Inflammatory pseudopolyps are a recognized complication of inflammatory bowel disease (IBD). However, their development in the context of well-controlled IBD is poorly understood. A 73-year-old woman with longstanding ileocolonic Crohn's disease that had been in endoscopic and histologic remission on sulfasalazine for 8 years developed a rapidly growing, fungating, ulcerated pedunculated rectal lesion, endoscopically indistinguishable from rectal carcinoma, within 1 year of a completely normal surveillance colonoscopy. An en bloc hot snare polypectomy confirmed an inflammatory pseudopolyp on histology, with no dysplasia or malignancy. She was subsequently escalated to vedolizumab after individualized consideration of her advanced liver disease and the agent's gut-selective mechanism, with sustained clinical improvement. This case highlights that quiescent IBD does not preclude alarming endoscopic findings, that inflammatory polyps can develop rapidly and mimic malignancy, and that even patients with apparent remission may have residual histologic disease activity. Pathologic evaluation remains indispensable, and such lesions should prompt reassessment of therapeutic adequacy.
We present the case of a 52-year-old man with insulin-dependent type 2 diabetes mellitus with multiple 2 to 3 cm firm subcutaneous masses on the abdomen, where biopsy confirmed nodular amyloidosis via apple green birefringence when stained with Congo red. Insulin, along with enfuvirtide, is one of two known medications capable of causing iatrogenic nodular amyloidosis, and patients should avoid repeat insulin injections into sites of amyloidosis, as absorption of insulin may be altered in these areas. Accurate amyloid typing may obviate the need for systemic evaluation and prevent accompanying costs and morbidity.
BACKGROUND:The prevalence of metabolic dysfunction-associated steatotic liver disease (MASLD) continues to rise, with strong associations with obesity and cardiometabolic diseases. Bariatric surgery (BS) has shown metabolic benefits in MASLD, but its impact on major adverse cardiovascular and cerebrovascular events (MACCE) remains unclear. METHODS:National Inpatient Sample data from 2016 to 2022 were used to identify adults aged ≥18 years with hepatic steatosis or steatohepatitis and at least one metabolic risk factor, approximating established MASLD criteria. Patients were then stratified by prior BS status, and multivariable logistic regression was used to assess the outcomes after adjustment for potential confounders. Outcomes were reported as adjusted odds ratios (aOR) with 95% confidence intervals (CI). RESULTS:Among 3,668,314 MASLD patients, 394,535 underwent BS. BS was associated with lower odds of all-cause mortality (aOR 0.33, 95% CI 0.32-0.34), myocardial infarction (aOR 0.38, 95% CI 0.36-0.39), stroke (aOR 0.87, 95% CI 0.86-0.88), atrial fibrillation (aOR 0.73, 95% CI 0.72-0.74), and heart failure (aOR 0.52, 95% CI 0.52-0.57); all P < 0.001. Length of stay and total hospital charges were also significantly reduced. CONCLUSION:BS was associated with lower risk of MACCE, mortality, and resource utilization in patients with MASLD, supporting its beneficial role.
BACKGROUND:Acute kidney injury (AKI) may worsen outcomes of delirium tremens (DT), but data are limited. We investigated the association between AKI and hospital outcomes in DT and identified factors associated with AKI. METHODS:We conducted a retrospective observational study using the National Inpatient Sample (2017-2022) and ICD-10 codes. Adult hospitalizations with a principal diagnosis of DT were identified and stratified by AKI as a secondary diagnosis. Primary outcomes were endotracheal intubation rate, hospital length of stay, and all-cause hospital mortality. Multivariate regression, inverse probability of treatment weighting, and augmented inverse probability weighting were performed. RESULTS:Among 267,375 DT hospitalizations, 11.26% had AKI. Patients with AKI had longer length of stay (9.09 vs 5.88 days), a higher endotracheal intubation rate (13.62% vs 5.04%), and a higher hospital mortality rate (2.23% vs 0.28%) (all P < 0.001). In adjusted analyses, AKI was independently associated with increased odds of mortality (odds ratio [OR] 4.21) and intubation (OR 2.33), as well as longer hospital length of stay (all P < 0.001). These findings were consistent after weighting analyses. AKI was associated with male sex, Black race, sepsis, obesity, and higher Charlson Comorbidity Index. CONCLUSIONS:AKI is common among patients hospitalized with DT and is associated with worse hospital outcomes.
BACKGROUND:The southern region of the USA including Texas is projected to see increasing temperatures. Heat-related illness (HRI) is a consequence of rising temperatures, and vulnerable populations are disproportionately affected. METHODS:This retrospective cohort study analyzed electronic health record data in Central Texas. Subjects presenting to the emergency department with HRI in 2015-2016 and 2022-2023 were identified via International Classification of Diseases codes. Variables collected included age, sex, race, month, and urban-rural status. Local temperature trends were examined. RESULTS:The overall incidence of HRI increased from 0.08% of total presentations to 0.15% (P < 0.001). Subjects aged 64 to 97 years and Hispanic subjects showed a disproportionate increase. Metropolitan areas had a higher incidence than rural areas. Presentations significantly clustered from May through August. The mean age increased by 5.28 years, while local temperatures did not differ significantly. CONCLUSION:The incidence of HRI increased over time, with a higher prevalence among older adults and Hispanic populations. Targeted public health interventions are needed for marginalized communities and older adults in underserved areas to mitigate HRI morbidity and mortality.
BACKGROUND:Pheochromocytoma and paragangliomas are unique neuroendocrine tumors that can be a significant source of morbidity and mortality. It was previously thought that these tumors were largely sporadic. There is a paucity of literature to support routine genetic testing. The aim of this study was to determine the utility of preoperative genetic testing for these tumors. METHODS:This study was a retrospective review of all patients >18 years of age with a diagnosis of a pheochromocytoma or paraganglioma who were evaluated in our surgical oncology clinic from January 1, 2014, through January 1, 2025. Basic demographic data, along with genetic testing, recurrence, and final pathology findings, were collected. RESULTS:A total of 48 patients were reviewed, with 21 patients completing genetic testing. Fourteen patients (66.6%) were found to have negative genetic testing, while 7 patients (33.3%) had positive genetic testing. There was no difference in age, race, or sex of the patients with positive and negative genetic testing. There was no difference in recurrence (P = 1.0) or findings of metastasis (P = 1.0) on final pathology between patients with positive versus negative genetic testing. CONCLUSION:Given the high rate of genetic mutations found in this study, we recommend that all patients with pheochromocytomas and paragangliomas undergo genetic testing.
BACKGROUND:Autologous stem cell transplantation (ASCT) remains the standard for transplant-eligible multiple myeloma (MM) patients. However, data on inpatient arrhythmias among MM-ASCT hospitalizations with preexisting cardiovascular disease (CVD) remain limited. We evaluated present-on-admission (POA)-coded new-onset inpatient arrhythmias according to preexisting CVD status. METHODS:We analyzed the unweighted National Inpatient Sample (2016-2022) and identified adult MM-ASCT hospitalizations with valid POA indicators. Preexisting CVD included coronary artery disease, atrial fibrillation, valvular disease, conduction disorders, congestive heart failure, and prior cardiac arrest. The primary outcome was POA-coded new-onset inpatient arrhythmia. Secondary outcomes included length of stay, hospital charges, and discharge disposition. Firth's penalized logistic regression was used for sparse events, with LASSO regression performed as an exploratory sensitivity analysis. RESULTS:Among 58 MM-ASCT hospitalizations, 12 (21%) had preexisting CVD. New-onset inpatient arrhythmias occurred in 9 hospitalizations (16%) and were more frequent with preexisting CVD (66.7% vs 2.2%, P < 0.001). No clear differences were observed in length of stay, charges, or discharge disposition. CONCLUSIONS:New-onset inpatient arrhythmias were more frequent among MM-ASCT hospitalizations with preexisting CVD. These findings are hypothesis-generating and warrant validation in larger clinically adjudicated cohorts.
BACKGROUND:Metabolic dysfunction-associated steatotic liver disease (MASLD) affects lean individuals, but the contribution of environmental exposures remains poorly understood. This study investigated whether blood volatomic profiling of volatile organic compounds (VOCs) identifies environmental chemicals associated with MASLD and advanced fibrosis in lean adults using explainable machine learning. METHODS:We performed a cross-sectional analysis of lean adults from the NHANES 2017-2020 survey with whole-blood measurements of nine VOCs. XGBoost decision trees were used to evaluate associations between VOC profiles, MASLD, and advanced fibrosis. Shapley additive explanations (SHAP) quantified the contribution of individual VOCs and characterized exposure-response patterns. RESULTS:Among 860 lean adults, 9.0% had MASLD and 1.6% had advanced fibrosis. The MASLD model demonstrated modest discrimination (area under the receiver-operating characteristic curve [AUC-ROC] 0.65), whereas the advanced fibrosis model performed poorly (AUC-ROC 0.24) because of limited events. Chloroform was the strongest VOC associated with both MASLD and advanced fibrosis, followed by o-xylene, bromodichloromethane, benzene, and furan. SHAP analyses demonstrated nonlinear exposure-response relationships and high sensitivity to small variations in low-level VOC concentrations. CONCLUSION:Blood volatomic profiling identified distinct VOC signatures associated with MASLD in lean adults, with chloroform as the dominant contributor. Exploratory findings also suggested potential associations with advanced fibrosis that warrant validation in larger studies.
BACKGROUND:Gastrointestinal bleeding (GIB) often affects older, medically complex patients, yet national patterns of inpatient palliative care documentation in GIB are unknown. We aimed to characterize trends and factors associated with palliative care documentation and examine associated inpatient care and outcome patterns. METHODS:We conducted a retrospective serial cross-sectional study of adult principal-diagnosis upper or lower GIB hospitalizations in the 2016 to 2022 National Inpatient Sample. Documentation was defined by ICD-10-CM Z51.5 in any diagnosis field. Survey-weighted regression assessed associated factors and inpatient outcomes. RESULTS:Among 2,435,099 weighted hospitalizations, palliative care documentation was present in 65,675 (2.70%), increasing from 2.13% in 2016 to 3.43% in 2022. Associated factors included metastatic cancer (adjusted odds ratio [aOR], 8.276), age ≥85 years (aOR, 5.626), respiratory failure (aOR, 3.159), and dementia (aOR, 3.101). Relative to the White category, Black (aOR, 0.802) and Hispanic (aOR, 0.791) categories had lower adjusted odds. Documentation was associated with lower odds of endoscopy but higher odds of mechanical ventilation and renal replacement therapy. Among in-hospital decedents, coded do-not-resuscitate status was more frequent (80.2% vs 40.5%), and several treatments were less frequent. Adjusted length of stay and hospital charges were 4.3% and 1.1% higher, respectively. CONCLUSIONS:Palliative care documentation was uncommon and concentrated in higher-acuity hospitalizations. Because the code does not identify provider specialty, timing, or content, patterns are associations rather than effects and require validation in clinically richer data.
BACKGROUND:Recent studies suggest shifting epidemiological patterns in hepatobiliary cancers (HBC), with an increasing incidence among younger populations. This study evaluated incidence and mortality trends of HBC in adolescents and young adults (AYA) in the United States. METHODS:We conducted a retrospective population-based study using SEER 21 Registries. Individuals aged 15 to 39 years diagnosed with liver and intrahepatic bile duct cancers from 2000 to 2022 were included. Adults aged 40 to 64 years served as a comparator group. Age-adjusted incidence (AAI) and mortality rates (MR) per 100,000 were calculated, and trends were analyzed using annual percent change (APC). RESULTS:Among AYA, AAI increased from 0.34 (95% confidence interval [CI] 0.29-0.40) per 100,000 in 2000 to 0.56 (95% CI 0.49-0.63) in 2022. This was driven by an increase among females: APC 3.18%, 95% CI 2.24-4.30. Hispanic females had the greatest increase, with an APC of 6.96% (95% CI 4.07-20.03). The incidence in adults aged 40 to 64 years peaked in 2014 and declined thereafter. Mortality increased in AYA females (APC 0.99%, 95% CI 0.27-1.75), while remaining stable in males. CONCLUSION:HBC incidence is rising among AYAs in the United States, disproportionately affecting females, especially Hispanic women, and is accompanied by increasing mortality. Further research is needed to identify underlying causes, including potential metabolic risk factors.
BACKGROUND:Adjunctive therapies targeting pathologic vasodilation in septic shock are increasingly used when standard vasoactive strategies fail. Although methylene blue (MB) and high-dose hydroxocobalamin (HC) have shown potential hemodynamic benefits, comparative data in sepsis are lacking. We compared outcomes among septic patients treated with MB or HC using a large multicenter electronic health record network. METHODS:We conducted a retrospective cohort study using the TriNetX US network (65 health systems). Adults hospitalized with sepsis, severe sepsis, or septic shock from 2016 to 2025 who received MB or HC were included. Patients with nitroprusside exposure, methemoglobinemia, cardiogenic shock, or neither therapy were excluded. Propensity score matching (1:1) balanced 91 covariates. RESULTS:A total of 732 matched patients were analyzed (366 MB, 366 HC). Mortality and acute kidney injury rates were similar between groups. HC was associated with higher continuous renal replacement therapy initiation at 3-7 days and 7 days after treatment (both P < 0.001). Stroke and prolonged vasopressor use were more frequent with HC during days 3-7 but not by day 7. Other secondary outcomes were comparable. CONCLUSIONS:MB and HC demonstrated similar early mortality, but MB was associated with lower continuous renal replacement therapy use and fewer early strokes and prolonged vasopressor requirements. These findings suggest MB may be the more favorable adjunctive therapy, although prospective comparative studies are needed to confirm these observational results.
The rapid expansion of social media has fundamentally altered how physicians communicate with colleagues, patients, institutions, and the public. While online platforms offer unprecedented opportunities for education, networking, and professional identity formation, they also introduce significant risks related to patient confidentiality, professional boundaries, liability, and public trust. Seemingly casual posts can have serious consequences. Best practices include protecting patient privacy, assuming permanence, having separate personal and professional identities, using disclaimers, knowing institutional policies, monitoring one's online presence, and staying within one's scope of practice. By cultivating mindful and professional online practices, physicians can shape a digital footprint that aligns with the values of the medical profession and supports high-quality patient care.
