Beaumont Cancer Institute, Beaumont Health.

Objective: The objective of this study is to compare the incidence, demographics, tumor characteristics, and survival between patients with pancreatic neuroendocrine tumors (PNETs) and pancreatic adenocarcinomas.

Materials And Methods: Between 2004 and 2012, all cases of pancreatic adenocarcinomas and PNETs were extracted from the population-based cancer registries of the Surveillance Epidemiology and End Results program. To identify the cases, a combination of topographical and histology codes based on ICD-O-3 were used. Incidence, demographics, tumor characteristics, and survival was then compared between these 2 histologic subtypes of pancreatic cancer.

Results: A total of 57,688 patients with pancreatic cancer were identified, of which 53,753 (93%) had pancreatic adenocarcinoma and 3935 (7%) had PNET. The overall age-adjusted incidence of PNETs between 2004 and 2012 was 0.52 per 100,000 per year, whereas that for pancreatic adenocarcinomas during the same period was 7.34 per 100,000 per year. PNETs had a significantly younger median age at diagnosis (61 vs. 69 y). A significant proportion of PNETs were diagnosed at stage I (20.5% vs. 6.0%) and were well differentiated (32.8% vs. 4.5%) compared with adenocarcinomas. Five-year cause-specific survival was 51.3% and 5.0% for PNETs and pancreatic adenocarcinomas, respectively. In multivariate analysis, pancreatic adenocarcinomas had a hazard ratio for death of 4.02 (95% confidence interval, 3.79-4.28) when compared with PNETs.

Conclusions: PNETs present with favorable features such as higher proportion of early-stage tumor, higher proportion of well differentiated tumors, and younger age at diagnosis. PNETs have a significantly better survival than pancreatic adenocarcinomas even after adjusting for age, sex, race, site, grade, and stage.
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http://dx.doi.org/10.1097/COC.0000000000000305DOI Listing
May 2018

Colon Ischemia After Weight-Loss Medication in a 36-Year-Old Woman.

Conn Med 2016 Apr;80(4):213-5

Weight-loss medications have been associated with many conditions, including valvular heart disease, ischemic colitis, and pulmonary hypertension. There is a constant increase in the use of these drugs, especially new medications with better efficacy. Phentermine is one such drug, approved for short-term use to lose weight. We report a case of ischemic colitis in a female patient linked to inappropriate phentermine intake. The patient presented with symptoms of severe abdominal pain and repeated bowel movement associated with rectal bleeding for two weeks. Initial blood work was unremarkable for infectious and inflammatory causes. A CT scan was performed which revealed findings of ischemic colitis extending from transverse to descending colon. A biopsy study confirmed the same. Upon further questioning, the patient admitted to taking 37.5 mg of phentermine for two years beyond her prescribed period of 12 weeks. Hence, we propose that inappropriate use of phentermine caused ischemic colitis. With the widespread use of these medications, there is a need for heightened awareness among clinicians regarding adverse effects of phentermine.
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April 2016

A combination of intramural stomach and portal venous air: conservative treatment.

J Community Hosp Intern Med Perspect 2016 17;6(1):30519. Epub 2016 Feb 17.

Department of Internal Medicine (Rheumatology, Allergy and Immunology), Virginia Commonwealth University, Richmond, VA, USA.

Emphysematous gastritis is a severe and rare form of gastritis with characteristic findings of intramural gas in the stomach. It is an acute life-threatening condition resulting from gas-producing microorganisms invading the stomach wall. Early diagnosis and initiation of treatment with bowel rest, hydration, and intravenous broad-spectrum antibiotics is imperative for an effective outcome. Surgical intervention is reserved for perforations, peritonitis, strictures, and uncontrolled disseminated sepsis. We present a case of an 82-year-old female with prior history of colon and uterine cancer on remission treated with surgeries who presented with bilious vomiting, abdominal discomfort, and nausea. She was tachycardic and had a diffusely tender abdomen with rebound on examination. Her laboratory results including blood count, serum chemistry, and coagulation studies were normal. She was diagnosed with emphysematous gastritis based on the characteristic radiographic findings of intramural stomach gas and also the presence of gas in the portal venous system. It is important to differentiate emphysematous gastritis from gastric emphysema because of the difference in management and prognosis, as emphysematous gastritis has a worse outcome and requires aggressive management. Despite an anticipated poor prognosis due to the known grave outcomes of emphysematous gastritis, our patient was successfully managed with conservative treatment. We concluded that she developed emphysematous gastritis probably secondary to immunosuppression and possible mucosal tears from multiple bouts of vomiting. She had a stable hospital course and resolution with medical management most likely due to early diagnosis and initiation of appropriate treatment.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4763600PMC
http://dx.doi.org/10.3402/jchimp.v6.30519DOI Listing
April 2016

Transfusion-free management of gastrointestinal bleeding: the experience of a bloodless institute.

J Clin Gastroenterol 2015 Mar;49(3):206-11

*Department of Medicine ‡Department of Gastroenterology, Englewood Hospital and Medical Center, Englewood, NJ †University of Miami Leonard Miller School of Medicine, Miami, FL.

Goals: The Institute for Patient Blood Management and Bloodless Medicine at the Englewood Hospital has considerable experience in managing patients with gastrointestinal bleeding who do not accept blood-derived products. We present our data and experience over the last 8 years in managing such patients.

Background: There is paucity of data on management and outcomes of gastrointestinal bleeding in patients who do not accept blood-derived products.

Study: We performed a retrospective study of patients from 2003 to 2011 presenting with gastrointestinal bleeding who do not accept blood-derived products. Inclusion criteria were either overt bleeding with a presenting hemoglobin (Hb) of <12 g/dL or a decrease in Hb of >1.5 g/dL.

Results: Ninety-six patients who met the inclusion criteria were included. Forty-one upper and 48 lower gastrointestinal bleeding sources were identified. Mean Hb was 8.8 g/dL and mean nadir was 6.9 g/dL. Among 37 patients (80.5%) with Hb ≤6.0 g/dL, 30 (81%) survived. Four of 7 patients (57%) with a Hb <3 g/dL survived. The overall mortality rate was 10.4%. In unadjusted logistic regression models, age [1.06 (1.01-1.12 y)], admission to ICU [6.37(1.27-31.9)], and anticoagulation use [6.95 (1.57-30.6)] were associated with increased mortality. Initial Hb [0.68 (0.51-0.92)] and nadir Hb [0.48 (0.29-0.78)] inversely predicted mortality.

Conclusions: These results suggest that transfusion-free management of gastrointestinal hemorrhage can be effective with mortality comparable with the general population accepting medically indicated transfusion. Management of these patients is challenging and requires a dedicated multidisciplinary team approach knowledgeable in techniques of blood conservation.
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http://dx.doi.org/10.1097/MCG.0000000000000200DOI Listing
March 2015