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A Case-Based Approach to Constipation in Primary Care [Case Report]

Snell, David B; Faruqui, Saamia; Bosworth, Brian P
Primary care physicians frequently evaluate patients with constipation. The history is crucial in uncovering warning symptoms and signs that warrant colonoscopy. Particular elements in the history and rectal examination also can provide clues regarding the underlying etiology. Regardless of etiology, lifestyle modifications, fiber, and laxatives are first-line therapies. Patients who fail first-line therapies can be offered second-line treatments and/or referred for testing of defecatory function. In those with severely refractory symptoms, referrals to a gastroenterologist and a surgeon should be considered.
PMID: 33246523
ISSN: 1557-9859
CID: 4730552

Telehealth in the time of COVID-19: Gastroenterologists' use and attitudes [Meeting Abstract]

Snell, D B; Wallace, T; Pochapin, M B; Gross, S A; Brodsky, T
INTRODUCTION: Telehealth involves the use of electronic information and telecommunications to promote healthcare. Physician experience is critical in assessing the impact of telehealth on clinical outcomes and utilization. Gastroenterologists' use and attitudes towards telehealth are largely unknown. We aimed to identify gastroenterologists' professional attitudes towards their use of telehealth and its effect on patient care during the COVID-19 pandemic.
METHOD(S): We performed a cross sectional survey of outpatient gastroenterologists and hepatologists at a single tertiary academic medical center in June 2020. Clinicians were invited to participate in an electronic survey. Survey questions involved either single or multiple categorical responses.
RESULT(S): A total of 46 respondents (51 +/- 14 years old) participated, 70% of which were male. 44 (96%) respondents had no telehealth experience prior to the pandemic. Clinicians conducted 19 +/- 13 visits weekly with a mean length of 24 +/- 9 minutes. 88% of providers reported telehealth allowed for increased flexibility, both in patient scheduling and their personal lives. Telehealth was always or usually effective in addressing patients' clinical needs 91% of the time. 29 (63%) respondents estimated that 10% or fewer patients required in-person follow-up. Clinicians estimated 93% of patients desired the continued option of telehealth, and 42 (91%) providers wanted to continue telehealth in some capacity, conditional on reimbursement. Those interested would use telehealth for follow-up visits (28%), on a patient-by-patient basis (23%), or for new visits (20%). While 21 (46%) respondents felt that telehealth and in-person visits required equal effort, 16 (35%) felt telehealth required more effort. Reasons cited for telehealth requiring more effort included coordination of care (30%), technical difficulty for the patient (20%), and more charting (17%).
CONCLUSION(S): While most clinicians had no telehealth experience before the pandemic, a majority were interested in using telehealth in the future, citing increased flexibility for both provider and patient. Physicians felt that telehealth was effective in addressing patients' needs. However, many felt that telehealth required more effort, particularly in regard to coordination of care and technical difficulties. Newer telehealth platforms should address connectivity issues. Future studies should focus on patients' attitudes towards telehealth, and the effect of telehealth on healthcare outcomes, utilization and costs
ISSN: 1572-0241
CID: 4720482

Gastric food retention at endoscopy is associated with severity of liver cirrhosis

Snell, David B; Cohen-Mekelburg, Shirley; Weg, Russell; Ghosh, Gaurav; Buckholz, Adam P; Mehta, Amit; Ma, Xiaoyue; Christos, Paul J; Jesudian, Arun B
BACKGROUND:Gastrointestinal symptoms are prevalent in patients with cirrhosis. Cirrhotic patients have a known predilection to delayed gastric emptying compared to those without cirrhosis. However, the contributing factors have not been fully elucidated. Retained gastric food on esophagogastroduodenoscopy (EGD) has been used as a surrogate marker for delayed gastric emptying with reasonably high specificity. Therefore, we hypothesize that the frequency of retained gastric food contents at EGD will be higher in a cirrhotic population compared to a control population without liver disease. Additionally, we hypothesize that increased frequency of gastric food contents will be associated with increased severity of cirrhosis. AIM/OBJECTIVE:To determine the relative frequency of delayed gastric emptying among cirrhotics as compared to non-cirrhotics and to identify associated factors. METHODS:We performed a retrospective case-control study of cirrhotic subjects who underwent EGD at an academic medical center between 2000 and 2015. Three hundred sixty-four patients with confirmed cirrhosis, who underwent a total of 1044 EGDs for the indication of esophageal variceal screening or surveillance, were identified. During the same period, 519 control patients without liver disease, who underwent a total of 881 EGDs for the indication of anemia, were identified. The presence of retained food on EGD was used as a surrogate for delayed gastric emptying. The relative frequency of delayed gastric emptying among cirrhotics was compared to non-cirrhotics. Characteristics of patients with and without retained food on EGD were compared using univariable and multivariable logistic regression analysis to identify associated factors. RESULTS:0.01) were also associated with a higher likelihood of food retention on EGD. CONCLUSION/CONCLUSIONS:Cirrhotics have a higher frequency of retained food at EGD than non-cirrhotics. Decompensated cirrhosis, defined by Child-Pugh class C, is associated with a higher likelihood of delayed gastric emptying.
PMID: 31772719
ISSN: 1948-5182
CID: 4336352

The rise of Clostridioides difficile infections and fall of associated mortality in hospitalized advanced cirrhotics

Rosenblatt, Russell; Mehta, Amit; Cohen-Mekelburg, Shirley; Shen, Nicole; Snell, David; Lucero, Catherine; Jesudian, Arun; Fortune, Brett; Crawford, Carl V; Kumar, Sonal
BACKGROUND & AIMS:Cirrhotics are at increased risk of Clostridioides difficile infection (CDI) and its associated high morbidity and mortality. However, the impact of CDI in cirrhotics over time remains unclear. This study analyses prevalence and mortality in CDI in hospitalized patients with advanced cirrhosis over 15 years and identifies trends. METHODS:Using the Nationwide Inpatient Sample (NIS) from 1998 to 2014, 3 049 696 weighted patients with advanced cirrhosis (defined as evidence of decompensation or oesophageal varices) were identified using a validated algorithm of ICD-9-CM codes and included in the study. Trends were analysed using Cochran Armitage test and joinpoint regression and compared to the general population. Multivariable logistic regression was performed controlling for risk factors that affect mortality in cirrhotics. RESULTS:CDI prevalence in advanced cirrhotics increased from 0.8% to 2.6%, annual percent change (APC) 8.8% (compared to 7.6% for the general population), while CDI-related mortality decreased from 20.7% to 11.3%, APC -3.4% (compared to -2.0% for the general population), from 1998 to 2014. CDI independently increased mortality in advanced cirrhotics (OR 1.47, P < 0.001) and was associated with acute kidney injury (AKI) (OR 2.09, P < 0.001), which itself significantly increased mortality (OR 4.54, P < 0.001). Hepatic encephalopathy and Hispanic ethnicity were interestingly associated with a lower prevalence of CDI. CONCLUSIONS:CDI is increasingly common in advanced cirrhotics, but on the contrary, its associated mortality is decreasing. Despite improvements in outcomes in patients with advanced cirrhosis, CDI is associated with an increased mortality, driven by AKI, and therefore, requires aggressive identification and therapy.
PMID: 30790420
ISSN: 1478-3231
CID: 4898442

Ultrasonographic Nonalcoholic Fatty Pancreas Is Associated with Advanced Fibrosis in NAFLD: A Retrospective Analysis

Rosenblatt, Russell; Mehta, Amit; Snell, David; Hissong, Erika; Kierans, Andrea Siobhan; Kumar, Sonal
BACKGROUND:Nonalcoholic fatty pancreas disease (NAF-P) is strongly linked with nonalcoholic fatty liver disease (NAFLD), but its relationship with advanced liver disease is unknown. AIMS:This study investigated the association between NAF-P and both advanced fibrosis and nonalcoholic steatohepatitis (NASH). METHODS:This retrospective study evaluated adults with biopsy-proven NAFLD with a sonogram within 1 year of liver biopsy. NAF-P was diagnosed by comparing the echogenicity of the pancreas to the kidney and was graded by severity. The primary outcome was the effect of NAF-P on the presence of advanced fibrosis and NASH, while secondary outcomes included the association of extensive NAF-P (grade II/III). Propensity score matching for independent risk factors of advanced fibrosis (age, gender, body mass index, and diabetes) was performed. RESULTS:One hundred and four patients were included in the study and 91 (87.5%) had NAF-P. After propensity score matching, NAF-P was significantly associated with advanced fibrosis (OR 10.52, p < 0.001) but not NASH (p = 0.27). Extensive NAF-P was predictive of advanced fibrosis (OR 3.35, p = 0.006) and NASH (OR 5.37, p < 0.001). NAF-P had a negative predictive value (NPV) of 93% for advanced fibrosis. When matching for the NAFLD fibrosis score in addition to the variables above, both NAF-P (OR 5.36, p = 0.001) and extensive NAF-P (OR 5.38, p = 0.002) still significantly predicted advanced fibrosis. CONCLUSION:NAF-P is predictive of advanced fibrosis, even when controlling for independent predictors of advanced fibrosis and the NAFLD fibrosis score. NAF-P has an excellent NPV and is a safe, inexpensive finding that can rule out advanced fibrosis.
PMID: 30269271
ISSN: 1573-2568
CID: 4898432

Engineering oxidoreductases: maquette proteins designed from scratch

Lichtenstein, Bruce R; Farid, Tammer A; Kodali, Goutham; Solomon, Lee A; Anderson, J L Ross; Sheehan, Molly M; Ennist, Nathan M; Fry, Bryan A; Chobot, Sarah E; Bialas, Chris; Mancini, Joshua A; Armstrong, Craig T; Zhao, Zhenyu; Esipova, Tatiana V; Snell, David; Vinogradov, Sergei A; Discher, Bohdana M; Moser, Christopher C; Dutton, P Leslie
The study of natural enzymes is complicated by the fact that only the most recent evolutionary progression can be observed. In particular, natural oxidoreductases stand out as profoundly complex proteins in which the molecular roots of function, structure and biological integration are collectively intertwined and individually obscured. In the present paper, we describe our experimental approach that removes many of these often bewildering complexities to identify in simple terms the necessary and sufficient requirements for oxidoreductase function. Ours is a synthetic biology approach that focuses on from-scratch construction of protein maquettes designed principally to promote or suppress biologically relevant oxidations and reductions. The approach avoids mimicry and divorces the commonly made and almost certainly false ascription of atomistically detailed functionally unique roles to a particular protein primary sequence, to gain a new freedom to explore protein-based enzyme function. Maquette design and construction methods make use of iterative steps, retraceable when necessary, to successfully develop a protein family of sturdy and versatile single-chain three- and four-α-helical structural platforms readily expressible in bacteria. Internally, they prove malleable enough to incorporate in prescribed positions most natural redox cofactors and many more simplified synthetic analogues. External polarity, charge-patterning and chemical linkers direct maquettes to functional assembly in membranes, on nanostructured titania, and to organize on selected planar surfaces and materials. These protein maquettes engage in light harvesting and energy transfer, in photochemical charge separation and electron transfer, in stable dioxygen binding and in simple oxidative chemistry that is the basis of multi-electron oxidative and reductive catalysis.
PMID: 22616867
ISSN: 1470-8752
CID: 4898412