Depression is Associated with Weight Gain in Patients Transplanted for NASH Cirrhosis but Not Other Etiologies of Cirrhosis

The present study was to bridge this gap in knowledge by evaluating the relationship between depression, liver disease and weight change after LT. Weight gain after liver transplantation (LT) is common, particularly in patients transplanted for NASH cirrhosis, and is associated with reduced survival. In non-LT patients, presence and sub-optimal management of depression is closely associated with weight gain and obesity. The impact of depression as predictor of post-LT weight gain is currently not known. Method:All adult patients receiving LT between 7/2007 to 7/2017 were included in the analysis. Patients with graft failure or death within 6 months after LT were excluded. Baseline weight was weight 2 weeks after LT to avoid contribution of peri-transplant edema. Screening for depression was performed by a psychologist or psychiatrist using DSM-IV/V guidelines. Antidepressant use was quantified through chart review. Results: The presence of depression did not affect weight change in patients transplanted for HCV and alcoholic cirrhosis; however, in patients transplanted for NASH cirrhosis depression was positively associated with 60 months post-LT weight gain. Patients receiving treatment for depression, the weight gain was mitigated, whereas in patients with NASH cirrhosis and depression not on anti-depressants the weight gain was significantly more profound at each follow up.Conclusion: Presence and under-treatment of depression are associated with more profound weight gain in patients transplanted for NASH cirrhosis, likely reflecting poor coping mechanisms. Additional trials with aggressive screening and treatment of depression in patients transplanted for NASH cirrhosis are essential to mitigate post-LT weight gai

Fibrosis Progression Rate in Biopsy-Proven Nonalcoholic Fatty Liver Disease Among People With Diabetes Versus People Without Diabetes: A Multicenter Study

Background & aimsThere are limited data regarding fibrosis progression in biopsy-proven nonalcoholic fatty liver disease (NAFLD) in people with type 2 diabetes mellitus (T2DM) compared with people without T2DM. We assessed the time to fibrosis progression in people with T2DM compared with people without T2DM in a large, multicenter, study of people with NAFLD who had paired liver biopsies.MethodsThis study included 447 adult participants (64% were female) with NAFLD who had paired liver biopsies more than 1 year apart. Liver histology was systematically assessed by a central pathology committee blinded to clinical data. The primary outcome was the cumulative incidence of a ≥1-stage increase in fibrosis in participants with T2DM compared with participants without T2DM.ResultsThe mean (SD) age and body mass index (calculated as weight in kilograms divided by the square of the height in meters) were 50.9 (11.5) years and 34.7 (6.3), respectively. The median time between biopsies was 3.3 years (interquartile range, 1.8-6.1 years). Participants with T2DM had a significantly higher cumulative incidence of fibrosis progression at 4 years (24% vs 20%), 8 years (60% vs 50%), and 12 years (93% vs 76%) (P = .005). Using a multivariable Cox proportional hazards model adjusted for multiple confounders, T2DM remained an independent predictor of fibrosis progression (adjusted hazard ratio, 1.69; 95% CI, 1.17-2.43; P = .005). The cumulative incidence of fibrosis regression by ≥1 stage was similar in participants with T2DM compared with participants without T2DM (P = .24).ConclusionsIn this large, multicenter cohort study of well-characterized participants with NAFLD and paired liver biopsies, we found that fibrosis progressed faster in participants with T2DM compared with participants without T2DM. These data have important implications for clinical practice and trial design

The development and validation of a scoring tool to predict the operative duration of elective laparoscopic cholecystectomy

Background: The ability to accurately predict operative duration has the potential to optimise theatre efficiency and utilisation, thus reducing costs and increasing staff and patient satisfaction. With laparoscopic cholecystectomy being one of the most commonly performed procedures worldwide, a tool to predict operative duration could be extremely beneficial to healthcare organisations. Methods: Data collected from the CholeS study on patients undergoing cholecystectomy in UK and Irish hospitals between 04/2014 and 05/2014 were used to study operative duration. A multivariable binary logistic regression model was produced in order to identify significant independent predictors of long (> 90 min) operations. The resulting model was converted to a risk score, which was subsequently validated on second cohort of patients using ROC curves. Results: After exclusions, data were available for 7227 patients in the derivation (CholeS) cohort. The median operative duration was 60 min (interquartile range 45–85), with 17.7% of operations lasting longer than 90 min. Ten factors were found to be significant independent predictors of operative durations > 90 min, including ASA, age, previous surgical admissions, BMI, gallbladder wall thickness and CBD diameter. A risk score was then produced from these factors, and applied to a cohort of 2405 patients from a tertiary centre for external validation. This returned an area under the ROC curve of 0.708 (SE = 0.013, p  90 min increasing more than eightfold from 5.1 to 41.8% in the extremes of the score. Conclusion: The scoring tool produced in this study was found to be significantly predictive of long operative durations on validation in an external cohort. As such, the tool may have the potential to enable organisations to better organise theatre lists and deliver greater efficiencies in care

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Early Colonoscopy in Patients With Acute Diverticular Bleeding Is Associated With Improvement in Healthcare-Resource Utilization

Background: Diverticular bleeding (DB) is the most common cause of severe acute lower gastrointestinal bleeding (GIB) in developed countries. The role of early colonoscopy (\u3c24 hours) continues to remain controversial and data on early colonoscopy in acute DB are scant. We aimed to evaluate the effect of timing of colonoscopy on outcomes in patients with acute DB using a nationwide inpatient sample. Methods: Data from the nationwide inpatient sample from 2012 to 2014 were used. The ninth version of the International Classification of Diseases coding system ICD 9 was used for patient selection. We included discharges with the primary and secondary inpatient diagnosis of diverticulosis with bleeding and diverticulitis with bleeding. Discharges with no primary or secondary diagnosis of diverticulosis with bleeding, diverticulitis with bleeding, patients who were less than 18 years old and those who did not undergo colonoscopy during the admission were excluded. The primary outcomes were length of stay (LOS) and total hospitalization costs. Results: A total of 88 600 patients were included in our analysis, amongst whom 45 020 (50.8%) had colonoscopy within 24 hours of admission (early colonoscopy), while 43 580 (49.2%) patients had colonoscopy after 24 hours of admission (late colonoscopy). LOS was significantly lower in patients with early colonoscopy as compared to those with late colonoscopy (3.7 vs 5.6 days, P \u3c 0.0001). Total hospitalization costs were also significantly lower in patients with early colonoscopy ($9317 vs$11 767, P \u3c 0.0001). There was no difference in mortality between both groups (0.7 vs 0.8%). After adjusting for potential confounders, the differences in LOS and total hospitalization costs between early and late colonoscopy remained statistically significant. Conclusions: Early colonoscopy in acute DB significantly reduced LOS and total hospitalization costs. There was no significant difference in mortality observed. Performance of early colonoscopy in the appropriate patients presenting with acute DB can have potential cost-saving implications. Further research is needed to identify which patients would benefit from early colonoscopy in DB

Opioid Use Disorder is Associated with Increased Mortality and Morbidity in Patients with Gastroparesis

Background: Opioid use disorder (OUD) epidemic has been declared a nationwide public health emergency by the Department of Health and Human Services. There are limited data regarding OUD in patients with gastroparesis. This study aimed to evaluate the impact of OUD on the outcomes in patients hospitalized with gastroparesis and to delineate the trends associated with OUD and gastroparesis using a nationally representative sample. Methods: We used the National (Nationwide) Inpatient Sample database from 2005-2014 to identify patients hospitalized with a primary diagnosis of gastroparesis (ICD 9 Code: 536.3) and a concurrent diagnosis of OUD. We used Pearson chi-square analysis to compare demographics, the independent samples t-test to assess differences in length of stay and cost of care, and multivariate regression analysis to adjust for confounders. Results: Between 2005 and 2014, a total of 145,700 patients with a primary diagnosis of gastroparesis were hospitalized in the United States, of whom 4519 (3.1%) had a concurrent diagnosis of OUD. The prevalence of OUD in gastroparesis doubled from 2.1% in 2005 to 4.3% in 2014. After adjusting for confounders, patients with OUD had greater in-hospital mortality (adjusted odds ratio 2.7, 95% confidence interval: 2.1-3.5). Patients with OUD also had significantly longer hospital stays and higher costs. Independent predictors of OUD in patients with gastroparesis were younger age, female sex, alcohol use, depression, and Medicaid insurance. Conclusion: OUD in patients with gastroparesis is associated with greater mortality and healthcare resource utilization

Biological Synthesis of Silver Nanoparticles and Prospects in Plant Disease Management

Exploration of nanoparticles (NPs) for various biological and environmental applications has become one of the most important attributes of nanotechnology. Due to remarkable physicochemical properties, silver nanoparticles (AgNPs) are the most explored and used NPs in wide-ranging applications. Also, they have proven to be of high commercial use since they possess great chemical stability, conductivity, catalytic activity, and antimicrobial potential. Though several methods including chemical and physical methods have been devised, biological approaches using organisms such as bacteria, fungi, and plants have emerged as economical, safe, and effective alternatives for the biosynthesis of AgNPs. Recent studies highlight the potential of AgNPs in modern agricultural practices to control the growth and spread of infectious pathogenic microorganisms since the introduction of AgNPs effectively reduces plant diseases caused by a spectrum of bacteria and fungi. In this review, we highlight the biosynthesis of AgNPs and discuss their applications in plant disease management with recent examples. It is proposed that AgNPs are prospective NPs for the successful inhibition of pathogen growth and plant disease management. This review gives a better understanding of new biological approaches for AgNP synthesis and modes of their optimized applications that could contribute to sustainable agriculture

Paraneoplastic pemphigus as a presentation of acute myeloid leukemia: Early diagnosis and remission

Skin lesions are frequently encountered in clinical practice which can be a presentation of systemic diseases not excluding an occult malignancy. Commonly reported paraneoplastic dermatologic manifestations include acanthosis nigricans, dermatomyositis, erythroderma, hypertrophic osteoarthropathy, Sweet syndrome, and paraneoplastic pemphigus (PNP).PNP is a rare autoimmune mucocutaneous disease characterized by severe stomatitis, polymorphic skin eruptions, and associated underlying neoplasms most commonly non-Hodgkin’s lymphoma, chronic lymphocytic leukemia, and Castleman disease. PNP is characterized on histopathology as dyskeratotic epithelial cells with acantholysis with a typical immunofluorescence staining pattern of direct and/or indirect staining of intercellular, basement membrane, and dermoepidermal junction with immunoglobulin-G and C3. PNP has been described to have poor prognosis with a mortality range of 75–90% and a mean survival of less than 1 year.We describe a previously unreported case of PNP associated with acute myeloid leukemia (AML) where the patient presented with a nonhealing ulcer and hemorrhagic crusting on the face that did not respond to antimicrobials and steroids. Investigations revealed leukocytosis with peripherally circulating blasts. Skin biopsy revealed an evolving PNP and bone marrow biopsy confirmed evidence of AML. The patient underwent induction, consolidation, and then successful allogenic bone marrow transplantation with complete remission. The skin lesion, which was initially refractory to treatments, surprisingly resolved within 7 days of starting induction chemotherapy.In this case, the skin lesion was a key factor in early diagnosis and instituting treatment for the underlying AML. Early intervention gave our patient a better outcome with an ongoing survival of 18 months since diagnosis, maintaining complete remission. Keywords: Acute myeloid leukemia, Criteria, Paraneoplastic pemphigus, Presentation, Skin, Resolutio