JGH Open最新文献

Background

Hookworms primarily parasitize in the intestinal tract, and the gastric involvement is extremely rare, which often leads to misdiagnosis. We present two cases of hookworm infection that mimicked early gastric carcinoma.

Case Summary

Two patients presented with clear boundaries gastric mucosa lesions exhibiting brownish discoloration, resembling early gastric mucosal cancer. Live hookworms were identified on the gastric mucosal surface using magnifying endoscopy combined with narrow-band imaging. Hookworm eggs were detected in both patients through fecal etiological evaluation. Following standard anthelmintic treatment, both the lesions and the worms resolved.

Conclusions

In the differential diagnosis of localized well-defined gastric mucosal lesions, parasitic infections should be considered in addition to neoplastic lesions. Magnifying endoscopy plays a critical role in distinguishing gastric mucosal lesions suspicious for parasitic infection.

Background

Treatments for hepatorenal syndrome with acute kidney injury (HRS-AKI) that are not FDA-approved have been widely used in the United States (US) with variable outcomes. This study describes the practice patterns, outcomes, and healthcare utilization around vasopressor use before terlipressin approval in 2022.

Methods

A retrospective chart review study was conducted at 10 US medical centers, assessing adult patients diagnosed with HRS-AKI between 2016 and 2019. The primary outcome was treatment response (change in serum creatinine [SCr] from the day of vasopressor treatment initiation to Day 14/vasopressor discontinuation). Secondary outcomes included overall and transplant-free survival, treatment patterns, and healthcare resource use.

Results

Of the 198 eligible patients, 129 and 69 had mild/moderate (SCr < 5 mg/dL, acute-on-chronic liver failure [ACLF] ≤ 2) and severe disease (SCr ≥ 5 mg/dL, ACLF > 2), respectively. The mean age was 57 years; 52.5% were males, and 71.2% were White. Alcohol-associated cirrhosis (53.5%) was the most common cause of cirrhosis. All 198 patients had a physician-diagnosed HRS-AKI, and only 30.3% met all International Club of Ascites (ICA)-HRS criteria. Most patients (85.4%) initiated treatment with midodrine and octreotide for a median of 7 days. The overall response rate (n = 157) was 20.3%. Median (95% CI) overall and transplant-free survival from vasopressor initiation was 48 (32–81) and 28 (19–36) days. Notably, 33.8% of patients died during hospitalization, and 31.3% required renal replacement therapy.

Conclusion

Before 2022, hospitalized HRS-AKI patients experienced suboptimal treatment response with off-label treatments and poor survival. There remains an unmet need for safe and effective non-transplant treatments for hospitalized HRS-AKI patients in the United States.

Introduction

Diverticular hemorrhage is the most common cause of lower gastrointestinal bleeding (LGIB). Because spontaneous hemostasis frequently occurs, identifying the bleeding diverticulum via colonoscopy or iodinated contrast angiography remains challenging. Recently, several reports have demonstrated the utility of CO2 angiography in identifying the bleeding source.

Case Presentation

The patient was a 73-year-old male referred to our hospital for hematochezia and was ultimately diagnosed with colonic diverticular hemorrhage. Despite repeated massive hemorrhage, spontaneous hemostasis prevented localization of the bleeding site; neither colonoscopy nor conventional iodinated contrast angiography detected the source. Finally, CO2 angiography was performed to successfully identify the bleeding site, which enabled transcatheter arterial embolization to achieve hemostasis.

Conclusion

In cases of recurrent diverticular bleeding where the bleeding site remains undetectable, CO2 angiography may be an effective method to identify the source and guide targeted therapy.

Introduction

Vascular intestinal disorders (VID), including mesenteric ischemia, ischemic colitis, and intestinal angiodysplasia, have a global incidence of 8.11/100 000/year and a mortality of 1.26/100 000/year (15.5% death rate), rising from ~1% to ~3% in childhood to ~50% after 95 years. In the US, the incidence of acute vascular insufficiency of the intestine (AVII) is rising, warranting detailed trend analysis.

Methods

CDC WONDER death certificates (1999–2020) for adults > 25 years were analyzed using ICD-10 code N55. Age-adjusted mortality rates (AAMRs) per 100 000 were stratified by year, sex, race/ethnicity, and region. Joinpoint Regression (v5.2.0) calculated annual percent changes (APCs); significance was defined as p < 0.05.

Results

Overall AAMR declined from 9.35 (1999) to 5.81 (2020). Women had higher AAMRs (7.63; 95% CI: 7.6–7.66) than men (6.5; 95% CI: 6.49–6.56). By race/ethnicity, AAMRs were highest in NH American Indian (7.89; 95% CI: 7.57–8.21), NH Black (7.84; 95% CI: 7.75–7.9), NH White (7.25; 95% CI: 7.22–7.28), Hispanic (5.91; 95% CI: 5.83–6), and NH Asian (3.59; 95% CI: 3.5–3.68). Micropolitan areas had higher AAMRs (7.92) than metropolitan (6.99). Regional AAMRs were highest in the Midwest (7.7; 95% CI: 7.65–7.75), followed by South (7.17; 95% CI: 7.13–7.21), West (7.02; 95% CI: 6.96–7.07), and Northeast (6.85; 95% CI: 6.79–6.9). Kentucky had the highest state AAMR (9.67; 95% CI: 9.43–9.9), Hawaii the lowest (4.59; 95% CI: 4.31–4.87). Oklahoma, Rhode Island, Tennessee, West Virginia, and Wyoming ranked in the top 90th percentile.

Conclusion

Despite an overall decline, VID mortality remains high among women, NH American Indians, rural areas, and the Midwest—underscoring the need for targeted interventions.

Aim

Although pemafibrate, a selective peroxisome proliferator-activated receptor α (PPARα) modulator primarily prescribed for hypertriglyceridemia, may improve liver function in patients with metabolic dysfunction-associated steatotic liver disease (MASLD), its efficacy has not been sufficiently evaluated. This study aimed to assess the effect of pemafibrate on liver function in patients with MASLD using a nationwide multicenter cohort.

Methods

In this nationwide multicenter study, we analyzed 352 patients diagnosed with MASLD and hypertriglyceridemia who newly initiated pemafibrate therapy. The primary outcome was the rate of ALT normalization (ALT ≤ 30 U/L). Laboratory data were collected at baseline and 3, 6, and 12 months after pemafibrate initiation, and longitudinal changes were evaluated.

Results

The mean ALT levels decreased significantly from 60.1 ± 1.8 U/L at baseline to 44.9 ± 1.4, 41.6 ± 1.3, and 38.1 ± 1.3 U/L at 3, 6, and 12 months, respectively (all p < 0.001). The ALT normalization rate increased from 30.4% at baseline to 46.0%, 50.9%, and 56.6% at 3, 6, and 12 months (p < 0.001), respectively, with marked improvement at three months and maintenance throughout follow-up.

Conclusions

Pemafibrate treatment significantly improved ALT levels and ALT normalization rates in MASLD patients with hypertriglyceridemia, with improvement observed at three months and a sustained effect up to 12 months. This is a large-scale multicenter study to date evaluating pemafibrate in MASLD, providing robust evidence for its potential as a therapeutic option in this population.

Introduction

Cirrhosis progresses from compensated to decompensated phases, often marked by portal hypertension and complications like ascites, variceal hemorrhage, and hepatic encephalopathy. The ammonia-to-urea (A-to-U) ratio, reflecting urea cycle efficiency, may offer superior diagnostic performance compared to plasma ammonia levels alone. This study compared the diagnostic accuracy of the A-to-U ratio and plasma ammonia levels for identifying portal hypertension.

Methods

We conducted a derivation (2019–2020) and validation (2020–2022) study in patients with chronic liver disease. In the derivation study, outcomes included imaging findings of portal hypertension and clinically significant portal hypertension (CSPH) per BAVENO VII criteria. Validation outcomes encompassed CSPH, gastroesophageal varices, and portal hypertensive gastropathy.

Results

In the derivation study (n = 180), the A-to-U ratio, but not plasma ammonia, showed high diagnostic accuracy for detecting imaging findings suggestive of portal hypertension and CSPH (A-to-U ratio > 1.53 mg/g; diagnostic odds ratio [dOR], 4.04 [95% CI, 1.98–8.24; p < 0.0001] and dOR, 5.71 [95% CI, 2.87–11.37; p < 0.0001], respectively), and this association with CSPH remained significant after adjustment for renal function. In the validation study (n = 232), an A-to-U ratio > 1.53 mg/g had a dOR of 9.42 (95% CI, 4.63–19.21; p < 0.0001) for the diagnosis of CSPH. An A-to-U ratio > 1.53 mg/g showed independent associations with esophageal varices (dOR 4.44; 95% CI, 1.44–13.72; p = 0.01) and portal hypertensive gastropathy (dOR 9.33; 95% CI 2.65–32.92; p = 0.0005), whereas the BAVENO VII criteria did not.

Discussion

Our study suggests that an A-to-U ratio > 1.53 mg/g may serve as a useful noninvasive tool for identifying CSPH, gastroesophageal varices, and portal hypertensive gastropathy in patients with chronic liver disease.

Background

Global evidence has observed that individuals with inflammatory bowel disease (IBD) are at a heightened risk of experiencing psychiatric disorders, which often coincide with a decrease in their quality of life.

Objective

To assess the prevalence of anxiety and depression symptoms and associated factors among patients with IBD.

Methods

An institutional-based cross-sectional study was conducted at Tikur Anbesa Specialized Hospital and Adera Medical Center. Categorical variables were presented using frequency and percentage and compared between groups using the chi-square test. The normal distribution of the continuous variables was assessed using the Shapiro–Wilk test. Mean and standard deviation were calculated for normally distributed data, while the median and interquartile range were calculated for skewed data. We used univariate and multivariate binary logistic regression analysis to examine the factors associated with depression and anxiety; results were reported as adjusted odds ratios (OR) with 95% confidence intervals and p value < 0.05 considered statistically significant.

Results

The prevalence of anxiety and depression was 5.1% and 7.1%, respectively, in IBD. Moderate disease activity (AOR = 16.1 (1.7, 156.7), p = 0.015) and severe disease activity (AOR = 49.8 (2.1, 1144.02), p = 0.014) had a statistically significant association with increased rates of depressive symptoms. Moderate disease activity (AOR = 9.9, 95% CI: 0.9, 106.2, p = 0.058) had a positive association. Severe disease activity (AOR = 45.3, 95% CI: 2.0, 1018.0, p = 0.016) has a significant associated factor with having anxiety symptoms.

Conclusion

The prevalence of anxiety and depressive symptoms in this study was generally low but can increase due to important factors such as disease activity, smoking, unemployment, a short duration after diagnosis, and having ulcerative IBD.

Aims

Many patients develop Fontan-associated liver disease (FALD) after undergoing the Fontan procedure—a surgical treatment for congenital heart disease such as single ventricle—owing to changes in venous pressure and cardiac output. Liver biopsy is the gold standard for diagnosing FALD, but has limitations. Magnetic resonance elastography (MRE) is a popular non-invasive method for evaluating liver stiffness and fibrosis in FALD; however, no unified view exists. This study aimed to assess the usefulness of MRE in evaluating the pathophysiology of FALD, including its correlation with cardiovascular parameters and histological findings.

Methods and Results

This retrospective cohort study included 22 patients with FALD who underwent MRE at Yokohama City University Hospital. Patients with other liver diseases or a history of heavy alcohol consumption were excluded. Liver biopsies were assigned a congestive hepatic fibrosis score (CHFS). Liver stiffness was measured using MRE, and hemodynamic data were obtained using cardiac catheterization. The correlation between MRE-based liver stiffness and clinical, laboratory, and pathological findings was analyzed.

Patients' median age was 21.5 years, and the Fontan procedure was performed 16.3 years (mean) ago. Biochemical findings showed elevated gamma-glutamyl transpeptidase (GGT) levels. Mean liver stiffness measured using MRE was high (5.3 kPa), which significantly correlated with CHFS stage of liver fibrosis, and also correlated with GGT levels, fibrosis 4 index, and central venous pressure.

Conclusion

MRE seems a promising non-invasive tool for liver fibrosis evaluation in FALD. However, it may also reflect hepatic congestion. Further studies are needed to establish its clinical utility and standard cutoff values.

Objective

To compare the timing intervals of surveillance colonoscopies after resection for colorectal cancer with recommendations in the Australian Clinical Practice Guidelines for Surveillance Colonoscopy.

Study Design

A retrospective, observational study.

Data Sources

Adults who had a resection for colorectal cancer from the Costs of Surviving Cancer—Queensland Study (COS-Q), which is a retrospective population-based cohort study of all individuals diagnosed with a primary cancer from 2005 to 2015.

Results

In total, 7265 patients that underwent resection of colorectal cancer were included for analysis. Most patients had a pre-operative colonoscopy (6636, 87.6%) while 899 patients (12.4%) had no pre-operative colonoscopy. 82.1% of patients had their first surveillance colonoscopy as recommended by the Guidelines. In contrast, after the first post-operative surveillance colonoscopy without polypectomy, 978 of 1015 (96.4%) had a second surveillance colonoscopy early by at least 6 months. Thirty seven (1.7%) had the surveillance colonoscopy on time or later than recommended. Being female or having a pre-operative colonoscopy was associated with an early second surveillance colonoscopy (odds ratio 2.2, p < 0.05). Early surveillance colonoscopies incurred costs up to AU$3.78 million.

Conclusions

Most post-resection surveillance colonoscopies for patients with colorectal cancer are performed earlier than recommended. Since colonoscopies in patients at low risk of cancer recurrence were generally performed too early, there is evidence of the potential overuse of healthcare resources and the opportunity to improve hospital efficiency.

Introduction

Potential delays in patient care during weekends have not been studied in liver transplantation (LT) for acute liver failure (ALF). We evaluated the impact of listing after a weekend on waitlist (WL) and post-LT outcomes in ALF patients.

Methods

In a retrospective cohort study of adult ALF patients from February 2002 to May 2023 in the United Network for Organ Sharing (UNOS) database, the primary exposure was listing after a weekend. Multinomial regression and Cox models assessed WL outcomes and post-LT mortality, respectively, adjusting for potential confounders. Inverse probability censoring weighting addressed censoring bias.

Results

Among 6600 adults listed for LT, 840 (13%) were listed after a weekend. The median number of days from admission to waitlisting was 2 (IQR1–3). Accounting for potential confounders, patients listed after a weekend had a lower likelihood of spontaneous survival (SS; relative risk ratio 0.74, 95% CI 0.61–0.90, LT as reference). Post-LT mortality at 1 year was higher in patients listed after a weekend (HR 1.25, 95% CI: 1.01–1.54). IPW cohort outcomes corroborated these findings.

Conclusions

Among adults with acute liver failure, listing for liver transplantation after a weekend was associated with lower rates of spontaneous survival and higher one-year post-transplant mortality. Identifying system-level factors contributing to delays in transplant evaluation over weekends may help improve the timeliness and efficiency of care.