Citations

Malnutrition, defined as deficiency, excess, or imbalance of nutrients, is a common complication in patients with liver disease, especially those with cirrhosis. Malnutrition may present as an isolated micronutrient deficiency, such as zinc deficiency, and it commonly presents as frailty and/or sarcopenia in patients with advanced liver disease. Patients with cirrhosis and/or alcohol-associated hepatitis should be assessed for malnutrition because it adversely affects patient outcomes including mortality, as well as waitlist and posttransplant outcomes among liver transplant candidates. The prevalence of malnutrition varies based on the method of assessment and disease severity, being higher in those with advanced liver disease. Among stable outpatients with cirrhosis, counseling should be done to eat small frequent meals, a night-time snack between 7 PM and 10 PM, and 2 or more cups of coffee daily. In selected patients with metabolic dysfunction-associated steatohepatitis, vitamin E 800 IU/d should be provided. Among hospitalized patients with cirrhosis, nutritional supplementation preferably by enteral route should be implemented in those with poor oral intake of daily requirements of proteins and/or calories. Protein intake should not be restricted including patients with decompensated cirrhosis and hepatic encephalopathy. A vegetable source of protein seems to be better tolerated than an animal source of protein in patients with hepatic encephalopathy. Branched chain amino acids augment the efficacy of lactulose and rifaximin in the treatment of hepatic encephalopathy. Level of evidence and strength of recommendations were evaluated using the Grading of Recommendations, Assessment, Development, and Evaluations system. This guideline was developed under the auspices of the American College of Gastroenterology Practice Parameters Committee.

Background Previous studies have demonstrated disparities in the utilization of diabetes technology among youth with type 1 diabetes (T1D) based on race and socioeconomic status (SES). Few studies have examined these differences on a national scale or among youth with commercial health insurance. Aim To investigate differences in the fill rates of insulin pumps and continuous glucose monitors (CGMs) among commercially insured children with T1D across diverse racial and SES groups. Methods Using medical and pharmacy claims included in the OptumLabs Data Warehouse, we calculated the proportion of youth <18 years with T1D who had a fill for an insulin pump or a CGM, overall and stratified by race/ethnicity and annual household income, between 2011 and 2021. Results Among 13,246 youth with T1D, 36.1% had CGM and 30.9% had pump fills. White youth had higher CGM and pump fills than black (CGMs: 35.8% vs 22.5%; pumps: 31.9% vs 21.2%, p<0.001) and Hispanic (CGMs: 35.8% vs 32.6%, p=0.047; pumps: 31.9% vs 25.0%, p<0.001). Youth from households with income <US$40,000 had lower CGM and pump fills than those with income ≥US$200,000 (CGM 25.4% vs 43.8%; pumps: 22.4% vs 38.8%, p<0.001). Within similar incomes <US$40,000, black youth had fewer CGM and pump fills than white youth (CGM: 15.2% vs 27.9%, p=0.006; pumps: 12.9% vs 25.5%, p=0.004). This racial difference disappeared with income ≥US$200,000 (CGMs: 47.5% for black vs 43.1% for white; pumps: 45.9% for black vs 38.3% for white, p=0.45 and p=0.57, respectively). Conclusions In a cohort of commercially insured youth with T1D, both race and income are important factors that can independently influence the use of diabetes technology. Racial disparities decrease with higher income and disappear at incomes ≥US$200,000. Black youth with income <US$40,000 are at the highest exclusion risk from essential technologies. Greater effort is needed at both the system and individual levels to mitigate these disparities.

Abstract Aims Aortic regurgitation (AR) arises from leaflet disease and/or dilatation of the functional aortic annulus complex. Understanding the mechanisms of AR informs surgical planning of valve and aorta repair. This study investigates the mechanisms, aetiologies, and outcomes of isolated native severe AR in a consecutive cohort of patients. Methods and results Patients with moderate-to-severe (3+)/severe (4+) native valve AR, identified from our institutional echocardiography database (2014–2018), were included. Exclusions were significant concomitant valve disease, endocarditis, or aortic dissection. AR was classified per the El-Khoury system: Type I (normal leaflet motion: Ia–ascending aorta/sinotubular junction dilatation, Ib–aortic root dilation, Ic–aortic annular dilation), Type II (leaflet prolapse), and Type III (leaflet restriction). Valve anatomy and clinical outcomes, including mortality and surgical intervention, were analyzed. Of 282 patients (77.3% male), 58.5% had multiple AR mechanisms. Type II (leaflet prolapse) was most common (48.6%), followed by Type III (36.2%). Bicuspid aortic valve (BAV) represented 35.5% of the population, with leaflet prolapse observed in 72%. Multiple mechanisms were more frequent in BAV (77% vs. 48%, P &lt; 0.001). After a median follow-up of 4.7 years (available for 97.5% of patients), 158 (57.5%) underwent an intervention with 48.7% having an aortic valve repair or valve-sparing aortic root replacement. Conclusion Although leaflet prolapse (Type II) was the pre-dominant AR mechanism, multiple contributing mechanisms were often present, particularly in BAV patients. Aortic valve repair accounted for nearly half of surgical interventions, underscoring the importance of mechanism identification to optimize repair and avoid valve replacement.

Left ventricular assist device (LVAD) thrombosis typically presents late and may have devastating consequences for patients. While LVAD pump thrombosis is uncommon with current pump designs, many patients worldwide remain supported with previous generations of LVADs, including the HeartWare device (HVAD). Researchers have focused on investigating the acoustic signatures of LVADs to enable earlier detection and treatment of this condition. This study explored the use of machine learning algorithms to predict thrombosis from harmonic power values determined from the acoustic signatures of a cohort of HVAD patients (n = 11). The current dataset was too small to develop a predictive model for new data, but exhaustive cross validation indicated that machine learning models using the first two or the first three harmonic power values both resulted in reasonable prediction accuracy of the thrombosis outcome. Furthermore, when principal component analysis (PCA) was applied to the harmonic power variables from these promising models, the use of the resulting PCA variables in machine learning models further increased the thrombosis outcome prediction accuracy. K-nearest neighbor (KNN) models gave the best predictive accuracy for this dataset. Future work with a larger HVAD recording dataset is necessary to develop a truly predictive model of HVAD thrombosis. Such a predictive model would provide clinicians with a marker to detect HVAD thrombosis based directly on pump performance, to be used along with current clinical markers.

Cardiac cachexia (CC) is a severe complication of advanced heart failure (HF), characterized by involuntary weight loss and muscle wasting, leading to poor outcomes and higher mortality. Despite its severity, CC remains under-recognized and undertreated, lacking targeted therapies specifically addressing its pathophysiology. Glucagon-like peptide-1 receptor agonists (GLP-1RAs), though beneficial in reducing cardiovascular risk in patients with HF, may exacerbate muscle wasting in cachectic patients, necessitating further investigation. Non-pharmacological strategies, including tailored nutritional support and exercise programs, have shown positive effects on body composition and quality of life in patients with CC. However, there remains a gap in recommendations tailored to preventive strategies and pharmacologic therapies for patients with CC and concomitant GLP-1RA use. This review highlights the multifactorial mechanisms underlying CC and current and emerging therapeutic approaches for mitigating HF-related sarcopenia while on GLP-1RAs.

Percutaneous gastrostomy tube insertion in post Roux-en-Y patients can be challenging due to decompression of the excluded stomach and its discontinuity with the proximal enteric tract. Presented here is a 65-year-old woman status post Roux-en-Y gastric bypass who required gastrostomy tube placement for enteral feeding. The remnant stomach collapsed, and direct percutaneous gastric access was not possible for insufflation. To facilitate insufflation, computed tomography (CT) was used to access the duodenal bulb. This duodenal access was used to insufflate the stomach in a retrograde fashion which created a safe percutaneous window for gastrostomy tube placement into the remnant stomach. The technique described in this study can be a useful tool in patients with difficult to access remnant stomachs. Utilizing either direct or transhepatic access to the duodenum with ultrasound or CT guidance for remnant stomach insufflation can facilitate gastrostomy tube placement in challenging cases.

ABSTRACTBackgroundThis study investigates the association between thromboembolic events (TE) and castration‐resistant prostate cancer (CRPC) patients receiving oral androgen receptor pathway inhibitors (ARPi) compared to those undergoing chemotherapy, both with and without a pre‐existing history of cardiovascular disease (CVD).MethodsA total of 2779 men diagnosed with CRPC were identified using the Surveillance, Epidemiology, and End Results (SEER) Medicare Linked Database from 2012 to 2016. Patients were stratified based on their CVD history. Within each CVD stratum (pre‐existing CVD vs. no pre‐existing CVD), patients were further categorized into two treatment groups: those receiving oral ARPi and those undergoing chemotherapy. Unadjusted and inverse probability treatment weight (IPTW)‐adjusted proportional hazards models, using Fine and Gray's method, were applied to evaluate the potential association between ARPi treatment and TE.ResultsPatients with pre‐existing CVD treated with ARPi exhibited a significantly lower crude hazard ratio (HR) for TE compared to chemotherapy (HR 0.39, 95% CI 0.27–0.58, p < 0.001). However, after adjustment using IPTW, this association was no longer significant (adjusted hazard ratio [AHR] 1.00, 95% CI 0.75–1.32, p = 0.99). For patients without CVD, ARPi use was also associated with a reduced risk of TE in the crude analysis (HR 0.53, 95% CI 0.32–0.87, p = 0.01), but this effect was not statistically significant after IPTW adjustment (HR 0.99, 95% CI 0.69–1.41, p = 0.94).ConclusionARPi demonstrated no significant effect on TE risk compared to chemotherapy, regardless of pre‐existing CVD status. Similarly, when excluding patients with a prior history of TE, ARPi use remained non‐significantly associated with new TE in the IPTW‐adjusted competing risk analysis, highlighting the need for further investigation.

Summary: Computer vision has emerged as a useful technology that may prove capable of facilitating remote clinical examinations in hand surgery. This study’s primary aim is to evaluate the efficacy of computer vision for assessing peripheral motor function and range of motion of the hand for future clinic and telemedicine purposes. Five healthy volunteer subjects (10 hands total) were filmed performing three static hand examinations (“peace sign,” “hitchhiker thumb,” and “OK sign”) as well as apposition. Videos were processed using the proprietary H.AI.ND program based on the MediaPipe API (Google, v0.9.2.1), generating temporal and spatial data for joint angle analysis. The median joint angles determined for each test were compared with their manually derived counterparts to assess accuracy and reliability. The measurements were compared at a population level using Wilcoxon signed rank tests and at the individual video level using interclass correlation analyses. The artificial intelligence–generated angle outputs demonstrated a high level of reliability when compared with manually determined measurements for the 3 clinical positions included in this study. Assessment of compound appositional movement also demonstrated high reliability with time-dependent multijoint evaluation. Goniometric analysis through computer vision applications may provide an easy and reliable alternative for hand evaluation in the normal population for both static and dynamic function. Further study is warranted to evaluate this program’s potential role for diagnostic assessment in the diseased population before and after surgical investigation.