B-Type Natriuretic Peptide: A Predictor for Mortality, Intensive Care Unit Length of Stay, and Hospital Length of Stay in Patients With Resolving Sepsis

Background: B-type natriuretic peptide (BNP) is a hormone secreted by cardiomyocytes in response to myocardial ischemia, increased ventricular wall tension, and overload. BNP is utilized as a diagnostic and prognostic marker in congested heart failure (CHF). Its prognostic value in sepsis is unknown. The aim of this study is to determine if BNP correlates with increased in-hospital mortality for septic patients. Methods: This was a retrospective study of 505 patients admitted for sepsis or severe sepsis or septic shock during the period of January 2013 and August 2014. Patients that received \u3e 3 L of intravenous fluids on presentation were included. Intensive care unit length of stay (ICULOS), hospital length of stay (HLOS) and in-hospital mortality were measured. Mean BNP level was calculated and compared to ICULOS and HLOS and in-hospital mortality. Controlled variables included ejection fraction (measured by echocardiogram within 6 months of presentation), glomerular filtration rate (calculated by Cockroft-Gault equation), patient demographics, and lactic acid trends. Exclusion criteria were no echocardiogram within 6 months of admission, no BNP levels on admission, and no repeat lactate or rising lactate levels within 24 h to indicate worsening sepsis. Results: Patients\u27 mean BNP with in-hospital mortality was 908 pg/mL as compared to mean BNP of 678 pg/mL in survivors. T-test comparisons were statistically significant (P = 0.0375). The Kaplan-Meier curve for BNP as a predictor for in-hospital mortality showed that for the first 25 days, patients with BNP higher than 500 pg/mL had a higher mortality than patients with BNP lower than 500 pg/mL. When comparing HLOS, there is a statistically significant correlation (P = 0.0046). A similar scatter plot was prepared for ICULOS which showed there was a weak positive correlation (r = 0.199). Conclusion: Septic patients with in-hospital mortality had an average BNP of 908 pg/mL and statistically significant higher HLOS

Efficacy and Safety of Intragastric Balloon (IGB) in Non-alcoholic Fatty Liver Disease (NAFLD): a Comprehensive Review and Meta-analysis

Intragastric balloon (IGB) therapy has shown efficacy in weight loss but its role in NAFLD remains unknown. We conducted a systematic review and meta-analysis to evaluate the efficacy of IGB in NAFLD. Meta-analysis was performed to estimate the pooled proportion of patients with improvement in steatosis as determined by imaging and histology following IGB placement. Nine studies were included in our analysis. Four hundred forty-two IGBs were placed. Improvement in steatosis was seen in 79.2% of patients and NAS in 83.5% of patients, and HOMA-IR score improved in 64.5% of patients. A reduction in liver volume by CT scan was noticed in 93.9% of patients undergoing IGB placement. IGB is an effective and safe short-term therapeutic modality for patients with NAFLD

Locoregional treatments in cholangiocarcinoma and combined hepatocellular cholangiocarcinoma

none10siCholangiocarcinoma (CCA) is a primary and aggressive cancer of the biliary tree. Combined hepatocellular cholangiocarcinoma (CHC) is a distinctive primary liver malignancy which has properties of both hepatocytic and cholangiocytic differentiation. CHC appears to have a worse prognosis compared to hepatocellular carcinoma, and similar to that of intrahepatic CCA. While significant advances have been made in understanding the pathophysiology and treatment of these two tumor types, their prognosis remains poor. Currently, liver resection is the primary treatment modality; however, only a minority of patients are eligible for surgery. However, the use of locoregional therapies proves an alternative approach to treating locally advanced disease with the aim of converting to resectability or even transplantation. Locoregional therapies such as transarterial chemoembolization (TACE), selective internal radiation therapy (SIRT), radiofrequency ablation (RFA), and photodynamic therapy (PDT) can provide patients with tumor control and increase the chances of survival. In this review, we appraise the evidence surrounding the use of locoregional therapies in treating patients with CCA and CHC.openRenzulli M.; Ramai D.; Singh J.; Sinha S.; Brandi N.; Ierardi A.M.; Albertini E.; Sacco R.; Facciorusso A.; Golfieri R.Renzulli M.; Ramai D.; Singh J.; Sinha S.; Brandi N.; Ierardi A.M.; Albertini E.; Sacco R.; Facciorusso A.; Golfieri R

Progressive liver fibrosis in non-alcoholic fatty liver disease

Non-alcoholic steatohepatitis (NASH) is a chronic and progressive form of non-alcoholic fatty liver disease. Its global incidence is increasing and makes NASH an epidemic and a public health threat. Non-alcoholic fatty liver disease is associated with major morbidity and mortality, with a heavy burden on quality of life and liver transplant requirements. Due to repeated insults to the liver, patients are at risk for developing hepatocellular carcinoma. The progression of NASH was initially defined according to a two-hit model involving an initial development of steatosis, followed by a process of lipid peroxidation and inflammation. In contrast, current evidence pro-poses a “multi-hit” or “multi-parallel hit” model that includes multiple pathways promoting progressive fibrosis and oncogenesis. This model includes multiple cellular, genetic, immunological, metabolic, and endocrine pathways leading to hepatocellular carcinoma development, underscor-ing the complexity of this disease

Hospital frailty risk score is independently associated with mortality and encephalopathy in hospitalized patients with hepatocellular carcinoma

Frailty represents a state of vulnerability to multiple internal physiologic factors, as well as external pressures, and has been associated with clinical outcomes. We aim to understand the impact of frailty on patients admitted with hepatocellular carcinoma (HCC) by using the validated Hospital Frailty Risk Score, which is implemented in several hospitals worldwide. We conducted a nation-wide retrospective cohort study to determine the effect of frailty on the risk of in-patient mortality, hepatic encephalopathy, length of stay and cost. Frailty was associated with a 4.5-fold increased risk of mortality and a 2.3-fold increased risk of hepatic encephalopathy. Adjusted Cox regression showed that frailty was correlated with increased risk of in-patient mortality (hazard ratio: 2.3, 95% CI 1.9–2.8, p < 0.001). Frail HCC patients had longer hospital stay (median 5 days) vs. non-frail HCC patients (median 3 days). Additionally, frail patients had higher total costs of hospitalization ($40,875) compared with non-frail patients ($31,667). Frailty is an independent predictor of hepatic encephalopathy and in-patient mortality. Frailty is a surrogate marker of hospital length of stay and cost

Comparative efficacy of different methods for difficult biliary cannulation in ERCP: a systematic review and network meta-analysis

Several methods with variable efficacy have been proposed for difficult biliary cannulation in ERCP. We assessed the comparative efficacy of different strategies for difficult biliary cannulation, through a network meta-analysis combining direct and indirect treatment comparisons

Efficacy & safety of EUS-directed transgastric endoscopic retrograde cholangiopancreatography (EDGE) in Roux-en-Y gastric bypass anatomy: a systematic review & meta-analysis

Background: In patients with Roux-en-Y gastric bypass (RYGB) anatomy, laparoscopic endoscopic retrograde cholangiopancreatography (LA-ERCP) and enteroscopy-assisted ERCP (E-ERCP) have been utilized to achieve pancreaticobiliary access. Endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography (EDGE) has recently emerged as an alternate and efficient approach. As data regarding EDGE continues to evolve, concerns about safety and efficacy remain, limiting wide adoptability. We performed a systematic review and meta-analysis to assess the safety and efficacy of EDGE and compare it to the current standard of care. Methods: A comprehensive search of major databases (inception to Nov 2022) identified published studies on EDGE. A random-effects model was used to calculate the pooled rates and heterogeneity (I2). Risk ratio (RR) and standardized difference in means (SMD) were utilized for head-to-head comparison analysis between EDGE vs. LA-ERCP and EDGE vs. E-ERCP. Primary outcomes assessed pooled EDGE safety (adverse events) and efficacy (technical/clinical success). Secondary outcomes assessed efficacy and safety profiles via a comparative analysis of EDGE vs. LA-ERCP and EDGE vs. E-ERCP. Results: A total of 16 studies (470 patients) were included. EDGE pooled technical success (TS) rate was 96% (95% CI 92-97.6, I2 = 0), and clinical success was 91% (85-95, I2 = 0). Pooled rate of all adverse events with EDGE was 17% (14-24.6, I2 = 32%). On sub-group analysis, these included failure of fistula closure 17% (10-25.5, I2 = 48%), stent migration 7% (4-12, I2 = 51%), bleeding 5% (3.2-7.9, I2 = 0), post-EDGE weight gain 4% (2-9, I2 = 0), perforation 4% (2.1-5.8, I2 = 0), and post-ERCP pancreatitis 2% (1-5, I2 = 0). EDGE TS was comparable to LA-ERCP (97% vs. 98%; RR, 1.00; CI, 0.85-1.17, p = 0.95) and E-ERCP (100% vs. 66%; RR, 1.26; CI, 0.99-1.6, p = 0.06). No statistical difference was noted in adverse events between EDGE and LA-ERCP (13% vs. 17.6%; RR, 0.61; CI, 0.28-1.35, p = 0.52) and E-ERCP (9.6% vs. 16%; RR, 0.61; CI, 0.28-1.35, p = 0.22). EDGE procedure time and hospital stay were shorter than LA-ERCP and E-ERCP (p < 0.001). Conclusion: Our analysis shows that EDGE is safe and efficacious to the current standard of care. Further head-to-head comparative trials are needed to validate our findings

Comparative efficacy of different methods for difficult biliary cannulation in ERCP: systematic review and network meta-analysis

Background and Aims: Several methods with variable efficacy have been proposed for difficult biliary cannulation in ERCP. We assessed the comparative efficacy of different strategies for difficult biliary cannulation through a network meta-analysis combining direct and indirect treatment comparisons. Methods: We identified 17 randomized controlled trials (2015 patients) that compared the efficacy of different adjunctive methods for difficult biliary cannulation (needle-knife techniques, pancreatic guidewire-assisted technique, pancreatic-assisted technique, and transpancreatic sphincterotomy) either with each other or with persistence with the standard cannulation techniques. The success rate of biliary cannulation and the incidence of post-ERCP pancreatitis (PEP) were the outcomes of interest. We performed pairwise and network meta-analysis for all treatments and used Grading of Recommendations Assessment, Development and Evaluation criteria to appraise quality of evidence. Results: Low-quality evidence supported the use of transpancreatic sphincterotomy over persistence with standard cannulation techniques (risk ratio [RR], 1.29; 95% confidence interval [CI], 1.05-1.59) and over any other adjunctive intervention (RR, 1.21 [95% CI, 1.01-1.44] vs pancreatic guidewire-assisted technique, RR, 1.19 [95% CI, 1.01-1.43] vs early needle-knife techniques, RR, 1.47 [95% CI, 1.03-2.10] vs pancreatic stent-assisted technique) for increasing the success rate of biliary cannulation. No other significant results were observed in any other comparisons. Based on the network model, transpancreatic sphincterotomy (P-score, .97) followed by early needle-knife techniques (P-score, .62) were ranked highest in terms of increasing the success rate of biliary cannulation. Early needle-knife techniques outperformed persistence with standard cannulation techniques in terms of decreasing PEP rate (RR, .61; 95% CI, .37-1.00), whereas both early needle-knife techniques and transpancreatic sphincterotomy led to lower PEP rates as compared with pancreatic guidewire-assisted technique (RR, .49 [95% CI, .23-.99] and .53 [95% CI, .30-.92], respectively). Conclusions: Transpancreatic sphincterotomy increases the success rate of biliary cannulation as compared with persistence with the standard cannulation techniques. Early needle-knife techniques and transpancreatic sphincterotomy are superior to other interventions in decreasing PEP rates and should be considered in patients with difficult cannulation