Bassett Medical Center

Non-variceal upper gastrointestinal bleeding (NVGIB) represents an urgent medical condition with high mortality. Standard endoscopic therapies (ST) still carry a high rebleeding rate. Novel modalities such as the over-the-scope clip (OTSC) and hemostatic powder (HP) could be promising alternatives, but their efficacy and cost-effectiveness remain to be explored. A network meta-analysis and cost-effectiveness analyses were conducted to compare OTSC vs HP vs ST. Primary endpoints include 30-day rebleeding and 30-day further bleeding. Markov models with a 12-month time horizon were created across 3 different health care settings: the United States, Thailand with Boston Scientific products (TH-BOS), and Thailand with China-manufactured alternatives (TH-CHN). Incremental cost-effectiveness ratio (ICER) was evaluated at a willingness-to-pay of $100,000 per quality-adjusted life year for the US model and THB 150,000 per quality-adjusted life year for the TH-BOS and TH-CHN models. Ten randomized controlled trials with 1,120 patients with NVGIB were included in the network meta-analysis. Lowest 30-day rebleeding was seen in OTSC ( P -score: 0.996), followed by ST (0.296) and HP (0.208). Similarly, OTSC also achieved lowest 30-day further bleeding (0.906), followed by HP (0.570) and ST (0.024). In cost-effective analysis, the US model reported OTSC as a dominant approach compared with HP (ICER: -$314) and ST (-$3,112). In the TH model, OTSC still dominated ST (ICER: -THB 28,423 for TH-BOS and -22,858 for TH-CHN) and was more cost-effective than HP (THB 1,833 for TH-BOS and THB 2,026 for TH-CHN). OTSC was superior to HP and ST in efficacy and cost-effectiveness, favoring its use as a first-line endoscopic hemostasis intervention for NVGIB.

Crooke cell adenomas (CCAs) are a rare subtype of pituitary corticotroph adenomas with a prevalence of less than 1% of pituitary adenomas. CCAs have variable clinical manifestations and can present as functional adenomas secreting adrenocorticotropic hormone (ACTH), resulting in hypercortisolism, as well as silent invasive macroadenomas. CCAs also exhibit a higher risk for recurrence, less biochemical remission, and normalization of pituitary function after tumor resection compared to other secretory corticotroph adenomas. Refractory hypokalemia and hypertension as manifestations of hypercortisolism are more commonly seen in patients with ectopic ACTH syndrome than pituitary-dependent Cushing syndrome. We present a 39-year-old female who presented with refractory hypokalemia, hypertension, lower extremities edema, and newly diagnosed diabetes mellitus. Evaluation revealed an ACTH-dependent hypercortisolemia from a 5- × 3-mm pituitary microadenoma. She underwent transsphenoidal resection of the microadenoma with resolution of symptoms immediately after surgery and up to 20 months of follow-up. The histopathology of the microadenoma revealed more than 50% of corticotrophs demonstrated Crooke hyaline change compatible with Crooke cell adenoma. To our knowledge, only one case of CCA presenting with a microadenoma and similar clinical manifestations has been reported to date. Our case highlights an atypical and infrequent clinical presentation of CCA.

Laparoscopic common bile duct exploration (LCBDE) is a safe and effective alternative to endoscopic retrograde cholangiopancreatography (ERCP) plus laparoscopic cholecystectomy (LC), but with a shorter length of stay (LOS). Nevertheless, LCBDE remains highly underutilized. Since 2021, our institution has conducted simulation-based LCBDE training for surgeons and residents. We sought to determine our current LCBDE utilization rate and potential utilization rate by identifying "missed opportunities" for LCBDE. We reviewed LCBDE or ERCP plus LC cases from 2023 to 2024 at a single institution. We excluded LC for hepatobiliary cancer and ERCP for non-gallstone disease. Contraindications to LCBDE were severe cholangitis, severe pancreatitis, malignancy concern, or significant comorbidities. We defined "missed opportunities" as cases eligible for LCBDE wherein ERCP was chosen instead. Median LOS (days) was compared between groups. A total of 87 patients underwent LC plus LCBDE or ERCP. LCBDE was performed in 38% (n = 33, LOS = 2). ERCP with appropriate justification was performed in 25% (n = 22, LOS = 4.5) due to severe acute cholangitis (15%, n = 13), concern for malignancy (6%, n = 5), surgeon judgment (3%, n = 3), severe pancreatitis (1%, n = 1), severe comorbidities (1%, n = 1), patient preference (1%, n = 1), and diagnostic uncertainty (2%, n = 2). "Missed opportunities" represented the remaining 37% (n = 32, LOS = 3) due to: surgeon consulted after ERCP (18%, n = 16), patient transferred for ERCP only (5%, n = 4), surgeon not LCBDE trained (2%, n = 2), unavailable operating room (1%, n = 1), and unclear reasons (10%, n = 9). Our potential LCBDE utilization rate was 75%. Most ERCP cases represented "missed opportunities" for LCBDE despite our robust LCBDE adoption. "Missed opportunities" had a significantly longer median LOS than LCBDE (3 vs. 2days, p = 0.048). Efforts to optimize LCBDE utilization could significantly reduce LOS. The highest yield quality improvement opportunity may be to optimize ERCP/LC referral patterns. The 10% of unclear "missed opportunities" cases require additional investigation.

ABSTRACT Objectives Farm injuries impact more than the farmer, they affect family members, the community, and the local economy. In the Northeastern United States, while technology has improved safety measures significantly, rates of agricultural injuries, and fatalities are still very high. Methods In this study, we spoke with farmers who experienced a traumatic work injury as well as farm-support professionals to better understand the burden of agricultural injuries on the farmer and those closest to them. Interviews were recorded, transcribed, and coded in NVIVO 12. Results Using qualitative thematic analysis approach when coding and analyzing the interview dialogue, two prominent themes emerged; i) the role of familial support post-injury and, ii) the burden of navigating a complex administrative system when seeking assistance. The injured farmers that lacked strong family support struggled to keep their businesses viable and often felt isolated and overwhelmed. In these cases, mental health counselors acted much like surrogate family members by providing emotional and structural support, but in a limited capacity. Between both the farmers and farm-support professionals interviewed, many expressed their frustrations with the time-consuming and ineffective administrative processes that injured farmers experience when trying to obtain social assistance such as unemployment, disability, or assistive technology. Conclusion These data may be used to better inform policy recommendations that affect injured farmers.

Mechanical circulatory support (MCS) devices, such as the Impella, have become critical tools in managing cardiogenic shock (CS), offering temporary hemodynamic support to improve cardiac output and stabilize patients. This study aimed to evaluate gender-based differences in clinical outcomes following Impella implantation for CS secondary to myocardial infarction (MI). Using real-world data from the TriNetX database, all patients with CS secondary to MI who underwent Impella implantation were identified and then divided into two cohorts based on gender. To minimize selection bias, propensity score matching (PSM) was applied at a 1:1 ratio based on baseline characteristics, including age, race, and comorbidities. Outcomes included in-hospital mortality, acute kidney injury (AKI), cardiac arrest, acute ischemic and hemorrhagic strokes, intraoperative bleeding, acute aortic dissection, critical limb ischemia, acute pulmonary embolism, and readmission rates. Our analysis identified 6,687 individuals who underwent Impella implantation for cardiogenic shock. After PSM, two matched cohorts comprising 1,760 individuals were included. Male gender was associated with a significantly increased incidence of AKI (RR: 1.21, p < 0.001) and readmission (RR: 1.09, p = 0.006). On the other hand, females had a 60% greater chance of developing critical limb ischemia compared to males (RR: 0.40, p < 0.001). Gender did not impact the incidence of cardiac arrest (p = 0.243), acute ischemic strokes (p = 0.953), pulmonary embolism (p = 0.275), or mortality (p = 0.919). The incidences of hemorrhagic stroke, aortic dissection, and intraoperative bleeding were equal in both groups (p = 1). Our study showed that male patients had a higher risk of acute kidney injury and readmissions compared to females, whereas females were more likely to experience critical limb ischemia. These findings highlight the need for gender-specific considerations in the management of CS and the use of MCS.

ABSTRACTIntroductionWhile gastrointestinal involvement is a common manifestation of systemic lupus erythematosus (SLE), the association between gastroparesis and SLE remains unclear.MethodsWe analyzed data from the National Inpatient Sample (NIS) database from 2016 to 2021. Patients with gastroparesis were categorized into SLE and non‐SLE groups. Similarly, patients with SLE were categorized into gastroparesis and nongastroparesis groups. Clinical characteristics, comorbidities, hospitalization data, and outcomes were compared. The primary outcome was the association between SLE and primary gastroparesis. Secondary outcomes were clinical impacts of gastroparesis in patients with or without SLE.ResultsA total of 12 538 228 patients were included from the NIS database. Of these, 1 165 925 patients (9.3%) were diagnosed with gastroparesis during hospitalization, while 11 372 303 patients (90.7%) did not have gastroparesis. SLE was significantly more common in patients with gastroparesis compared to those without (1.6% vs. 0.7%, p &lt; 0.001; aOR 1.87 [95% CI: 1.80–1.95]). Among patients hospitalized with gastroparesis, those with SLE had a longer length of stay, with a β‐coefficient of 0.31 (95% CI: 0.07–0.55, p = 0.009), lower hospitalization charges, with mean differences of $4761 (95% CI: 442–9080, p = 0.031), and a higher rate of intervention needs, with odds ratios of 1.31 (95% CI: 1.09–1.56, p = 0.003). After propensity‐score matching (1:1), SLE patients aged ≥ 65 had higher hospital charges, with mean differences of $7287 (95% CI: 2928–11 646, p = 0.01), compared to non‐SLE patients.ConclusionGastroparesis is associated with SLE, contributing to longer hospitalizations, higher costs, and increased need for invasive interventions. These findings underscore the importance of evaluating gastroparesis in SLE patients to enable early management and reduce potential complications.

Background: Rural patients, including those with rectal cancer, continue to be underrepresented in research and medically underserved with unique challenges to accessing care. Like the rest of America, rural patients are experiencing rising rates of rectal cancer; however, unlike the rest of the country, they also have rising rectal cancer-related mortality. This study aims to review the literature regarding care for patients with rectal cancer in rural settings, from presentation and diagnosis to treatment algorithms, oncologic outcomes, their unique preferences, and the goals of care. Methods: A literature search was performed on PubMed, on 31 October 2024, using synonyms of “rural” and “rectal cancer” to identify relevant articles. Articles from outside the USA and Canada and those offering only commentary were eliminated during the initial screening/retrieval. A full-text review was performed on the remaining articles; all the studies that did not address the identified primary or secondary outcomes in rural rectal cancer patients were then excluded. All the primary and secondary outcomes are briefly summarized in narrative form, with more detail on the primary outcomes provided in tables. The variability in the key criteria between the studies is also summarized in the tables and appendices provided. Results: Thirty studies were identified that addressed the outcomes of interest in rural rectal cancer patient populations. The total number of participants could not be assessed given the use of overlapping databases. Of the articles, 21 addressed treatment modalities (surgery, chemotherapy, radiation), 13 addressed oncologic outcomes, and a mix of additional studies addressed the diagnostic work up, costs, and patient preferences. The studies addressing treatment demonstrated similar practices in regard to chemotherapy and surgical management, aside from lower rates of minimally invasive surgery, along with decreased neoadjuvant radiotherapy use and increased under-dosing in rural patients. The oncologic outcomes were overall similar to worse for rural patients as compared to urban patients, even for those receiving treatment at high-volume urban centers. Additionally, rural patients have higher healthcare costs for rectal cancer care. Discussion/Conclusions: Rural patients are an at-risk group, with a rising disease burden and worsening rectal cancer outcomes, despite advances in rectal cancer care and improving oncologic outcomes in the general population. Analysis of the situation is complicated due to the underrepresentation of rural patients in research and the lack of uniformity in the definition of “rural”. Moreover, significant gaps in the literature remain, such that the evaluation of guideline-concordant care is incomplete, including an absence of literature about watch-and-wait approaches in rural populations. While regionalization of rectal cancer care has shown promise, the improvements in outcomes may not be commensurate for rural patients. Thus, a specific focus on the impact of this shift for rural patients is necessary to mitigate unintended consequences.