Kröner, Paul T.

Abstract Background and study aims With newer imaging modalities, indications for use of endoscopic retrograde cholangiopancreatography (ERCP) have changed in the last decade. Despite advances in ERCP, paucity in recent literature regarding utilization and outcomes of ERCP exists. Thus, the aim of this study was to assess the inpatient use of ERCP, outcomes, and most common indications. Patients and methods Retrospective-cohort study using the Nationwide Inpatient Sample 2007–2016. All patients with ICD9–10CM procedural codes for ERCP were included. The primary outcome was the use of ERCP. Secondary outcomes included determining procedural specifics (stenting, sphincterotomy and dilation), complications (post-ERCP pancreatitis [PEP], bile duct perforation), hospital length of stay, total hospital costs and charges. Multivariate regression analysis was used to adjust for confounders. Results A total of 1,606,850 patients underwent inpatient ERCP. The mean age was 59 years (60 % female). The total number of ERCPs increased over the last decade. Patients undergoing ERCP in 2016 had greater odds of undergoing bile duct stent placement, pancreatic duct (PD) stenting, biliary dilation, pancreatic sphincterotomy, PEP and biliary perforation. Inpatient mortality decreased. Hospital charges increased, while length of stay (LOS) decreased. Conclusions The number of ERCPs increased in the past decade. Odds of therapeutic interventions and complications increased. The most common principal diagnoses were choledocholithiasis and gallstone-related AP. Hence, physicians must be aware to promptly diagnose and treat complications. These findings may reflect the increased case complexity and fact that ERCP continues to evolve into an increasingly interventional tool, contrasting from its former role as a predominantly diagnostic and gallstone extraction tool.

Abstract Inflammatory bowel disease can manifest in many extraintestinal organ systems. The most frequently involved extraintestinal locations include the mucocutaneous, hepatobiliary, and ocular organ systems. The respiratory tract is less commonly involved and is therefore frequently overlooked. Consequently, it is believed that involvement of the respiratory tract in patients with inflammatory bowel disease is underreported. The pathogenesis is thought to be multifactorial, involving the common embryologic origin shared by the respiratory and luminal digestive tract, molecular mimicry, and immunologic interactions leading to immune-complex deposition in affected tissue. The spectrum of manifestations of the respiratory tract related to inflammatory bowel disease is broad. It not only includes direct involvement of the respiratory tract (ie, airways, interstitium, and pleura) but also can result as a consequence of systemic involvement such as in thromboembolic events. In addition, it may also be related to other conditions that affect the respiratory tract such as sarcoidosis and alpha-1 antitrypsin deficiency. Though some conditions related to respiratory tract involvement might be subclinical, others may have life-threatening consequences. It is critical to approach patients with suspected inflammatory bowel disease–related respiratory tract involvement in concert with pulmonology, infectious diseases, and any other pertinent experts, as treatments may require a multidisciplinary overlap of measures. Therefore, it is of paramount importance for the clinician to be aware of the array of respiratory tract manifestations of patients with inflammatory bowel disease, in addition to the possible spectrum of therapeutic measures.

Background/Objectives: Arthritis is a known manifestation of hereditary hemochromatosis. However, whether patients with hereditary hemochromatosis have an increased risk of having joint replacement surgery compared to the general population is still unknown. This meta-analysis was conducted to better characterize this risk. Methods: A comprehensive literature review was conducted utilizing the MEDLINE and EMBASE databases through September 2019 to identify all cohort studies that compared prevalence or incidence of joint replacement surgery (hip, ankle, or knee) between patients with hereditary hemochromatosis and individuals without hereditary hemochromatosis. Effect estimates from each study were extracted and combined together using the random-effect, generic inverse variance method of DerSimonian and Laird. Results: A total of five studies with 1 293 407 participants fulfilled the eligibility criteria and were included in the meta-analysis. Overall, the risk of having joint replacement surgery was significantly increased in patients with hereditary hemochromatosis compared to individuals without hereditary hemochromatosis with the pooled relative risk (RR) of 3.32 [95% confidence interval (CI), 1.60–6.86; I 2 88%]. Analysis by joint found a significantly increased risk of having hip and ankle replacement surgery among patients with hereditary hemochromatosis compared with the pooled RR of 2.62 (95% CI, 2.09–3.30; I 2 47%) and 8.94 (95% CI, 3.85–20.78; I 2 14%), respectively. The risk of having knee replacement surgery was also increased but was not statistically significant (pooled RR 1.57, 95% CI, 0.83–2.98; I 2 66%). Conclusions: A significantly increased risk of needed joint replacement surgery among patients with hereditary hemochromatosis compared to patients without hereditary hemochromatosis was demonstrated in this study. Further studies are required to determine whether this association is causal.

Abstract Objective To characterize inpatient epidemiology and economic burden of granulomatosis with polyangiitis (GPA). Methods Patients with GPA were identified from the Nationwide Inpatient Sample (NIS), the largest inpatient database in the USA consisting of over 4000 non-federal acute care hospitals, using the ICD-9 CM code. A cohort of comparators without GPA was also constructed from the same database. Data on demographics, procedures, length of stay, mortality, morbidity and total hospitalization charges were extracted. All analysed data were extracted from the database for the years 2005–2014. Results The inpatient prevalence of GPA was 32.6 cases per 100 000 admissions. GPA itself (38.3%), pneumonia (13.7%) and sepsis (8.4%) were the most common reasons for admission. After adjusting for potential confounders, the all-cause mortality adjusted odds ratio (aOR) of patients with GPA was significantly higher than that of patients without GPA (aOR 1.20; 95% CI: 1.41, 1.61). This was also true for several morbidities, including acute kidney injury, multi-organ failure, shock and need for intensive care unit admission. Hospitalizations of patients with GPA were associated with higher cost as demonstrated by an adjusted additional mean of $5125 (95% CI: $4719, $5531) for total hospital cost and an adjusted additional mean of $16 841 (95% CI: $15 280, $18 403) for total hospitalization charges when compared with patients without GPA. Conclusion Inpatient prevalence of GPA was higher than what would be expected from prevalence in the general population. Hospitalizations of patients with GPA were associated with higher morbidity, mortality and cost.

Background This study aimed to evaluate the hospitalization rate for Hepatitis A virus (HAV) among kidney transplant (KTx) recipients and its outcomes as well as resource utilization. Methods The 2005–2014 National Inpatient Sample database was used to identify all hospitalized KTx recipients with an associated diagnosis of HAV. The hospital mortality, resource utilization, and associated liver conditions were compared between patients with and without HAV, adjusting for potential confounders. Results Of 871 024 KTx recipients identified, 204 had HAV. The overall inpatient prevalence of HAV in KTx recipients over 10 years in the United States was 23.42 cases per 100 000 admissions. There were no statistically significant changes in the inpatient prevalence of HAV in KTx recipients during the study period (P = 0.77), ranging from 9.2 to 34.3 per 100 000 admissions. Among hospitalized KTx recipients with HAV, 27.9% were from Northeast, 29.2% were from Midwest, 23.8% were from South, and 19.1% were from West. HAV was not significantly associated with increased hospital mortality, multiorgan failure, need for abdominal ultrasound, hospital length of stay, and total hospitalization costs and charges when compared with those without HAV. However, it is significantly associated with increased ICU stay, coexisting hepatitis B and C infection, and liver failure. Conclusion Overall, inpatient prevalence of HAV in KTx recipients in the United States (years 2005–2014) was 23.42 cases per 100 000 admissions. Hospitalization for HAV after KTx is associated with increased ICU stay, coexisting hepatitis B and C infection, and liver failure.

Objective Cholangiocarcinoma (CCA) affects all ethnicities worldwide. The Hispanic population being the leading ethnic minority in the United States, its importance to the healthcare system cannot be understated. This study aims to assess the occurrence and outcomes of CCA in Hispanic patients in the United States. Methods This is a case-control study using the National Inpatient Sample 2014. All patients with ICD-9 CM codes for CCA were included. Hispanic patients were identified from the ethnic categories within the database. The primary outcomes were the occurrence and odds of CCA in the Hispanic population when compared with other ethnicities. Secondary outcomes were inpatient mortality, morbidity, ICU stay, multiorgan failure, and resource utilization. Results A total of 13 965 patients with CCA were identified, of which 2750 were propensity-matched to controls (1480 Hispanic). The inpatient occurrence of CCA in Hispanics relative to the national population was 2.73/100 000 persons, compared to 4.82/100 000 persons (39.9/100 000 relative to inpatient population) of all other ethnicities. After adjusting for confounders on multivariate analysis, Hispanic patients displayed adjusted propensity-matched odds of 1.28 (P < 0.01) of having CCA when compared with other ethnicities. Hispanics did not display different propensity-matched odds of inpatient mortality, morbidity, hospital length of stay, or resource utilization compared to non-Hispanic patients. Conclusion This study demonstrated that the odds of CCA in admitted patients are higher for the Hispanic population. This difference with the prevalence potentially suggests the presence of social factors such as disparities in cancer prevention or detection in this group.

Abstract Background Bacteremia due to Staphylococcus aureus is a known complication of liver transplantation (LT). Studies have shown that LT recipients are more predisposed to S. aureus infections than other solid-organ transplant patients; however, these studies have been limited in scope and mostly based out of single centers. Methods This is a retrospective cohort study using 2012–2016 NIS, the largest public inpatient database in the United States. All patients with ICD9-10CM procedural codes for LT were included. The cohort was stratified into two groups depending on whether they had MSSA or MRSA infection. The odds of inpatient mortality in both groups of patients undergoing LT were determined. The inpatient mortality odds were then compared with those of patients undergoing LT without associated S. aureus infection. Other outcomes included inpatient morbidity, resource utilization, hospital length of stay (LOS), and inflation-adjusted total hospital costs and charges. Multivariate regression analyses were used to adjust for demographic variables and Charlson Comorbidity Index. Results A total of 26,415 patients underwent LT in the study period, of which 180 had MSSA and 160 had MRSA infection reported. The mean age was 51.5 years and 35.6% were female. Patients with MSSA and MRSA displayed significantly higher inpatient mortality rates (11.1% and 9.4%, respectively) compared with non-MSSA/MRSA patients (3.4%) who underwent LT (P < 0.01). After adjusting for confounders, patients with MSSA infection displayed higher mortality odds (aOR: 4.45, P < 0.01), while patients with MRSA infection had non-statistically significant higher inpatient mortality odds (aOR: 3.10, P = 0.12) compared with patients without MSSA/MRSA infection. Both MSSA and MRSA cohorts displayed higher mortality odds if the infection resulted in sepsis (aOR: 9.92 and 5.70, respectively; P < 0.01). Conclusion There is a direct correlation between S. aureus bacteremia and increased mortality rates and incidence of sepsis and shock in LT recipients. Patients with S. aureus bacteremia spent more days in hospital and had higher cost of healthcare. Preventing and aggressively treating S. aureus infections in the immediate post-LT setting is key to reducing mortality, morbidity and resource utilization in patients undergoing LT. Disclosures All authors: No reported disclosures.

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.