Introduction: Given the high recurrence rate and the risk of fecal incontinence with surgical options, Injection of adipose tissue-derived stem cells (ASC) has been arising as a novel method for treating complex perianal fistulas (CPAF). Therefore, we conducted a meta-analysis to evaluate the efficacy and safety of ASC in the management of CPAF not associated with Crohn’s disease. Methods: We systematically searched Medline and Embase databases through April 20, 2022, for all studies that assessed the efficacy and safety of ASC for the treatment of CPAF not associated with Crohn’s disease. We excluded patients with rectovaginal fistulas and perianal fistulas associated with Crohn’s disease. Our primary outcome was the complete closure. The secondary outcomes included overall nonserious adverse events (NSAE), serious adverse events (SAE), and perianal abscess rate. All meta-analyses were conducted using a random-effect model. The publication bias was assessed by Egger’s test. Results: Ten studies (eight clinical trials and two observational studies) with 271 patients were included in the pooled analysis. Eight studies used autologous stem cells, one used allogeneic stem cells, and one did not report the source of stem cells. The mean age of the patients was 43.7 years. The follow-up period ranged from 3 months to 2 years. The pooled complete closure rate was 59.7% (95% confidence interval (CI): 0.46-0.73, Figure 1A). On subgroup analysis based on country of origin, six studies with 213 patients were conducted in European countries, and four studies with 58 patients were conducted in non-European countries. The complete closure rate was higher in European countries than non-European countries, 64.1% vs. 52.6%. Eight studies reported overall NSAEs with the pooled NSAE rate of 22.5% (95% CI: 0.11-0.34, Figure 1B). Seven studies reported SAEs with the pooled SAE rate of 1.7% (95% CI: 0.001-0.034, Figure 1C). Seven studies reported the perianal abscess rate with a pooled perianal abscess rate of 7.1% (95% CI: 0.016-0.125, Figure 1D). No evidence of publication bias was found (Egger’s test: P=0.36). Conclusion: Our meta-analysis demonstrated that ASC is a promising therapeutic option for CPAF not associated with Crohn’s disease with a clinically adequate efficacy and low rate of adverse events. However, more studies with larger sample sizes are needed to provide a definitive assessment of the effectiveness of ASCs for CPAF not associated with Crohn’s disease.Figure 1
Introduction: The management of inflammatory bowel disease (IBD), including ulcerative colitis (UC) and Crohn's disease (CD), has progressed with the advent of biological treatments. Anti-tumor necrosis factor (TNF) agents have been a primary treatment for moderate to severe CD for nearly 2 decades. Given CD's high healthcare costs due to complications, hospitalizations, and surgeries, our study analyzed these aspects annually using the nationwide Inpatient Sample (NIS) from 2004 to 2014. Methods: A retrospective cohort analysis with data from the Healthcare Cost and Utilization Project National Inpatient Sample (HCUP-NIS) between 2004 and 2014, representing a 20% sample of U.S. hospitalizations. Aimed to provide stable, precise estimates by expanding the sample size. Patients with CD diagnoses were identified using the International Classification of Diseases version 9 (ICD-9), and various epidemiological and clinical characteristics and hospitalization complications were examined. Statistical analyses were performed using R Statistical Software, with significance set at P-values less than 0.05. Results: A total of 1,966,664 discharges were associated with Crohn's disease. A significant proportion of these patients were under 35, accounting for 27.3% of the total. Females constituted the majority at 58.8% (1,155,797). We conducted a yearly comparison of the incidence of Crohn's disease complications from 2004 to 2014, and the results were as follows: The total cases of Crohn's disease escalated from 140,750 in 2004 to 201,345 in 2014. Incidences of abdominal abscesses rose from 3,510 to 9,495, while surgical interventions decreased slightly from 11,078 to 9,185. Lower gastrointestinal bleeding increased modestly from 2,765 to 3,270, while the association with malnutrition showed a significant surge from 7,212 to 24,145. Throughout the study period, the overall inpatient mortality rate stood at 1.04%. The average hospital charges were approximately 34,124 dollars, and patients typically stayed there for an average of 5.37 days. Conclusion: Our research demonstrated a consistent annual decline in surgical interventions. However, the incidence of expected complications, such as sepsis, Clostridioides difficile infection, anemia, and abdominal abscesses, persistently increased over the study period. This trend could be linked to the targeted activity of biological agents. More in-depth investigations that employ a prospective analysis are recommended to gain a clearer understanding of these outcomes (Table 1). Table 1. - Trending the major outcomes of Crohn's Disease from 2004-2014 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Crohn's Disease 140750 146516 146951 157778 187923 188216 195481 204449 196090 196485 201345 Main complications and outcomes in Crohn's patient population Abdominal Abscess 3510 4030 5209 6461 8205 8462 8559 9714 9015 9480 9495 sepsis 1794 2601 3008 4339 7084 8299 8621 10864 10005 12530 15075 Surgical intervention:(Colectomy), (Incision/Excision/anastamosis) of intestine 11078 10075 9685 9850 12292 9151 9549 9802 8800 8745 9185 Anemia 25612 27907 28774 32257 39253 43274 46505 52301 49845 51035 52700 Hypovolemia 4288 5349 6264 7621 10727 12351 13733 15904 15365 17160 18945 Fluid and electrolyte disorders 3306 3605 4053 4992 7280 8613 8993 10760 10405 12295 13625 Active fistulizing disease or intraabdominal abscess 4978 4284 4613 4754 6916 6037 7059 7644 7030 7830 7640 Stricturing diseases 319 388 437 429 553 605 603 760 680 785 885 Intestinal obstruction 9180 8708 9184 9797 11761 12329 12789 13793 14430 14150 16040 Unspecified lower gastrointestinal hemorrhage 2765 2719 2858 3244 3496 3696 3087 3559 2775 3275 3270 Malnutrition 7312 8013 8307 9612 14731 16568 17608 21960 20230 22440 24145 C. diff 1762 2423 2358 2382 3390 3497 4111 4852 5630 6160 6545 Colorectal cancer 149 148 186 186 224 275 310 375 270 445 385 Blood transfusion 10703 12003 11096 13832 17006 18503 18482 20197 17950 17405 16235
Introduction: Acute cholangitis presents as an acute biliary tract infection with potentially lethal outcomes. The primary objective of this study was to devise a reliable risk prediction model to aid physicians in categorizing patients with acute cholangitis into distinct treatment groups. Considering the widespread upheavals in healthcare services and the realignment of healthcare priorities amidst the COVID-19 pandemic, grasping its impacts on the handling and results of acute cholangitis could offer invaluable understanding. Methods: The study assessed mortality rate trends, leveraging data from the CDC WONDER database from 1999 to 2021. CDC WONDER, standing for Wide-ranging Online Data for Epidemiologic Research, was the main data repository employed for this research. This online platform, curated by the Centers for Disease Control and Prevention (CDC), provides public health professionals and the wider public easy access to an extensive range of public health data. For this study, the specific focus was on deaths resulting from acute cholangitis between 1999 and 2021, to scrutinize all such fatalities recorded in the United States during that timeframe. The analytical procedures and data visualizations were executed using R 4.2.2 software. The ggplot2 package was employed for the generation of all the graphical representations. Results: We analyzed data for 30,663 individuals who died from acute cholangitis from 1999 to 2021. We found that the overall mortality rate per 100,000 people increased from 0.41 in the pre-COVID period (1999-2018) to 0.54 during the COVID era (2019-2021), with the peak mortality rate observed in 2021 (0.58) and then 2020 (0.54). The average mortality rate for individuals above 85 years old was 9%, while 2.74% for those aged 74 to 85. Upon examining race, the mortality rate for Whites was higher (0.47) compared to the Black or African American population (0.30) (Figure 1, Table 1). Conclusion: This research aims to offer an essential understanding of the progression of this particular health concern during the unprecedented situation induced by the pandemic. By capitalizing on the vast dataset housed in the CDC WONDER database, this research intends to illuminate any potential links between the era of COVID-19 and the mortality rate associated with acute cholangitis.Figure 1.: Mortality rate across the US states (1999-2021). Table 1. - Mortality rate (1999-2021) Mortality Rate per 100,000 Pre COVID era During COVID era Variables 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 Total number of deaths 971 1065 1108 1156 1171 1127 1207 1112 1166 1220 1240 1228 1314 1265 1309 1444 1434 1539 1581 1613 1679 1783 1931 Total Population 279M 281M 285M 288M 290M 293M 296M 298M 301M 304M 307M 309M 312M 314M 316M 319M 321M 323M 326M 327M 328M 329M 332M Mortality rate Overall mortality rate 0.35 0.38 0.39 0.40 0.40 0.38 0.41 0.37 0.39 0.40 0.40 0.40 0.42 0.40 0.41 0.45 0.45 0.48 0.49 0.49 0.51 0.54 0.58 Gender Male 0.32 0.35 0.35 0.38 0.38 0.37 0.39 0.34 0.36 0.37 0.37 0.38 0.40 0.39 0.40 0.45 0.43 0.46 0.45 0.47 0.50 0.52 0.55 Female 0.38 0.41 0.42 0.42 0.43 0.4 0.43 0.4 0.41 0.44 0.44 0.42 0.44 0.41 0.42 0.46 0.47 0.49 0.52 0.52 0.52 0.56 0.62 Race White 0.37 0.40 0.41 0.43 0.43 0.42 0.43 0.41 0.41 0.43 0.43 0.43 0.47 0.44 0.44 0.50 0.49 0.52 0.53 0.54 0.56 0.59 0.64 Black or African American 0.27 0.32 0.32 0.28 0.31 0.27 0.29 0.23 0.29 0.29 0.30 0.28 0.23 0.26 0.30 0.30 0.31 0.28 0.33 0.31 0.31 0.37 0.43 Asian or Pacific Islander 0.19 0.20 0.20 0.25 0.21 0.21 0.32 0.23 0.33 0.25 0.31 0.28 0.30 0.33 0.30 0.30 0.24 0.43 0.39 0.37 0.37 0.41 0.50 American Indian or Alaska Native - - - 0.31 - - - 0.27 0.26 - 0.24 0.26 0.23 0.23 0.47 - 0.26 0.37 0.26 0.25 0.36 0.49 0.44 Age data 25-34 years - - 0.03 0.04 0.03 - - 0.03 0.03 0.02 - - 0.03 0.03 - - 0.02 0.03 - - - 0.03 0.03 35-44 years 0.05 0.05 0.06 0.05 0.05 0.06 0.07 0.06 0.04 0.06 0.07 0.02 0.05 0.05 0.06 0.06 0.05 0.08 0.03 0.03 0.07 0.08 0.06 45-54 years 0.12 0.16 0.18 0.13 0.13 0.12 0.11 0.11 0.11 0.13 0.14 0.11 0.11 0.14 0.13 0.14 0.15 0.11 0.14 0.14 0.14 0.17 0.16 55-64 years 0.43 0.37 0.34 0.39 0.41 0.31 0.37 0.3 0.37 0.28 0.35 0.29 0.35 0.36 0.35 0.34 0.33 0.31 0.37 0.35 0.39 0.46 0.45 65-74 years 0.86 0.98 0.99 1.13 1.02 0.99 0.95 0.84 0.93 0.94 0.94 0.88 0.89 0.87 0.86 0.98 0.88 1.03 1.06 1.15 1.01 1.16 1.28 75-84 years 2.22 2.58 2.6 2.61 2.73 2.76 2.84 2.69 2.61 2.64 2.67 2.66 2.91 2.44 2.61 2.83 2.84 2.86 2.86 2.99 3.06 2.94 3.25 85+ years 8.43 8.85 9.16 9.41 9.29 8.62 9.35 8.26 8.45 9.24 8.51 9.1 8.87 8.34 8.43 8.99 8.89 9.53 9.23 8.71 9.17 9.12 11.2 Hispanic origin Hispanic or Latino 0.17 0.20 0.18 0.16 0.17 0.14 0.22 0.19 0.16 0.19 0.22 0.17 0.20 0.20 0.21 0.22 0.20 0.22 0.27 0.24 0.27 0.29 0.3 Not Hispanic or Latino 0.37 0.40 0.42 0.44 0.44 0.42 0.44 0.40 0.43 0.44 0.44 0.44 0.47 0.44 0.45 0.50 0.50 0.53 0.53 0.55 0.57 0.6 0.65
Introduction: Eosinophilic esophagitis (EoE) is an immune mediated disorder that may be related to exposure to additive chemicals in crops, air pollutants, or supplements found within livestock. Co-occurring allergic or atopic diseases including atopic dermatitis, food allergies, and asthma are also commonly seen in 70% of cases and help guide diagnosis. Diagnosis of EoE requires eosinophilic infiltration greater than 15 eosinophils per high power field with endoscopic evidence of abnormal esophageal changes. Here, we discuss a rare presentation of food bolus impaction secondary to EoE after ingestion of a nasal decongestant and antihistamine pill that has previously never been described in the literature. Case Description/Methods: A 22-year-old- male with no significant past medical history presented to the emergency department (ED) with a chief complaint of a sudden onset respiratory distress, regurgitation of clear oral secretions, and globus sensation post ingestion of a fexofenadine-pseudoephedrine tablet. Prior to intake of the capsule, the patient was consuming liquids and solids appropriately. The patient was afebrile, hypertensive at 172/114, found to have a normal heart rate of 88 bpm, and respiration rate of 18 breaths per minute. A esophagogastroduodenoscopy (EGD) was performed and revealed a fexofenadine-pseudoephedrine capsule at 23 cm from the incisors along with a superficial ulceration at the corresponding level in the esophagus (Fig. 1A). The foreign body was successfully removed using raptor forceps (Fig. 1B). Further visualization demonstrated trachealization of the esophagus and furrowing and severe narrowing (< 10mm) which raised suspicion for eosinophilic esophagitis (Fig. 1C). Proximal biopsy indicated 16 intraepithelial eosinophils per high-power field within the squamous epithelium likely compatible with eosinophilic esophagitis. The patient tolerated the procedure well and was discharged on a 8 week course of proton pump inhibitors. Discussion: Eosinophilic esophagitis is defined as an immune-mediated esophageal disease characterized histologically by eosinophil-predominant inflammation. Our patient was reported to have up to 30 eosinophil per HPF from the proximal esophageal biopsy which satisfies the requirements for an EoE diagnosis. Based on current literature review, there have been no other reported cases of symptomatic food bolus impaction secondary to eosinophilic esophagitis after ingestion of antihistamines.Figure 1.: EGD results; A: Exofenadine-pseudoephedrine capsule at 23 cm from the incisors along with a superficial ulceration at the corresponding level in the esophagus. B: Foreign body was successfully removed using raptor forceps. C: Trachealization of the esophagus and furrowing with severe narrowing (< 10mm)
Introduction: Various endoscopic techniques are employed to achieve biliary cannulation when confronted with difficult biliary access. Every procedure carries its own risk in terms of bleeding, infection, pancreatitis, cholangitis etc. Our meta-analysis aims to compare pre-cut papillotomy and EUS-Rendezvous in terms of technical success of the procedure and post-procedure pancreatitis and bleeding. Methods: We conducted a systematic review and meta-analysis of studies that compared pre-cut papillotomy and EUS-Rendezvous. The primary outcome was technical success by achieving biliary cannulation. Secondary outcomes were postoperative pancreatitis and bleeding. A random-effects model was used to calculate the risk ratios (RR), mean differences (MD), and confidence intervals (CI). A P-value < 0.05 was considered statistically significant. Results: We included 3 studies comparing pre-cut papillotomy and EUS Rendezvous. Both procedures were similar in terms of clinical success (RR 0.98, 95%CI 0.94-1.02). No difference was found between rates of post procedure pancreatitis (RR 1.60, 95% CI 0.52, 4.94) and post procedure bleeding (RR 3.94, 95% CI 0.53, 29.39) (Figure 1). Conclusion: No difference in terms of technical success of procedure or post procedure pancreatitis and bleeding was found between pre-cut papillotomy and EUS-Rendezvous technique. More RCTs are needed to compare both techniques and complications but currently both procedures are accepted and safe when tackling DBC in the hands of experienced endoscopists.Figure 1.: Forrest Plot comparing technical success (A), post procedure pancreatitis (B), bleeding rate (C) between pre-cut papillotomy and EUS- Rendezvous technique for Difficult Biliary Cannulation (DBC).
The Prediction of customer churn plays significant importance within the telecommunications sector because of its immediate impact on the company's income stream. Nevertheless, the progress in machine learning has significantly improved the potential for generating accurate predictions. The methodology we propose consists of several steps. These steps include data preprocessing, feature analysis, feature selection using PCA and XGBoost, splitting of the data into training and testing sets, implementation of well-known predictive algorithms such as logistic regression, naive Bayes, support vector machine, random forest, and decision trees. Additionally, we apply boosting and ensemble techniques, perform cross-validation using K-folds for hyperparameter optimization, and evaluate model performance using confusion matrices and AUC curves. The combination of PCA or XGBoost with the CatBoost and Adaboost classifiers yielded notable results, with classification accuracy rates of 95.56% and 94.34% respectively, indicating their better performance. The experimental results demonstrate that the suggested model outperforms previously researched methodologies, achieving a prediction accuracy rate of 97%.
Introduction: Pancreatic necrosis complicates about 20% of acute pancreatitis cases, and 30-40% of those become infected. Current guidelines recommend that invasive intervention for pancreatic necrosis should be delayed to 4 or more weeks from disease onset. However, recent studies have challenged the optimal timing of intervention, especially with the advent of minimally invasive interventions. Methods: We conducted a systematic review and meta-analysis of studies that early and delayed minimally invasive intervention for infected pancreatic necrosis. We performed a comprehensive search in the databases of PubMed/MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials from inception through April 11, 2022. We considered randomized controlled trials, cohort studies, case-control studies, and case series. We excluded abstracts, animal studies, case reports, reviews, editorials, and letters to editors. From each study, we collected the number of patients who underwent early and late interventions for infected pancreatic necrosis. Early intervention was defined as an intervention that was carried out within 4 weeks of acute pancreatitis onset, while delayed intervention was carried out after 4 weeks of acute pancreatitis onset. Outcomes were mortality, gastrointestinal fistula or perforation, bleeding, and length of hospital stay. The random-effects model was used to calculate the risk ratios (RR), mean differences (MD), and confidence intervals (CI). A p value < 0.05 was considered statistically significant. Heterogeneity was assessed using the Higgins I2 index. (Figure) Results: Seven studies involving 742 patients were included in the meta-analysis. Timing of intervention had no statistically significant effect on mortality (RR 1.49, 95% CI 0.87 – 2.55, p = 0.15, I2 = 15%) or bleeding (RR 1.54, 95% CI 0.74 – 3.21, p = 0.24, I2 = 67%). However, early intervention was associated with a statistically significant higher risk of gastrointestinal fistula or perforation (RR 1.52, 95% CI 1.04 – 2.21, p = 0.03, I2 = 0%) and a longer hospital length of stay (MD 10.25 days, 95% CI 0.41 – 20.10, p = 0.04, I2 = 52%). Conclusion: Our meta-analysis demonstrated that the timing of intervention had no effect on mortality or bleeding in infected pancreatic necrosis. Early intervention resulted in a higher risk of gastrointestinal fistula or perforation and a longer length of hospital stay. Further randomized controlled trials are needed to confirm our findings.Figure 1.: Forest plots comparing early and late intervention in terms of (a) mortality, (b) gastrointestinal fistula or perforation, (c) bleeding, and (d) length of hospital stay
Introduction: Spontaneous bacterial peritonitis (SBP) is a common complication in decompensated liver cirrhosis. SBP is defined as ascitic fluid polymorphonuclear cell count > 250/mm3. Community acquired SBP (CA-SBP) occurs within 48-72 hours after hospital admission. Healthcare associated SBP (HA-SBP) is defined as SBP occurring in patients who were hospitalized in the preceding 90 days to 6 months. Nosocomial SBP (N-NBP) occurs 48-72 hours after hospital admission. Methods: We conducted a systematic review and meta-analysis on the studies that compared N-SBP, HA-SBP and CA-SBP. We performed a comprehensive database search in PubMed, Embase and Web of Science from inception through May 18, 2022. Randomized controlled trials, prospective and retrospective cohort studies and case series were included. Number of N-SBP, HA-SBP and CA-SBP episodes, ascitic fluid culture results and previous SBP episode data was gathered. The primary outcome was mortality rate in all types of SBP. Secondary outcome was resistance to third generation cephalosporins. The random effects model was used to calculate the risk ratios (RR), mean differences (MD) and confidence intervals (CI). A p value < 0.05 was considered statistically significant. Heterogeneity was assessed using the Higgins I2 index. Results: Fourteen retrospective and prospective cohort studies comprising of 2302 SBP episodes were included. The mortality rate was statistically significantly higher in N-SBP compared to HA-SBP (RR 1.84, p< 0.0001, CI 1.43- 2.37, I2=0%) and CA-SBP (RR 1.69, p< 0.00001, CI 1.4-1.98, I2= 33%), but not statistically significant between HA-SBP and CA-SBP (RR=1.40, p=0.34, CI=0.71-2.76, I2=53%). Resistance to third generation cephalosporins was statistically significantly higher in N-SBP compared to HA-SBP (RR=2.02, p=0.003, CI 1.26-3.22, I2=54%) and CA-SBP (RR=3.96, p< 0.00001, CI=2.50-3.60, I2=52%) and also between HA-SBP and CA-SBP (RR=2.25,p=0.002, CI=1.33-3.81, I2=0%). (Figure) Conclusion: Our meta-analysis demonstrated that mortality rate is higher in N-SBP compared to HA-SBP and N-SBP compared to CA-SBP. Third generation cephalosporin resistance is considerably higher in N-SBP and HA-SBP compared to CA-SBP. Lower threshold to start broad spectrum antibiotics with targeted therapy guided through culture data should be undertaken for appropriate treatment of SBP and to improve mortality in N-SBP and HA-SBP.Figure 1.: Nosocomial vs Community Acquired vs Healthcare associated SBP
Introduction: The differential diagnosis for a patient presenting with coffee ground emesis is broad. Isolated type 1 gastric varices are an uncommon cause of bleeding, and they are only seen in 1.6% of patients with gastric varices. We present a case of refractory gastrointestinal bleed found to be the result of an isolated type 1 gastric varices. Case Description/Methods: A 57-year-old male with a past medical history of diverticulosis presented to the hospital with an episode of coffee ground emesis. This was associated with nausea and melena. Patient reports a history of heavy NSAIDs use, but no previous history of upper gastrointestinal bleeding. On presentation, patient had an episode of hematemesis. His vital signs were significant for a heart rate of 140 beats/min and a blood pressure of 78/35 mm/Hg. Physical exam was unremarkable. Labs showed a white blood cell count of 15.3 x 10 9/L, hemoglobin of 7.3 g/dl (baseline was 13.5 g/dl), and platelets of 205 x 109/L. INR was 1.1. Patient was admitted to the ICU, and he was started on octreotide and protonix infusions. His hemoglobin continued to drop requiring 7 units of pRBCs. EGD was done the next day, and it showed dieulafoy lesions in the stomach and type 1 isolated gastric varices S/P epinephrine injections and two clips. CT angiogram abdomen showed no active source of arterial bleeding. It showed numerous vessels at the superior pole of the spleen. Two days later, patient had another episode of hematemesis with hemodynamic instability. Repeat EGD showed actively bleeding isolated gastric varix at the greater curvature of the gastric fundus which was ligated with two rubber bands. As patient remained hemodynamically unstable, he underwent arteriography and splenic embolization, especially of the upper pole, with improvement in his symptoms. Discussion: The most likely causes of the isolated gastric varices in this patient are either some sort of vascular malformation in the superior portion of the spleen or segmental venous thrombosis with development of the varices. As the patient’s condition was critical, it was decided to proceed with embolization at the risk of him needing a splenectomy later. The prominent upper pole vessels were aggressively embolized to diminish pressure within the splenic vein, which was patent, and to lessen the flow of blood into the gastric varices. That was successful in stopping the bleeding though the patient needed a splenectomy during his stay.Figure 1.: Band ligation of the actively bleeding Gastric fundus varix on greater curvature side (IGV1).
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