Sanjay Bhandari

Association of Inflammatory Bowel Disease (IBD) with depressive symptoms in the United States population and independent predictors of depressive symptoms in an IBD population: a NHANES study

Background/Aims There is a paucity of population-based studies on the association between inflammatory bowel disease (IBD) and depression in the U.S. population. We sought to study this association using the National Health and Nutrition Examination Survey (NHANES) database. Methods We used NHANES data from 2009 to 2010. Our study included 190,269,933 U.S. adults without IBD and 2,325,226 with IBD. We sought to determine whether IBD is an independent risk factor for depressive symptoms (DS) in the U.S. population and studied the independent predictors of DS in IBD population. Results DS was present in 49% of the IBD population versus 23% of the non-IBD population (p<0.001). During the multivariate analysis, we found that IBD was independently associated with DS in the U.S. population (p=0.002). The independent predictors of DS in the IBD population were older age (p=0.048) and divorced/separated/widowed status (p=0.005). There was nonsignificant increase in suicidal risk in IBD population with DS versus that in non-IBD population with DS (27% vs 12%, respectively, p=0.080). Only 36% of IBD individuals with DS visited mental health professional or psychiatrist within the past year. Conclusions IBD is independently associated with DS in the U.S. population. Further research is warranted on risk stratification, screening and management of those with IBD who are at risk of depression.

Novel Treatments for Cyclic Vomiting Syndrome: Beyond Ondansetron and Amitriptyline

Opinion statementCyclic vomiting syndrome (CVS) is a chronic functional gastrointestinal disorder that is characterized by episodic nausea and vomiting. Initially thought to only affect children, CVS in adults was often misdiagnosed with significant delays in therapy. Over the last decade, there has been a considerable increase in recognition of CVS in adults but there continues to be a lack of knowledge about management of this disorder. This paper seeks to provide best practices in the treatment of CVS and also highlight some novel therapies that have the potential in better treating this disorder in the future. Due to the absence of randomized control trials, we provide recommendations based on review of the available literature and expert consensus on the therapy of CVS. This paper will discuss prophylactic and abortive therapy and general measures used to treat an episode of CVS and also discuss pathophysiology as it pertains to novel therapy. Recent recognition of the association of chronic marijuana use with cyclic vomiting has led to the possibility of a new diagnosis called “Cannabinoid Hyperemesis Syndrome,” which is indistinguishable from CVS. The treatment for this purported condition is abstinence from marijuana despite scant evidence that marijuana use is causative. Hence, this review will also discuss emerging data on the role for the endocannabinoid system in CVS and therapeutic agents targeting the endocannabinoid system, which offer the potential of transforming the care of these patients.

Trends, predictors and outcomes of ischemic stroke and intracranial hemorrhage in patients with a left ventricular assist device

Background Patients with a left ventricular assist device (LVAD) are at a higher risk of ischemic stroke (IS) and intracranial hemorrhage (ICH). There is limited data available on risk factors and outcomes associated with IS and ICH in LVAD patients. Methods All patients >18 years of age with an LVAD were identified based on the U.S. Nationwide Inpatient Sample (NIS) database from the year 2007 to 2011. Patients with a discharge diagnosis of IS were compared to those without IS. In a separate analysis, patients with a discharge diagnosis of ICH were compared to patients without ICH. Trends, predictors and outcomes of IS and ICH were analyzed using a multivariate regression model. Results Out of 17,323 discharges with a primary diagnosis of heart failure with LVAD, 624 (3.6%) patients had a co-diagnosis of IS and 387 (2.2%) had a co-diagnosis of ICH. From 2007 to 2011, the discharge diagnosis of heart failure with LVAD increased from 946 to 5,540, but the proportion of patients with IS remained about 3.4%, while the incidence of ICH decreased from 3.8% in 2007 to a plateau of around 2.2% in the following years. After adjusting for potential confounders, increasing Charlson Comorbidity Index (CCI) score was an independent predictor of IS and ICH. In-hospital mortality was four-fold higher in the IS group (odds ratio: 4.2; 95% CI: 2.3-7.6; P<0.0001) and 18-fold higher in the ICH group (OR: 18; 95% CI: 9-34, P<0.0001). Renal disease (OR: 5.3; CI: 1.3-22.1; P=0.02), liver disease (OR: 4.9; CI: 1.1-21.2; P=0.03) and abnormal coagulation profile (OR: 4.8; CI: 1.6-14.4; P=0.01) were independent predictors of mortality in LVAD patients with IS. Presence of diabetes mellitus (OR 4.3, P=0.1) and liver disease (or 2.8, P=0.2) showed trends towards predicting mortality in LVAD patients with ICH but did not reach statistical significance. Conclusions Increasing comorbidity burden significantly increases the risk of both IS and ICH with LVAD. In our cohort, the incidence of IS and ICH increases the mortality 4- and 18-fold, respectively. Renal disease, liver disease and abnormal coagulation profile were independent predictors of mortality in LVAD patients with IS.

Increased Rate of Venous Thromboembolism in Hospitalized Inflammatory Bowel Disease Patients with Clostridium Difficile Infection

Background: Risk of venous thromboembolism (VTE) in patients with inflammatory bowel disease (IBD) is well established; however, there is paucity of data on the potential added risk of VTE in patients with IBD with Clostridium difficile infection (CDI). We sought to study the difference in VTE rates in hospitalized patients with IBD with CDI compared to those without CDI. Methods: We queried Nationwide Inpatient Sample from year 2011 to identify patients ≥18 years of age with a discharge diagnosis of IBD (i.e., Crohns disease and ulcerative colitis) based on ICD-9-CM codes 555.xx and 556.xx, respectively. Patients were further divided into 2 groups: those with and without CDI. To adjust and control for potential baseline differences between groups, 1:1 propensity matching was performed. Multivariate regression analysis was used to evaluate the difference in VTE rates in 2 groups. Results: Of 312,147 patients with the discharge diagnosis of IBD, 12,560 (4%) had CDI. VTE was present 6% in group with CDI versus 3% in group without CDI (P < 0.001). On performing multivariate analysis after propensity-score matching, CDI was significantly associated with VTE (adjusted odds ratio 1.7, 95% confidence interval 1.4–2.2, P < 0.001). On subgroup analysis, Crohns disease with CDI had a higher association with VTE compared with Crohns disease only. Similarly, ulcerative colitis with CDI had a higher association with VTE compared with ulcerative colitis only. Conclusions: Rate of VTE was higher in hospitalized patients with IBD with CDI compared with those without CDI, necessitating extra vigilance in this patient population.

Cyclic vomiting syndrome: epidemiology, diagnosis, and treatment

Cyclic-vomiting syndrome (CVS) is a chronic functional gastrointestinal disorder characterized by recurrent episodes of nausea and vomiting. Although once thought to be a pediatric disorder, there has been a considerable increase in recognition of CVS in adults. The exact pathogenesis is unknown and several theories have been proposed. Migraine and CVS share a similar pathophysiology as suggested by several studies. Since there are no specific biomarkers available for this disorder, physicians should rely on Rome criteria for the diagnosis. Due to the lack of randomized control trials, the treatment of CVS is primarily empirical.

Predicting outcomes in patients with atrial fibrillation and acute mesenteric ischemia

Acute mesenteric ischemia (AMsI) is an infrequent but catastrophic condition associated with high mortality and morbidity. Thromboembolism due to atrial fibrillation (AF) is one of the causes of AMsI, but the overall effect of AF and anticoagulation on outcomes in these patients is not known. The

Marijuana users do not have increased healthcare utilization: A National Health and Nutrition Examination Survey (NHANES) study

• There is paucity of data on healthcare utilization due to marijuana use on a national scale.

Decreased trend in hospital mortality from pancreatic cancer despite increase in number of hospital admissions

Background and aim Pancreatic cancer is one of the common cancers in US and is associated with high mortality and morbidity. The objectives of our study were to look at the recent trends in the number of hospitalizations with pancreatic cancer. Methods We identified patients with a discharge diagnosis of pancreatic cancer in the National Inpatient Sample from 2007 to 2011 using International Classification of Diseases—Clinical Modification, 9th revision (ICD-9-CM) codes. We looked at the yearly trend in the hospitalizations with pancreatic cancer and the outcomes which included length of stay (LOS), hospital charges and in-hospital mortality. We also performed multivariate analysis to look for the predictors of mortality. Results There were 450, 414 patients with discharge diagnosis of pancreatic cancer. There was 18% increase in hospitalizations with pancreatic cancer in 2011 compared to 2007. Most of the patients were Caucasian (63%) with the mean age of 68 ± 0.14 years, had Medicare (57%) as primary insurance, were from Southern region (35%) and had higher Charlson Comorbidity Index (CCI) (87% with CCI > = 5). 6% underwent Whipple’s procedure in the index hospitalization. After the adjustment for inflation, the mean hospital charges increased from

Perceptions of Fourth-Year Medical Students on Writing and Presenting Case Reports

47,331 in 20007 to

General Care of the Liver Patient

53, 854 in 2011 (p = 0.01). LOS decreased from 7.31 ± 0.11 days in 2007 to 6.70 ± 0.09 days in 2011 (<0.001). Despite the increase in the number of hospitalizations of patients with pancreatic cancer, mortality decreased from 9.8% in 2007 to 8.1% in 2011 (p<0.001). On multivariate analysis, the independent factors associated with higher mortality were older age, male sex African-American race, insurance status other than Medicare, higher CCI and enrollment in palliative care. There was regional variation in mortality. Whipple’s procedure conferred lower mortality. Conclusions Our study showed downward trends in LOS and in-hospital mortality despite increasing hospitalizations with pancreatic cancer.