Kesler, Alex M.

Object Spinal arthropathy is associated with hereditary hemochromatosis and has been linked to calcium pyrophosphate dehydrate crystal deposition (CPPD) which resembles ankylosing spondylitis on radiograph, yet lacks clinical findings of inflammatory spinal arthritis. The aim of our study was to assess the use of spinal surgery and its outcomes in the US inpatient population with hereditary hemochromatosis from 2012 to 2016 by using the US Nationwide Inpatient Sample (NIS) database. Methods The observational retrospective cohort study uses the NIS 2012 to 2016. All patients with hereditary hemochromatosis were included using International Classification of Diseases 9th and 10th revisions, Clinical Modification codes. The cohort was stratified according to having undergone spinal surgery and substratified by the type of surgery. The primary outcome was determining the use of spinal surgery in patients with hereditary hemochromatosis. Secondary outcomes were determining length of hospital stay and total hospital charges and costs. Results A total of 39 780 patients with hereditary hemochromatosis were identified and propensity matched to nonhereditary hemochromatosis controls. The mean patient age was 61 years, and 65% were females. For the primary outcome patients with hereditary hemochromatosis underwent significantly more spinal fusion surgery compared to patients without hereditary hemochromatosis odds of 2.13 (P = 0.05). While there was no difference in mean LOS, or costs, patients with hereditary hemochromatosis had higher hospital charges. Conclusion Hereditary hemochromatosis is associated with higher odds of spinal fusion. It is a major complication not improved by phlebotomy, and there are currently no therapies to prevent this joint disease.

INTRODUCTION: Ileus is a known early complication following kidney transplant (KTx). There is limited data largely from case reports documenting the occurrence of ileus in KTx patients. Potential risk factors include post-operative setting, steroid withdrawal, or even peritoneal sclerosis in patients with a history of peritoneal dialysis (PD). The aim of this study is to assess inpatient prevalence and outcomes of ileus in the same admission as the KTx occurred. METHODS: Case-control study using the NIS 2012-2016. The ICD9-10CM procedural codes for KTx were used to identify all patients that underwent KTx during the same admission. None were excluded. Patients with associated ileus were identified using ICD9-10CM diagnostic codes. The primary outcome was determining the odds of ileus in post-KTx patients. Secondary outcomes were inpatient mortality, postoperative complications, resource utilization, length of hospital stay (LOS), total hospitalization charges and costs. Propensity score matching was used to create a matching population for gender, age and Charlson Comorbidity Index. Multivariate analysis were used to adjust for income in patients’ zip code, hospital region, location, size and teaching status. RESULTS: A total of 89,065 KTx patients were identified, of which 16,880 were propensity score matched for the selected covariates. The mean patient age was 50 years, and 40% were female. On multivariate analysis, the odds of ileus in the KTx cohort was 3.90 ( P < 0.01) compared to patients who did not undergo KTx surgery. When patients that underwent KTx and developed ileus during the admission, they had greater adjusted odds of shock, TPN, AKI, multi-organ failure, post-op infection, Deep Vein Thrombosis, Pulmonary Embolism, and bleeding compared to patients with no KTx. In addition, those who developed ileus had greater hospitals costs, charges, and length of stay (LOS) (Table 1). CONCLUSION: Patients undergoing kidney transplant are more likely to develop ileus than patients who did not have kidney transplant surgery, confirming known reports documenting ileus in the early post-operative period. This cohort of patients who developed ileus following transplant have greater odds of post-operative complications, as well as increased morbidity, resource utilization and economic burden. Future studies should focus on elucidating the etiology of ileus following kidney transplant, as well as associated factors, and creating strategies to address it.

INTRODUCTION: Patients with Celiac disease (CD) are at increased risk of infections, as evidenced by increased prevalence of tuberculosis, influenza, and sepsis. Alterations in immunity and microbiota can contribute to this predisposition. Although the prevalence of Clostridium difficile infection (CDI) continues to increase in the US, there is little data on the association and outcomes in patients with CD. The aim of this study was to assess inpatient prevalence, outcomes and resource utilization of patients with CD and CDI in the US in the past decade. METHODS: Retrospective cohort study using the NIS 2007 to 2016. All patients with CD were included using ICD9-10CM codes. Cohorts were stratified for CDI coexistence. None were excluded. The primary outcome was determining the association of CD with CDI. Secondary outcomes were determining the CDI inpatient prevalence trend in the CD patients, as well as mortality, morbidity, length of hospital stay (LOS), total hospital charges and costs, which were adjusted for inflation using the Consumer Price Index. Multivariate regression was used to adjust for age, gender, income in patient zip code, Charlson Comorbidity Index, hospital region, location, size and teaching status. RESULTS: A total of 337,201 patients with CD were identified, of which 5,500 had associated CDI. Mean age was 55 years and 71% were female. The inpatient prevalence of CDI in patients with CD increased from 0.9/100,000 admissions in 2007 to 1.65/100,000 admissions in 2016. Patients with CD displayed increased adjusted odds (aOR:1.56, P < 0.01) of coexisting CDI compared to patients without CD. Patients with CD had lower odds of mortality, ICU, shock, multiorgan failure, hospital costs, charges, and LOS but increased odds of requiring TPN compared to the general population admitted population with CDI. CONCLUSION: Patients with CD had higher odds of CDI compared to non-CD patients, which could be attributed to CD-related gut mucosal integrity, immunological or microbiome alterations. The inpatient prevalence of CDI in patients with CD increased from 2007 to 2016. This may be a reflection of the general increase of CDI cases in the inpatient population and with improved CD diagnostic modalities. Patients with CD and CDI did show decreased morbidity/mortality and resource utilization, suggesting that the clinical course is less severe. Further studies should further assess the gut immunological and microbiome changes in CD to clarify potential factors associated with CDI.

INTRODUCTION: Gender in ulcerative colitis (UC) is a well-studied topic with contradicting results with a slight male predominance seen in large population based studies in Olmsted County, Minnesota, while other studies have shown a slight female predominance. Yet, the relationship between UC and gender is not well-understood. Hence, it is unclear what is responsible for differences in gender. The aim of this study is to assess the inpatient prevalence and inpatients outcomes of UC by gender. METHODS: Case-control study using the NIS 2016, the largest public inpatient database in the US. All patients with ICD9-10CM codes for UC were included. None were excluded. Female patients were identified within the database using the female gender indicator. The primary outcome was determining the odds of UC in female patients compared to males. Secondary outcomes included determining inpatient morbidity, mortality, resource utilization, colectomy rates, hospital length of stay (LOS), and inflation-adjusted total hospital costs and charges. Propensity score matching was used to create a matching population for Charlson Comorbidity Index and age. Multivariate regression analyses were used to adjust for income in patient zip code, hospital region, location, size and teaching status. RESULTS: A total of 38, 950 patients with UC were identified and propensity matched for selected covariates. The mean patient age was 45, and 47.2% were female. For the primary outcome, females had decreased adjusted odds (aOR: 0.92, P < 0.01) of being admitted for UC. For secondary outcomes, female patients displayed lower adjusted odds of multi-organ failure, being placed on TPN, and undergoing colectomy. Females also had lower adjusted mean hospital costs, charges, and length of stay (LOS). All adjusted odds and means are displayed in Table 1. CONCLUSION: Females have lower inpatient prevalence of UC, complications, and economic burden compared to males. This reinforces the slight male predominance that was seen in the older Olmstead County population-based studies. One can speculate that the difference in complications, costs, charges, and LOS indicate that females have less severe disease at hospital admission. Numerous studies have examined the effect of gender on disease severity and outcomes, and there continues to be conflicting data. Thus, future studies are needed to determine what contributes to the variation in disease prevalence and course by gender, and possibly better tailor treatment regimens by gender.

INTRODUCTION: Esophageal food impaction is a commonly encountered clinical scenario that may warrant emergent intervention, but epidemiological studies are lacking. No major studies have examined the inpatient prevalence of food impaction during the weekend. Therefore, the aim of our study is to assess the inpatient prevalence of food impaction during the weekend compared to week days. METHODS: Case-control study using the NIS 2016, the largest public inpatient database in the US. All patients with ICD10CM codes for food bolus impactions were included. None were excluded. The primary outcome was determining the odds of food bolus impaction during the weekend days as compared to the weekdays. Secondary outcomes included determining rates of esophageal perforation, hospital costs, charges and length of stay (LOS) when comparing admissions during a weekend to admissions during a weekday. Multivariate regression analyses were used to adjust for age, gender, Charlson Comorbidity Index, income in patient zip code, hospital region, location, size and teaching status. RESULTS: 7,025 patients with food bolus impaction were identified. 2,475 underwent emergent EGD (within 24 hours) and 1,935 were admitted during the weekend. Mean patient age was 66.7 years (47.9% were female). Primary outcome: after adjusting for confounders, patients admitted for food impaction displayed significantly higher odds of admission during the weekend days (aOR:1.5, P < 0.01) when compared to the weekdays. No significant difference in esophageal perforation was observed between the two cohorts. Patients admitted during the weekend displayed lower hospitalization costs compared to patients admitted during the weekdays (aMean: -$1,756, P = 0.02), but no differences in hospitalization charges or length of stay were observed. All outcomes are displayed in Table 1. CONCLUSION: The odds of being admitted for esophageal food impaction are higher on weekends than weekdays. There are no different odds of esophageal perforation. This may be reflecting the previous studies demonstrating increased odds of food impaction during leisure times, as weekends in the US are often reserved for leisure activities rather than work. Interestingly, patients admitted during the weekend actually have lower adjusted mean hospital costs. This may suggest that these patients are likely admitted for observation or stay longer periods of time in the ED and hence do not generate the same hospital bill as an admission.

Abstract Hypokalemic periodic paralysis (HOKPP) is a rare neuromuscular disorder caused by altered transport of cellular potassium that leads to significant muscle weakness of the extremities. Paralytic attacks are induced by a drop in the serum potassium level and they have been associated with specific triggers. This case describes a 21-year-old male who has had recurrent presentations of acute paralytic attacks following vigorous physical activity. At presentation, this patient exhibited flaccid paralysis of all skeletal muscles below the neck, but was alert and oriented with stable vital signs. The patient was found to have a potassium level of 2.1 mmol/L and an EKG demonstrating U waves (characteristic of hypokalemia). The patient was treated with potassium supplementation with resolution of symptoms. The mainstay of prevention of long term permanent muscle weakness is avoidance of triggers that can lead to hypokalemia. Through education on disease process and lifestyle modifications, we were able to end the cycle of recurrent hospital readmissions and the subsequent financial burden this generated for the patient and his family.