Smit S. Deliwala, MD

All Publications

• Risk of De Novo Barrett's Esophagus Post Sleeve Gastrectomy: A Systematic Review and Meta-Analysis of Studies With Long-Term Follow-Up. Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association Chandan, S., Khan, S. R., Deliwala, S. S., Dahiya, D. S., Mohan, B. P., Ramai, D., Saghir, S. M., Dhindsa, B. S., Kassab, L. L., Facciorusso, A., Nandipati, K., Yang, D., Adler, D. G. 2025; 23 (1): 33-44.e10

  Abstract

  Sleeve gastrectomy (SG) is one of the most commonly performed bariatric procedures worldwide. Gastroesophageal reflux disease (GERD) is a major concern in patients undergoing SG and is a risk factor for Barrett's esophagus (BE). We conducted a systematic review and meta-analysis to assess the incidence of and analyze predictive factors for post-SG BE.A comprehensive literature search was conducted in April 2024, for studies reporting on incidence of BE, erosive esophagitis (EE), and hiatal hernia (HH) post-SG. Primary outcomes were post-SG pooled rates of de novo BE, EE, GERD symptoms, proton pump inhibitor use, and HH. Meta-regression analysis was performed to assess if patient and post-SG factors influenced the rates of post-SG BE.Nineteen studies with 2046 patients (79% females) were included. Mean age was 42.2 years (standard deviation, 11.1) and follow-up ranged from 2 to 11.4 years. The pooled rate of de novo BE post-SG was 5.6% (confidence interval, 3.5-8.8). Significantly higher pooled rates of EE (risk ratio [RR], 3.37], HH (RR, 2.09), GER/GERD symptoms (RR, 3.32), and proton pump inhibitor use (RR, 3.65) were found among patients post-SG. GER/GERD symptoms post-SG positively influenced the pooled BE rates, whereas age, sex, body mass index, post-SG EE, and HH did not.Our analysis shows that SG results in a significantly increased risk of de novo BE and higher rates of EE, proton pump inhibitor use, and HH. Our findings suggest that clinicians should routinely screen patients with SG for BE and future surveillance intervals should be followed as per societal guidelines.

  View details for DOI 10.1016/j.cgh.2024.06.041

  View details for PubMedID 39059544

• Cold Versus Hot Endoscopic Mucosal Resection for Sessile Serrated Colorectal Polyps ≥10 mm: A Systematic Review and Meta-analysis. Journal of clinical gastroenterology Malik, T. F., Mohan, B. P., Deliwala, S., Kassab, L. L., Chandan, S., Sharma, N. R., Adler, D. G. 2024; 58 (9): 889-895

  Abstract

  We performed a systematic review and meta-analysis studying the efficacy and safety of cold versus hot endoscopic mucosal resection (EMR) for resection of sessile serrated polyps (SSPs) ≥10 mm.Multiple databases were searched until January 2023 for studies reporting outcomes of cold versus hot EMR for SSPs ≥10 mm. The primary outcome was the residual SSP rate. Secondary outcomes included technical success rate, R0 resection rate, and adverse events. We used standard meta-analysis methods using the random-effects model, and I2 % was used to assess heterogeneity.Thirteen studies were included in the final analysis. In all, 1896 SSPs were included with a mean polyp size of 23.7 mm (range, 15.9 to 33). A total of 1452 SSPs were followed up for a median follow-up duration of 15.3 months (range, 6 to 37). The pooled residual SSP rate for cold EMR was 4.5% (95% CI: 1.0-17.4), and 5.1% (95% CI: 2.4-10.4) for hot EMR ( P =0.9). The pooled rates of technical success, R0 resection, immediate bleeding, and perforation were comparable. Hot EMR was significantly associated with lower piecemeal resection (59.2% vs. 99.3%, P <0.001), higher en-bloc resection (41.4% vs. 1.4%, P <0.001), and delayed bleeding rate (4% vs. 0.7%, P =0.05) compared to cold EMR.Cold EMR has similar efficacy compared to hot EMR for resection of SSP ≥ 10 mm, despite limitations in piecemeal R0 resection rate reporting. Although hot EMR was associated with a higher rate of en-bloc resection, it also showed an increased risk of delayed bleeding compared to cold EMR.

  View details for DOI 10.1097/MCG.0000000000001951

  View details for PubMedID 38019045

• Prophylactic pancreatic duct stenting to reduce the risk of post-ampullectomy pancreatitis: a comprehensive review and meta-analysis of 1858 patients. Surgical endoscopy Chandan, S., Canakis, A., Deliwala, S., Frohlinger, M., Khan, S. R., Mohan, B. P., Dahiya, D. S., Ramai, D., Facciorusso, A., Sharma, N. R., Adler, D. G., Kochhar, G. S. 2024; 38 (9): 4798-4813

  Abstract

  The effectiveness of prophylactic pancreatic duct stenting (PPDS) in preventing post-ampullectomy pancreatitis (PAP) at the time of endoscopic ampullectomy (EA) has been reported, however, results are conflicting. We conducted a systematic review and meta-analysis looking at the use of PPDS in reducing PAP as well as overall post-ampullectomy complications.Multiple databases were searched through May 2023 for studies reporting on EA. Meta-analysis was performed to determine pooled proportions and relative risk (RR) with 95% confidence intervals (CI) of PAP, with and without PPDS. Pooled rates of adverse events including perforation, delayed bleeding, cholangitis, and procedure related mortality were assessed. Random effects model was used for our meta-analysis and heterogeneity was assessed using the I2 statistics.Thirty-four studies (14 case series, 18 cohort studies and 2 randomized controlled trials) with 1868 patients were included. The overall pooled rate of PAP was 12.3% (CI 10.3-14.5). We found no statistically significant difference in rates of PAP among patients with PPDS, 11.9% (CI 8.9-15.7) and without PPDS, 16.6% (CI 13.4-20.4), RR 0.8 (CI 0.51-1.28), p = 0.4. In terms of severe PAP, we found no difference between the two groups. The overall pooled rates of successful en-bloc and piecemeal resection were 74.8% (CI 67.3-81.1) and 25.1% (CI 19-32.4). Additionally, pooled rates of ampullary stenosis, post procedural bleeding, perforation, cholangitis, and procedure related mortality were 3.6%, 11.1%, 4.2%, 3.5%, and 1.3%, respectively.Our analysis shows that PPDS at the time of EA does not offer a significant protective effect against PAP. While the incidence of PAP was higher among the no PPDS group, it is plausible that this is more likely due to variation among studies in terms of lesion size, length/size of pancreatic stent used and etiology of ampullary lesions. Future well-designed randomized controlled trials are needed to validate our findings.

  View details for DOI 10.1007/s00464-024-11019-y

  View details for PubMedID 39030415

  View details for PubMedCentralID 7049186

• Endoscopic outcomes using a novel through-the-scope tack and suture system for gastrointestinal defect closure: a systematic review and meta-analysis. Endoscopy Canakis, A., Deliwala, S. S., Frohlinger, M., Twery, B., Canakis, J. P., Shaik, M. R., Gunnarsson, E., Ali, O., Dahiya, D. S., Gorman, E., Irani, S. S., Baron, T. H. 2024; 56 (8): 605-611

  Abstract

  Closure of gastrointestinal defects can reduce postprocedural adverse events. Over-the-scope clips and an over-the-scope suturing system are widely available, yet their use may be limited by defect size, location, operator skill level, and need to reinsert the endoscope with the device attached. The introduction of a through-the-scope helix tack suture system (TTSS) allows for closure of large irregular defects using a gastroscope or colonoscope, without the need for endoscope withdrawal. Since its approval 3 years ago, only a handful of studies have explored outcomes using this novel device.Multiple databases were searched for studies looking at TTSS closure from inception until August 2023. The primary outcomes were the success of TTSS alone and TTSS with clips for complete defect closure. Secondary outcomes included complete closure based on procedure type (endoscopic mucosal resection [EMR], endoscopic submucosal dissection [ESD]) and adverse events.Eight studies met the inclusion criteria (449 patients, mean defect size 34.3 mm). Complete defect closure rates for TTSS alone and TTSS with adjunctive clips were 77.2% (95%CI 66.4-85.3; I2=79%) and 95.2% (95%CI 90.3-97.7; I2=42.5%), respectively. Complete defect closure rates for EMR and ESD were 99.2% (95%CI 94.3-99.9; I2 = 0%) and 92.1% (95%CI 85-96; I2=0%), respectively. The adverse event rate was 5.4% (95%CI 2.7-10.3; I2=55%).TTSS is a novel device for closure of postprocedural defects, with relatively high technical and clinical success rates. Comparative studies of closure devices are needed.

  View details for DOI 10.1055/a-2284-7334

  View details for PubMedID 38519045

• Cold Endoscopic Mucosal Resection (c-EMR) of Nonpedunculated Colorectal Polyps ≥20 mm: A Systematic Review and Meta-analysis. Journal of clinical gastroenterology Ramai, D., Clement, B., Maida, M., Previtera, M., Brooks, O. W., Wang, Y., Chandan, S., Dhindsa, B., Deliwala, S., Facciorusso, A., Khashab, M., Ofosu, A. 2024; 58 (7): 661-667

  Abstract

  There is increasing evidence that cold endoscopic mucosal resection (c-EMR) can effectively treat large colorectal polyps. We aim to appraise the current literature and evaluate outcomes following c-EMR for nonpedunculated colonic polyps ≥20 mm.Major databases were searched. Primary outcomes included recurrence rate and adverse events. Meta-analysis was performed using a random-effects model.Nine articles were included in the final analysis, which included 817 patients and 1077 colorectal polyps. Average polyp size was 28.8 (±5.1) mm. The pooled recurrence rate of polyps of any histology at 4 to 6 months was 21.0% (95% CI: 9.0%-32.0%, P <0.001, I2 =97.3, P <0.001). Subgroup analysis showed that recurrence was 10% for proximal lesions (95% CI: 0.0%-20.0%, P =0.054, I2 =93.7%, P =0.054) and 9% for distal lesions (95% CI: 2.0%-21.0%, P =0.114, I2 =95.8%, P =0.114). Furthermore, subgroup analysis showed that recurrence was 12% for adenoma (95% CI: 4.0%-19.0%, P =0.003, I2 =98.0%, P =0.003), and 3% for sessile serrated polyps (95% CI: 1.0%-5.0%, P =0.002, I2 =34.4%, P =0.002). Post-polypectomy bleeding occurred in 1% (n=8/817) of patients, whereas abdominal pain occurred in 0.2% (n=2/817) of patients.C-EMR for nonpedunculated colorectal polyps ≥20 mm shows an excellent safety profile with a very low rate of delayed bleeding as well as significantly less recurrence for sessile serrated polyps than adenomas.

  View details for DOI 10.1097/MCG.0000000000001958

  View details for PubMedID 38227846

• Role of endoscopic-ultrasound-guided biliary drainage with electrocautery-enhanced lumen-apposing metal stent for palliation of malignant biliary obstruction. World journal of gastrointestinal surgery Deliwala, S. S., Qayed, E. 2024; 16 (7): 1981-1985

  Abstract

  In this editorial, we discuss the article by Peng et al in the recent issue of the World Journal of Gastrointestinal Surgery, focusing on the evolving role of endoscopic-ultrasound-guided biliary drainage (EUS-BD) with electrocautery lumen apposing metal stent (LAMS) for distal malignant biliary obstruction. Therapeutic endoscopy has rapidly advanced in decompression techniques, with growing evidence of its safety and efficacy surpassing percutaneous and surgical approaches. While endoscopic retrograde cholangiopancreatography (ERCP) has been the gold standard for biliary decompression, its failure rate approaches 10.0%, prompting the exploration of alternatives like EUS-BD. This random-effects meta-analysis demonstrated high technical and clinical success of over 90.0% and an adverse event rate of 17.5%, mainly in the form of stent dysfunction. Outcomes based on stent size were not reported but the majority used 6 mm and 8 mm stents. As the body of literature continues to demonstrate the effectiveness of this technique, the challenges of stent dysfunction need to be addressed in future studies. One strategy that has shown promise is placement of double-pigtail stents, only 18% received the prophylactic intervention in this study. We expect this to improve with time as the technique continues to be refined and standardized. The results above establish EUS-BD with LAMS as a reliable alternative after failed ERCP and considering EUS to ERCP upfront in the same session is an effective strategy. Given the promising results, studies must explore the role of EUS-BD as first-line therapy for biliary decompression.

  View details for DOI 10.4240/wjgs.v16.i7.1981

  View details for PubMedID 39087127

  View details for PubMedCentralID PMC11287705

• Role of Duodenal Bulb Biopsy in Diagnosing Suspected Celiac Disease in Adult Patients: A Systematic Review and Meta-analysis. Journal of clinical gastroenterology Deb, A., Moond, V., Thongtan, T., Deliwala, S., Chandan, S., Mohan, B. P., Adler, D. G. 2024; 58 (6): 588-595

  Abstract

  Current guidelines recommend multiple biopsies from the first (D1) and second (D2) part of duodenum to establish a diagnosis of celiac disease. In this meta-analysis we aimed to find whether D1 biopsy can increase the diagnostic yield of adult celiac disease.Literature databases were searched until January 2023 for studies reporting diagnosis of celiac disease in the adult population using D1 biopsy. Meta-analysis was done using a random-effects model. Heterogeneity was assessed by I 2 % and 95% prediction interval statistics. Measured outcomes were diagnostic yield with D1 and D2 biopsies and from 4 versus 2 biopsy samples.A total of 16 studies were included in the final analysis. The pooled diagnostic rate of celiac disease from D1 biopsy was 77.4% [95% CI (64.7-86.5, I 2 94%)] and from D2 biopsy was 75.3% [60.8-85.7, I 2 96%]. The pooled rate of increase in diagnostic yield with D1 biopsy was 6.9% I [4.6-10.2, I 2 66%]. The pooled diagnosis rate with 2 biopsy samples were 77.3% [50-92, I 2 93%] and 86.4% I [58.4-96.7, I 2 87%] from D1 and D2 respectively, whereas that with 4 biopsy samples were 83.3% [49.8-96.2, I 2 76%] and 70.5% I [51-84.6, I 2 96%] from D1 and D2, respectively, the difference being non-significant.Our study demonstrates that taking 4 biopsy samples does not incur any additional diagnostic value over taking 2 biopsy samples from each duodenum segment. Although biopsy from the D1 and D2 has similar diagnostic yield in the adult population, there was an overall increase in diagnostic yield with D1 biopsy, especially in those with a patchy disease distribution.

  View details for DOI 10.1097/MCG.0000000000001913

  View details for PubMedID 37646538

• Safety and efficacy of the EndoRotor device for the treatment of walled-off pancreatic necrosis after EUS-guided cystenterostomy: A systematic review and meta-analysis ENDOSCOPIC ULTRASOUND Ramai, D., Ahmed, Z., Chandan, S., Facciorusso, A., Deliwala, S. S., Alastal, Y., Nawras, A., Maida, M., Barakat, M. T., Anderloni, A., Adler, D. G. 2024; 13 (3): 165-170

  View details for DOI 10.1097/eus.0000000000000031

  View details for Web of Science ID 001281650400005

• Effectiveness and safety of stag beetle knife (SB knife) in management of Zenker's diverticulum: a systematic review and meta-analysis. Diseases of the esophagus : official journal of the International Society for Diseases of the Esophagus Dahiya, D. S., Deliwala, S., Chandan, S., Ramai, D., Ali, H., Kassab, L. L., Facciorusso, A., Kochhar, G. S. 2024; 37 (4)

  Abstract

  Stag Beetle Knife (SB Knife) is increasingly being utilized for Zenker's Diverticulectomy (ZD). Our study assessed the effectiveness and safety of the SB Knife for the management of ZD. Ovid EBM reviews, Ovid Embase, Ovid Medline, ClinicalTrials.gov, Scopus, and Web of Science were searched to identify studies that utilized SB knife for ZD. Pooled proportions (PP) were calculated using the random-effects model. Heterogeneity was evaluated using I2 statistics. A total of 7 studies with 268 patients were included in the final analysis. Dysphagia and regurgitation were the most common clinical symptoms. The mean size of the ZD was 2.8 ± 0.7 cm and 28 (of 148) patients had undergone previous treatments. The PP of technical success was 98% (95% CI: 92.3-99.5; I20) with a mean procedure duration of 26.2 ± 8.3 minutes. The PP of clinical response at first follow-up and relapse after index procedure was 87.9% (95% CI: 81.6-92.3; I219) and 13.5% (95% CI: 9.6-18.6; I22), respectively. At final follow-up, the PP of clinical remission was 96.2% (95% CI: 91-98.4; I230.6) while the PP of procedure failure was 3.6% (95% CI: 1.6-8.1; I20). No severe adverse events (AEs) were noted while using the SB Knife. However, the PP of intraprocedural and postprocedural AEs was 13.2% (95% CI: 9.6-17.8; I20) and 9.3% (95% CI: 5.7-14.9; I2 < 20.9), respectively. SB Knife is highly safe and effective for Zenker's Diverticulectomy with a failure rate of only 3.6%.

  View details for DOI 10.1093/dote/doad069

  View details for PubMedID 38100729

• Safety and efficacy of the EndoRotor device for the treatment of walled-off pancreatic necrosis after EUS-guided cystenterostomy: A systematic review and meta-analysis. Endoscopic ultrasound Ramai, D., Ahmed, Z., Chandan, S., Facciorusso, A., Deliwala, S. S., Alastal, Y., Nawras, A., Maida, M., Barakat, M. T., Anderloni, A., Adler, D. G. 2024; 13 (3): 165-170

  Abstract

  Debridement of infected walled-off pancreatic necrosis is indicated to treat and prevent sepsis-related multiorgan failure. The aim of this study was to evaluate the efficacy and safety of the EndoRotor-powered endoscopic debridement system to remove solid debris under direct endoscopic visualization. Search strategies were developed for PubMed, EMBASE, and Cochrane Library databases from inception to June 2022, in accordance with Preferred Reporting items for Systematic Reviews and Meta-Analyses and Meta-Analysis of Observational Studies in Epidemiology guidelines. Outcomes of interest included technical success defined as successful use of device for debridement, clinical success defined as complete debridement and cyst resolution, and procedure-related adverse events. A random-effects model was used for analysis, and results were expressed as odds ratio along with 95% confidence interval. A total of 7 studies (n = 79 patients) were included. The mean walled-off pancreatic necrosis size was 154.6 ± 34.0 mm, whereas the mean procedure time was 71.4 minutes. The mean number of necrosectomy sessions required was 2.2 (range, 1-7). The pooled rate of clinical success was 96% (95% confidence interval, 91%-100%; I 2 = 0%) with a pooled technical success rate of 96% (91%-100%; I 2 = 0%). The pooled procedure-related adverse event rate was 8% (2%-14%; I 2 = 6%), which included procedure-associated bleeding, pneumoperitoneum, peritonitis, pleural effusion, and dislodgement of lumen-apposing metal stents. Our study shows that the novel EndoRotor device seems to be safe and effective for treating pancreatic necrosis. Patients undergoing endoscopic necrosectomy with the EndoRotor seem to require less debridement sessions when compared with studies using conventional instruments.

  View details for DOI 10.1097/eus.0000000000000031

  View details for PubMedID 39318651

  View details for PubMedCentralID PMC11419429

• The impact of COVID-19 on hospitalizations that underwent endoscopic retrograde cholangiopancreatography in the United States. Surgical endoscopy Dahiya, D. S., Pinnam, B. S., Chandan, S., Gangwani, M. K., Ali, H., Deliwala, S., Bapaye, J., Aziz, M., Merza, N., Inamdar, S., Al-Haddad, M., Sharma, N. 2024; 38 (1): 202-211

  Abstract

  COVID-19 impacts technical success of endoscopic retrograde cholangiopancreatography (ERCP). In this study, we aimed to assess the influence of COVID-19 on hospitalizations that underwent ERCP.We identified all adult COVID-19 and non-COVID-19 hospitalizations that underwent ERCP in the United States using the National Inpatient Sample for 2020. Hospitalization characteristics, clinical outcomes, and complications were compared between the two groups.In 2020, 2015 COVID-19 and 203,094 non-COVID-19 hospitalizations underwent ERCP. The COVID-19 cohort had a higher mean age (60.3 vs 55.6 years, p < 0.001) and a higher proportion of Blacks and Hispanics compared to the non-COVID-19 cohort. After adjusting for confounders, the COVID-19 cohort had higher all-cause inpatient mortality (4.77 vs 1.45%, aOR 4.09, 95% CI 2.50-6.69, p < 0.001), mean length of stay (LOS) [10.19 vs 5.94 days, mean difference: 3.88, 95% CI 2.68-5.07, p < 0.001] and mean total hospital charges (THC) [$152,933 vs $96,398, mean difference: 46,367, 95% CI 21,776-70,957, p < 0.001] compared to the non-COVID-19 cohort. Increasing age, higher Charlson Comorbidity Index, and post-ERCP pancreatitis were identified to be independent predictors of inpatient mortality for COVID-19 hospitalizations that underwent ERCP. Furthermore, the COVID-19 cohort had higher odds of developing post-ERCP pancreatitis (PEP) (11.55 vs 7.05%, aOR 1.64, 95% CI 1.19-2.25, p = 0.002) compared to the non-COVID-19 cohort, after adjusting for confounders. However, there was no statistical difference in the rates of bowel perforations and post-ERCP hemorrhage between the two groups.COVID-19 hospitalizations that underwent ERCP had higher inpatient mortality, mean LOS, mean THC, and odds of developing PEP compared to the non-COVID-19 cohort.This study is not a part of a clinical trial.

  View details for DOI 10.1007/s00464-023-10529-5

  View details for PubMedID 37957298

  View details for PubMedCentralID 7313959

• EUS-guided versus percutaneous liver biopsy: A comprehensive review and meta-analysis of outcomes. Endoscopic ultrasound Chandan, S., Deliwala, S., Khan, S. R., Mohan, B. P., Dhindsa, B. S., Bapaye, J., Goyal, H., Kassab, L. L., Kamal, F., Sayles, H. R., Kochhar, G. S., Adler, D. G. 2023; 12 (2): 171-180

  Abstract

  EUS-guided liver biopsy (EUS-LB) has gained momentum in recent years, especially with availability of newer needle designs. Given the emerging comparative data on EUS-LB with second-generation needles and percutaneous LB (PC-LB), we conducted a systematic review and meta-analysis to compare the safety and efficacy of the two techniques. We searched multiple databases from inception through November 2021 to identify studies comparing outcomes of EUS-LB and PC-LB. Pooled estimates were calculated using a random-effects model, and the results were expressed in terms of pooled proportions and odds ratio (OR) along with relevant 95% confidence intervals (CIs). Five studies with 748 patients were included in the final analysis. EUS-LB was performed in 276 patients and PC-LB in 472 patients. Across all studies, PC-LB had an overall higher diagnostic accuracy than EUS-LB, 98.6% confidence interval (CI: 94.7-99.7) versus 88.3% (49.6-98.3), OR: 1.65, P = 0.04. On assessing data from randomized controlled trials, there was no difference between the two. While pooled diagnostic adequacy and overall adverse events were not significantly different between PC-LB and EUS-LB, the former was superior in terms of the mean number of complete portal tracts (CPT) and total specimen length. PC-LB and EUS-LB produce similar results. PC-LB allows obtaining longer samples and more CPT. Further studies are needed to see if these trends hold up as more providers begin to perform EUS-LB.

  View details for DOI 10.4103/EUS-D-21-00268

  View details for PubMedID 36204798

  View details for PubMedCentralID PMC10237604

• Long-Term Outcomes of ERCP in the Management of Chronic Pancreatitis Over a 10-year Period at a Tertiary Care Center Emelogu, I. K., Brooks, C. G., Deliwala, S., Calderon, L. F., Abraham, F. O., Kumar, V., Willingham, F., Keilin, S., Patel, V., Orr, J., Park, W., Chawla, S. LIPPINCOTT WILLIAMS & WILKINS. 2023: S106

  View details for Web of Science ID 001091849300132

• Long-Term Outcomes of ERCP in the Management of Chronic Pancreatitis Over a 10-year Period at a Tertiary Care Center Emelogu, I. K., Brooks, C. G., Deliwala, S., Calderon, L. F., Abraham, F. O., Kumar, V., Willingham, F., Keilin, S., Patel, V., Orr, J., Park, W., Chawla, S. LIPPINCOTT WILLIAMS & WILKINS. 2023: S106

  View details for DOI 10.14309/01.ajg.0000950172.43870.23

  View details for Web of Science ID 001541354100010

• EUS-guided therapies for primary and secondary prophylaxis in gastric varices-An updated systematic review and meta-analysis. Endoscopic ultrasound Chandan, S., Nguyen, A. K., Mohan, B. P., Deliwala, S., Ramai, D., Kassab, L. L., Muthusamy, A., Facciorusso, A., Kamal, F., Bilal, M., Samanta, J., Adler, D. G. 2023; 12 (4): 351-361

  Abstract

  Gastric varices (GVs) are associated with a higher risk of uncontrolled bleeding and death when compared with esophageal varices. While endoscopic glue injection therapy has been traditionally used for secondary prophylaxis in GV, data regarding primary prophylaxis continue to emerge. Recently, EUS-guided therapies have been used in GV bleeding.We conducted a comprehensive search of several major databases from inception to June 2022. Our primary goals were to estimate the pooled rates of treatment efficacy, GV obliteration, GV recurrence, and rebleeding with EUS-guided therapy in primary and secondary prophylaxis. Overall adverse events and technical failures were assessed. Random-effects model was used for our meta-analysis, and heterogeneity was assessed using the I2 % statistics.Eighteen studies with 604 patients were included. In primary prophylaxis, pooled rate of GV obliteration was 90.2% (confidence interval [CI], 81.1-95.2; I2 = 0). With combination EUS-glue and coil therapy, the rate was 95.4% (CI, 86.7%-98.5%; I2 = 0). Pooled rate of posttherapy GV bleeding was 4.9% (CI, 1.8%-12.4%; I2 = 0). In secondary prophylaxis, pooled rate of treatment efficacy was 91.9% (CI, 86.8%-95.2%; I2 = 12). With EUS-glue, EUS-coil, and combination EUS-glue and coil, the rates were 94.3% (CI, 88.9%-97.1%; I2 = 0), 95.5% (CI, 80.3%-99.1%; I2 = 0), and 88.7% (CI, 76%-95.1%; I2 = 14), respectively. Pooled rate of GV obliteration was 83.6% (CI, 71.5%-91.2%; I2 = 74). With EUS-glue, EUS-coil, and combination EUS-glue and coil, the rates were 84.6% (CI, 75.9%-90.6%; I2 = 31), 92.3% (CI, 81.1%-97.1%; I2 = 0), and 84.5% (CI, 50.8%-96.7%; I2 = 75), respectively. Pooled rates of GV rebleeding and recurrence were 18.1% (CI, 13.1%-24.3%; I2 = 16) and 20.6% (CI, 9.3%-39.5%; I2 = 66), respectively.Our analysis shows that EUS-guided therapy for GVs is technically feasible and clinically successful in both primary and secondary prophylaxis of GV.

  View details for DOI 10.1097/eus.0000000000000017

  View details for PubMedID 37795350

  View details for PubMedCentralID PMC10547242

• New Alternative? Self-Assembling Peptide in Gastrointestinal Bleeding: A Systematic Review and Meta-Analysis. Digestive diseases and sciences Dhindsa, B. S., Tun, K. M., Scholten, K. J., Deliwala, S., Naga, Y., Dhaliwal, A., Ramai, D., Saghir, S. M., Dahiya, D. S., Chandan, S., Singh, S., Adler, D. G. 2023; 68 (9): 3694-3701

  Abstract

  Gastrointestinal bleeding (GIB) is a common and potentially fatal condition with all-cause mortality ranging from 3 to 10%. Endoscopic therapy traditionally involves mechanical, thermal, and injection therapies. Recently, self-assembling peptide (SAP) has become increasingly available in the United States. When applied to an affected area, this gel forms an extracellular matrix-type structure allowing for hemostasis. This is the first systematic review and meta-analysis to assess the safety and efficacy of this modality in GIB.We performed a comprehensive literature search of major databases from inception to Nov 2022. The primary outcomes assessed were the success of hemostasis, rebleeding rates, and adverse events. The secondary outcomes assessed were successful hemostasis with monotherapy with SAP and combined therapy, which may include mechanical, injection, and thermal therapies. Pooled estimates were calculated using random-effects models with a 95% confidence interval (CI).The analysis included 7 studies with 427 patients. 34% of the patients were on anticoagulation or antiplatelet agents. SAP application was technically successful in all patients. The calculated pooled rate of successful hemostasis was 93.1% (95% confidence interval (CI) 84.7-97.0, I2 = 73.6), and rebleeding rates were 8.9% (95% CI 5.3-14.4, I2 = 55.8). The pooled rates of hemostasis with SAP monotherapy and combined therapy were similar. No adverse events were noted related to SAP.SAP appears to be a safe and effective treatment modality for patients with GIB. This modality provides an added advantage of improved visualization over the novel spray-based modalities. Further, prospective, or randomized controlled trials are needed to validate our findings.

  View details for DOI 10.1007/s10620-023-08009-w

  View details for PubMedID 37402986

  View details for PubMedCentralID 6328962

• Vonoprazan versus lansoprazole in erosive esophagitis - A systematic review and meta-analysis of randomized controlled trials. Indian journal of gastroenterology : official journal of the Indian Society of Gastroenterology Chandan, S., Deliwala, S., Mohan, B. P., Ramai, D., Dhindsa, B., Bapaye, J., Kassab, L. L., Chandan, O. C., Facciorusso, A., Adler, D. G. 2023; 42 (4): 475-484

  Abstract

  Proton-pump inhibitors (PPIs) are the mainstay of treatment in erosive esophagitis (EE). An alternative to PPIs in EE is Vonoprazan, a potassium competitive acid blocker. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing vonoprazan to lansoprazole.Multiple databases searched through November 2022. Meta-analysis was performed to assess endoscopic healing at two, four and eight weeks, including for patients with severe EE (Los Angeles C/D). Serious adverse events (SAE) leading to drug discontinuation were assessed. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology.Four RCTs with 2208 patients were included in the final analysis. Vonoprazan 20 mg once-daily was compared to lansoprazole 30 mg once-daily dosing. Among all patients, at two and eight weeks post-treatment, vonoprazan resulted in significantly higher rates of endoscopic healing as compared to lansoprazole, risk ratios (RR) 1.1, p<0.001 and RR 1.04, p=0.03. The same effect was not observed at four weeks, RR 1.03 (CI 0.99-1.06, I2=0%) following therapy. Among patients with severe EE, vonoprazan resulted in higher rates of endoscopic healing at two weeks, RR 1.3 (1.2-1.4, I2=47%), p=<0.001, at four weeks, RR 1.2 (1.1-1.3, I2=36%), p=<0.001 and at eight weeks post-treatment, RR 1.1 (CI 1.03-1.3, I2=79%), p=0.009. We found no significant difference in the overall pooled rate of SAE and pooled rate of adverse events leading to drug discontinuation. Finally, the overall certainty of evidence for our main summary estimates was rated as high (grade A).Based on limited number of published non-inferiority RCTs, our analysis demonstrates that among patients with EE, vonoprazan 20 mg once-daily dosing achieves comparable and in those with severe EE, higher endoscopic healing rates as compared to lansoprazole 30 mg once-daily dosing. Both drugs have a comparable safety profile.

  View details for DOI 10.1007/s12664-023-01384-2

  View details for PubMedID 37418052

  View details for PubMedCentralID 5075558

• Response. Gastrointestinal endoscopy Ramai, D., Enofe, I., Deliwala, S. S., Mozell, D., Facciorusso, A., Gkolfakis, P., Mohan, B. P., Chandan, S., Previtera, M., Maida, M., Anderloni, A., Adler, D. G., Ofosu, A. 2023; 98 (2): 268-269

  View details for DOI 10.1016/j.gie.2023.03.027

  View details for PubMedID 37455059

• Endoscopic Stenting in Crohn's Disease-related Strictures: A Systematic Review and Meta-analysis of Outcomes. Inflammatory bowel diseases Chandan, S., Dhindsa, B. S., Khan, S. R., Deliwala, S., Kassab, L. L., Mohan, B. P., Chandan, O. C., Loras, C., Shen, B., Kochhar, G. S. 2023; 29 (7): 1145-1152

  Abstract

  Crohn's disease (CD) is a chronic progressive condition that is complicated by intestinal or colonic stricture in nearly 30% of cases within 10 years of the initial diagnosis. Endoscopic balloon dilation (EBD) is associated with a risk of perforations and recurrence rates of up to 60% at 5 years. Endoscopic stenting has been used as an alternative to EBD, but data on its safety and efficacy are limited. We conducted a systematic review and meta-analysis to assess the outcomes of endoscopic stenting in CD-related strictures.A systematic and detailed search was run in January 2022 with the assistance of a medical librarian for studies reporting on outcomes of endoscopic stenting in CD-related strictures. Meta-analysis was performed using random-effects model, and results were expressed in terms of pooled proportions along with relevant 95% confidence intervals (CIs).Nine studies with 163 patients were included in the final analysis. Self-expanding metal stents (SEMS) including both partial and fully covered were used in 7 studies, whereas biodegradable stents were used in 2 studies. Pooled rate of clinical success and technical success was 60.9% (95% CI, 51.6-69.5; I2 = 13%) and 93% (95% CI, 87.3-96.3; I2 = 0%), respectively. Repeat stenting was needed in 9.6% of patients (95% CI, 5.3-16.7; I2 = 0%), whereas pooled rate of spontaneous stent migration was 43.9% (95% CI, 11.4-82.7; I2 = 88%). Pooled incidence of overall adverse events, proximal stent migration, perforation, and abdominal pain were 15.7%, 6.4%, 2.7%, and 17.9%, respectively. Mean follow-up period ranged from 3 months to 69 months.Endoscopic stenting in CD-related strictures is a safe technique that can be performed with technical ease, albeit with a limited clinical success. Postprocedure abdominal pain and proximal stent migration are some of the common adverse events reported.

  View details for DOI 10.1093/ibd/izac153

  View details for PubMedID 35880681

• Acute pancreatitis in liver transplant hospitalizations: Identifying national trends, clinical outcomes and healthcare burden in the United States. World journal of hepatology Dahiya, D. S., Jahagirdar, V., Chandan, S., Gangwani, M. K., Merza, N., Ali, H., Deliwala, S., Aziz, M., Ramai, D., Pinnam, B. S., Bapaye, J., Cheng, C. I., Inamdar, S., Sharma, N. R., Al-Haddad, M. 2023; 15 (6): 797-812

  Abstract

  Acute pancreatitis (AP) in liver transplant (LT) recipients may lead to poor clinical outcomes and development of severe complications.We aimed to assess national trends, clinical outcomes, and the healthcare burden of LT hospitalizations with AP in the United States (US).The National Inpatient Sample was utilized to identify all adult (≥ 18 years old) LT hospitalizations with AP in the US from 2007-2019. Non-LT AP hospitalizations served as controls for comparative analysis. National trends of hospitalization characteristics, clinical outcomes, complications, and healthcare burden for LT hospitalizations with AP were highlighted. Hospitalization characteristics, clinical outcomes, complications, and healthcare burden were also compared between the LT and non-LT cohorts. Furthermore, predictors of inpatient mortality for LT hospitalizations with AP were identified. All P values ≤ 0.05 were considered statistically significant.The total number of LT hospitalizations with AP increased from 305 in 2007 to 610 in 2019. There was a rising trend of Hispanic (16.5% in 2007 to 21.1% in 2018, P-trend = 0.0009) and Asian (4.3% in 2007 to 7.4% in 2019, p-trend = 0.0002) LT hospitalizations with AP, while a decline was noted for Blacks (11% in 2007 to 8.3% in 2019, P-trend = 0.0004). Furthermore, LT hospitalizations with AP had an increasing comorbidity burden as the Charlson Comorbidity Index (CCI) score ≥ 3 increased from 41.64% in 2007 to 62.30% in 2019 (P-trend < 0.0001). We did not find statistically significant trends in inpatient mortality, mean length of stay (LOS), and mean total healthcare charge (THC) for LT hospitalizations with AP despite rising trends of complications such as sepsis, acute kidney failure (AKF), acute respiratory failure (ARF), abdominal abscesses, portal vein thrombosis (PVT), and venous thromboembolism (VTE). Between 2007-2019, 6863 LT hospitalizations with AP were compared to 5649980 non-LT AP hospitalizations. LT hospitalizations with AP were slightly older (53.5 vs 52.6 years, P = 0.017) and had a higher proportion of patients with CCI ≥ 3 (51.5% vs 19.8%, P < 0.0001) compared to the non-LT cohort. Additionally, LT hospitalizations with AP had a higher proportion of Whites (67.9% vs 64.6%, P < 0.0001) and Asians (4% vs 2.3%, P < 0.0001), while the non-LT cohort had a higher proportion of Blacks and Hispanics. Interestingly, LT hospitalizations with AP had lower inpatient mortality (1.37% vs 2.16%, P = 0.0479) compared to the non-LT cohort despite having a higher mean age, CCI scores, and complications such as AKF, PVT, VTE, and the need for blood transfusion. However, LT hospitalizations with AP had a higher mean THC ($59596 vs $50466, P = 0.0429) than the non-LT cohort.In the US, LT hospitalizations with AP were on the rise, particularly for Hispanics and Asians. However, LT hospitalizations with AP had lower inpatient mortality compared to non-LT AP hospitalizations.

  View details for DOI 10.4254/wjh.v15.i6.797

  View details for PubMedID 37397932

  View details for PubMedCentralID PMC10308289

• Successful Treatment of Intractable Rectal Varices with Gelfoam Slurry Embolisation and Coiling. European journal of case reports in internal medicine Chinnappan, J., Hussain, M. S., Deliwala, S. S., Bansal, A. 2023; 10 (7): 003930

  Abstract

  A 57-year-old male with heart failure and decompensated alcoholic liver cirrhosis presented with recurrent haematochesia due to rectal varices. After multiple failed therapy with endoscopic band ligation and surgical sclerotherapy, a discussion with an interventional radiologist was arranged. A transjugular intrahepatic portosystemic shunt (TIPS) was deferred due to a history of heart failure. A shared decision to proceed with transhepatic Gelfoam® slurry embolisation with coiling was made. During the procedure, a variant anatomy of the superior rectal vein was identified. The superior rectal vein was found to drain directly into the left portal vein with no connectivity between the inferior mesenteric vein and the rectal varices. As planned, Gelfoam slurry embolisation and coiling was done to the left and right superior rectal vein along with the common trunk it drains. The patient did not develop any further episodes of gastrointestinal bleeding or worsening ascites on follow-up after 6 months. This case represents a successful treatment of bleeding rectal varices when TIPS is contraindicated.Rectal varices are an infrequent outcome of portal hypertension formed by portocaval anastomosis between the superior rectal vein with the inferior mesenteric vein of the portal system upstream, and the middle and inferior rectal vein draining into the internal iliac and internal pudendal vein of the systemic circulation, respectively. Portal system variations are extremely rare.Most common modality of recurrent rectal varices bleed is a transhepatic intrajugular portosystemic shunt. The absolute contraindications to this include congestive heart failure among others.In the presence of multiple co-morbidities and contraindication for TIPS, various interventional radiological modalities on a case-by-case basis are available including percutaneous transhepatic rectal varices obliteration.

  View details for DOI 10.12890/2023_003930

  View details for PubMedID 37455691

  View details for PubMedCentralID PMC10348441

• Efficacy & safety of EUS-directed transgastric endoscopic retrograde cholangiopancreatography (EDGE) in Roux-en-Y gastric bypass anatomy: a systematic review & meta-analysis. Surgical endoscopy Deliwala, S. S., Mohan, B. P., Yarra, P., Khan, S. R., Chandan, S., Ramai, D., Kassab, L. L., Facciorusso, A., Dhawan, M., Adler, D. G., Kaul, V., Chawla, S., Kochhar, G. S. 2023; 37 (6): 4144-4158

  Abstract

  In patients with Roux-en-Y gastric bypass (RYGB) anatomy, laparoscopic endoscopic retrograde cholangiopancreatography (LA-ERCP) and enteroscopy-assisted ERCP (E-ERCP) have been utilized to achieve pancreaticobiliary access. Endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography (EDGE) has recently emerged as an alternate and efficient approach. As data regarding EDGE continues to evolve, concerns about safety and efficacy remain, limiting wide adoptability. We performed a systematic review and meta-analysis to assess the safety and efficacy of EDGE and compare it to the current standard of care.A comprehensive search of major databases (inception to Nov 2022) identified published studies on EDGE. A random-effects model was used to calculate the pooled rates and heterogeneity (I2). Risk ratio (RR) and standardized difference in means (SMD) were utilized for head-to-head comparison analysis between EDGE vs. LA-ERCP and EDGE vs. E-ERCP. Primary outcomes assessed pooled EDGE safety (adverse events) and efficacy (technical/clinical success). Secondary outcomes assessed efficacy and safety profiles via a comparative analysis of EDGE vs. LA-ERCP and EDGE vs. E-ERCP.A total of 16 studies (470 patients) were included. EDGE pooled technical success (TS) rate was 96% (95% CI 92-97.6, I2 = 0), and clinical success was 91% (85-95, I2 = 0). Pooled rate of all adverse events with EDGE was 17% (14-24.6, I2 = 32%). On sub-group analysis, these included failure of fistula closure 17% (10-25.5, I2 = 48%), stent migration 7% (4-12, I2 = 51%), bleeding 5% (3.2-7.9, I2 = 0), post-EDGE weight gain 4% (2-9, I2 = 0), perforation 4% (2.1-5.8, I2 = 0), and post-ERCP pancreatitis 2% (1-5, I2 = 0). EDGE TS was comparable to LA-ERCP (97% vs. 98%; RR, 1.00; CI, 0.85-1.17, p = 0.95) and E-ERCP (100% vs. 66%; RR, 1.26; CI, 0.99-1.6, p = 0.06). No statistical difference was noted in adverse events between EDGE and LA-ERCP (13% vs. 17.6%; RR, 0.61; CI, 0.28-1.35, p = 0.52) and E-ERCP (9.6% vs. 16%; RR, 0.61; CI, 0.28-1.35, p = 0.22). EDGE procedure time and hospital stay were shorter than LA-ERCP and E-ERCP (p < 0.001).Our analysis shows that EDGE is safe and efficacious to the current standard of care. Further head-to-head comparative trials are needed to validate our findings.

  View details for DOI 10.1007/s00464-023-09926-7

  View details for PubMedID 36792784

  View details for PubMedCentralID 8249251

• Safety and Efficacy of Fecal Microbiota Transplant in Chronic Pouchitis-A Systematic Review With Meta-Analysis. Gastro hep advances Kahan, T., Chandan, S., Khan, S. R., Deliwala, S., Chang, S., Axelrad, J., Shaukat, A. 2023; 2 (6): 843-852

  Abstract

  Pouchitis is the most common long-term complication after ileal-pouch anal anastomosis in patients with ulcerative colitis. We conducted a systematic review and meta-analysis evaluating the safety and efficacy of fecal microbiota transplant (FMT) in chronic antibiotic dependent and refractory pouchitis.Multiple databases were searched through April 2022 for studies that reported the efficacy and safety of FMT in patients with chronic pouchitis. Meta-analysis using random effects model was performed to calculate pooled rates.Eight studies with a total of 89 patients were included in our review, with 74 patients having received FMT and 15 patients having received placebo. The mean age ranged from 32.6 to 51.5 years. In patients that received FMT, the pooled rates of overall remission was (Pouchitis Disease Activity Index score < 7) 22% (95% CI, 9%-43%; I2, 29%), clinical remission was 20% (95% CI, 6%-49%; I2, 25%), clinical response rate was 42% (95% CI, 30%-54%; I2, 7%), and the relapse rate 60% (95% CI, 40%-77%, I2 16%) over the mean follow up of 4.67 months (range 1-12 months). The pooled proportion of patients with adverse events was 54% (95% CI, 21%-84%; I2, 73%). There were no serious adverse events or deaths.In patients with chronic pouchitis, FMT is safe though there are mixed results in terms of its long-term efficacy. Future Randomized Controlled Trials with larger sample sizes and greater standardization in terms of preparation, delivery, and length of treatment of FMT are needed to determine efficacy.

  View details for DOI 10.1016/j.gastha.2023.04.005

  View details for PubMedID 39130120

  View details for PubMedCentralID PMC11307912

• Single-incision needle-knife biopsy for the diagnosis of GI subepithelial tumors: a systematic review and meta-analysis. Gastrointestinal endoscopy Naga, Y. S., Dhindsa, B. S., Deliwala, S., Tun, K. M., Dhaliwal, A., Ramai, D., Bhat, I., Singh, S., Chandan, S., Adler, D. G. 2023; 97 (4): 640-645.e2

  Abstract

  A histologic diagnosis of GI subepithelial tumors (SETs) is important because of the malignant potential of these lesions. The current modalities of choice, including EUS-guided FNA and biopsy (EUS-FNA/FNB) have demonstrated suboptimal diagnostic success. Single-incision with needle-knife (SINK) biopsy has emerged as an alternative diagnostic approach to increase tissue acquisition and diagnostic success. The aim of this study was to perform a systematic review and meta-analysis to evaluate the technical success, diagnostic success, and adverse events of SINK biopsy.We searched multiple databases including PubMed, EMBASE, CINAHL, Cochrane, Web of Science, and Google Scholar from inception to July 2022. The primary outcomes assessed were the technical success and diagnostic success of SINK in GI SETs. The secondary outcomes assessed were adverse events and whether immunohistochemical analysis could be successfully performed on tissue samples obtained via SINK.Seven studies with a total of 219 SINK biopsy procedures were included in this meta-analysis. The technical success rate was 98.1% (95% CI, 94.9%-99.3%; P = .000; I2 = .0%), and the diagnostic success rate was 87.9% (95% CI, 82.6%-91.7%; P = .000; I2 = .0%). The immunohistochemical success rate was 88.3% (95% CI, 78.7%-93.9%; P = .000; I2 = 3.5%). The rate of adverse events was 7.5% (95% CI, 4.3%-12.7%; P = .00; I2 = 7.2%), and bleeding was the most common adverse event.SINK biopsy is a safe diagnostic procedure with a high technical and diagnostic success in patients with GI SET. Further randomized controlled trials and direct comparison studies are needed to validate these findings.

  View details for DOI 10.1016/j.gie.2022.11.021

  View details for PubMedID 36460089

• Hemostatic spray (TC-325) vs. standard endoscopic therapy for non-variceal gastrointestinal bleeding: A meta-analysis of randomized controlled trials. Endoscopy international open Deliwala, S. S., Chandan, S., Mohan, B. P., Khan, S., Reddy, N., Ramai, D., Bapaye, J. A., Dahiya, D. S., Kassab, L. L., Facciorusso, A., Chawla, S., Adler, D. 2023; 11 (3): E288-E295

  Abstract

  Background and study aims  Hemospray (TC-325) is a mineral powder with adsorptive properties designed for use in various gastrointestinal bleeding (GIB) scenarios. We conducted a systematic review & meta-analysis of randomized controlled trials (RCTs) comparing TC-325 to standard endoscopic therapy (SET) for non-variceal GIB (NVGIB). Methods  Multiple databases were searched through October 2022. Meta-analysis was performed using a random-effects model to determine pooled relative risk (RR) and proportions with 95 % confidence intervals (CI) for primary hemostasis, hemostasis failure, 30-day rebleeding, length of stay (LOS), and need for rescue interventions. Heterogeneity was assessed using I 2 %. Results  Five RCTs with 362 patients (TC-325 178, SET 184) - 123 females and 239 males with a mean age 65 ± 16 years). The most common etiologies were peptic ulcer disease (48 %), malignancies (35 %), and others (17 %). Bleeding was characterized as Forrest IA (7 %), IB (73 %), IIA (3 %), and IIB (1 %). SET included epinephrine injection, electrocautery, hemoclips, or a combination. No statistical difference in primary hemostasis between TC-325 compared to SET, RR 1.09 (CI 0.95-1.25; I 2 43), P =  0.2, including patients with oozing/spurting hemorrhage, RR 1.13 (CI 0.98-1.3; I 2 35), P =  0.08. Failure to achieve hemostasis was higher in SET compared to TC-325, RR 0.30 (CI 0.12-0.77, I 2 0), P =  0.01, including patients with oozing/spurting hemorrhage, RR 0.24 (CI 0.09 - 0.63, I 2 0), P =  0.004. We found no difference between the two interventions in terms of rebleeding, RR 1.13 (CI 0.62-2.07, I 2 26), P =  0.8 and LOS, standardized mean difference (SMD) 0.27 (CI, -0.20-0.74; I 2 62), P =  0.3. Finally, pooled rate of rescue interventions (angiography) was statistically higher in SET compared to TC-325, RR 0.68 (CI 0.5-0.94; I 2 0), P =  0.02. Conclusions  Our analysis shows that for acute NV GIB, including oozing/spurting hemorrhage, TC-325 does not result in higher rates of primary hemostasis compared to SET. However, lower rates of failures were seen with TC-325 than SET. In addition, there was no difference in the two modalities when comparing rates of rebleeding and LOS.

  View details for DOI 10.1055/a-2032-4199

  View details for PubMedID 36968978

  View details for PubMedCentralID PMC10038751

• Early (<4 weeks) versus standard (≥4 weeks) endoscopic drainage of pancreatic walled-off fluid collections: a systematic review and meta-analysis. Gastrointestinal endoscopy Ramai, D., Enofe, I., Deliwala, S. S., Mozell, D., Facciorusso, A., Gkolfakis, P., Mohan, B. P., Chandan, S., Previtera, M., Maida, M., Anderloni, A., Adler, D. G., Ofosu, A. 2023; 97 (3): 415-421.e5

  Abstract

  Previous studies have demonstrated that the ideal time for drainage of walled-off pancreatic fluid collections is 4 to 6 weeks after their development. However, some pancreatic collections, notably infected pancreatic fluid collections, require earlier drainage. Nevertheless, the optimal timing of the first intervention is unclear, and consensus data are sparse. The aim of this study was to evaluate the clinical efficacy and safety of EUS-guided drainage of pancreatic fluid collections <4 weeks after development compared with ≥4 weeks after development.Search strategies were developed for PubMed, Embase, and Cochrane Library databases from inception. Outcomes of interest were technical success, defined as successful endoscopic placement of a lumen-apposing metal stent; clinical success, defined as a reduction in cystic collection size; and procedure-related adverse events. A random-effects model was used for analysis, and results are expressed as odds ratio (OR) with 95% confidence interval (CI).Six studies (630 patients) were included in our final analysis, in which 182 patients (28.9%) were enrolled in the early drainage cohort and 448 patients (71.1%) in the standard drainage cohort. The mean fluid collection size was 143.4 ± 18.8 mm for the early cohort versus 128 ± 19.7 mm for the standard cohort. Overall, technical success was equal in both cohorts. Clinical success did not favor either standard drainage or early drainage (OR, .39; 95% CI, .13-1.22; P = .11). No statistically significant differences were found in overall adverse events (OR, 1.67; 95% CI, .63-4.45; P = .31) or mortality (OR, 1.14; 95% CI, .29-4.48; P = .85). Hospital stay was longer for patients undergoing early drainage compared with standard drainage (23.7 vs 16.0 days, respectively).Both early (<4 weeks) and standard (≥4 weeks) drainage of walled-off pancreatic fluid collections offer similar technical and clinical outcomes. Patients requiring endoscopic drainage should not be delayed for 4 weeks.

  View details for DOI 10.1016/j.gie.2022.11.003

  View details for PubMedID 36395824

• Reply to Lissing et al. Comment on "Ramai et al. Risk of Hepatocellular Carcinoma in Patients with Porphyria: A Systematic Review. Cancers 2022, 14, 2947". Cancers Ramai, D., Deliwala, S. S., Chandan, S., Lester, J., Singh, J., Samanta, J., di Nunzio, S., Perversi, F., Cappellini, F., Shah, A., Ghidini, M., Sacco, R., Facciorusso, A., Giacomelli, L. 2023; 15 (4)

  Abstract

  We thank Dr. Lissing and colleagues for providing us with these helpful comments [...].

  View details for DOI 10.3390/cancers15041187

  View details for PubMedID 36831530

  View details for PubMedCentralID PMC9954193

• Efficacy of topical hemostatic agents in malignancy-related GI bleeding: a systematic review and meta-analysis. Gastrointestinal endoscopy Karna, R., Deliwala, S., Ramgopal, B., Mohan, B. P., Kassab, L., Becq, A., Dhawan, M., Adler, D. G. 2023; 97 (2): 202-208.e8

  Abstract

  Despite advances in endoscopic therapies, malignancy-related GI bleeding remains difficult to manage with high rates of treatment failure and rebleeding. Topical hemostatic agents (THAs) are easier to apply to the wide bleeding surface of tumors. We conducted this systematic review and meta-analysis to evaluate the efficacy of THAs in malignancy-related GI bleeding.We conducted a comprehensive search of multiple electronic databases to identify studies reporting on the use of THAs in malignancy-related GI bleeding. The primary outcome was the achievement of hemostasis; secondary outcomes were early rebleeding (≤3 days), delayed rebleeding (>3 days), aggregate rebleeding, all-cause mortality, and GI bleeding-related mortality. A meta-analysis of proportions was done for all outcomes.Out of 355 citations, 16 studies with 530 patients were included. Primary hemostasis was achieved in 94.1% (95% confidence interval [CI], 91.5-96.0). Early rebleeding was seen in 13.9% (95% CI, 9.7-19.4) and delayed rebleeding in 11.4% (95% CI, 5.8-21.1). Aggregate rebleeding was seen in 24.2% (95% CI, 18.5-31.0). All-cause mortality was 33.1% (95% CI, 23.7-44.0), whereas GI bleeding-related mortality occurred in 5.9% (95% CI, 2.2%-14.8).THAs are highly effective for achieving primary hemostasis in malignancy-related GI bleeding. It should be considered as an alternative to traditional endotherapy methods in malignancy-related GI bleeding. Future studies should be designed to evaluate its efficacy and safety as a primary method of hemostasis as compared with traditional endotherapy measures.

  View details for DOI 10.1016/j.gie.2022.07.033

  View details for PubMedID 35944608

• Adverse Events of Endoscopic Clip Placement: A MAUDE Database Analysis. Journal of clinical gastroenterology Ramai, D., Deliwala, S. S., Mozell, D., Facciorusso, A., Chandan, S., Persaud, A., Singh, K., Anderloni, A., Barakat, M. T. 2023

  Abstract

  BACKGROUND: Clips are endoscopic mechanical devices with tensile and closure strength that can approximate tissue and provide hemostasis through a tamponade effect. Clips are ubiquitously used in endoscopic practice, and numerous studies have validated the clinical efficacy of clips, with recent guidelines recommending them as a first-line intervention for recurrent and persistent nonvariceal gastrointestinal bleeding. However, the safety profile for these devices has yet to be delineated, thus, we aim to investigate this feature by examining the adverse events reported to the Food and Drug Administration.METHODS: Postmarketing surveillance data from the Food and Drug Administration Manufacturer And User Facility Device Experience database were analyzed from January 2012 to January 2021. The Manufacturer And User Facility Device Experience database is a reporting software and does not independently verify the details of complications.RESULTS: Two thousand five hundred forty reports were issued, of which 287 were patient adverse events and 2766 were device problems. Activation, separation, and positioning issues were most common. No consequences or clinically significant impact on patients were seen in 1968 reports. Foreign bodies were seen in 97 cases, hemorrhage in 57 cases, tissue damage in 42 cases, embedded clips in tissues/plaques in 16 cases, perforation in 15 cases, lacerations in 6 cases, and infection in 3 cases.CONCLUSIONS: While the most commonly reported device problems involved activation, separation, and positioning, most patients were clinically unaffected. Moreover, perforation and infection were exceedingly rare, further highlighting the safety profile of endoscopic clips.

  View details for DOI 10.1097/MCG.0000000000001822

  View details for PubMedID 36728443

• Safety and efficacy of liquid nitrogen spray cryotherapy in Barrett's neoplasia - a comprehensive review and meta-analysis. Endoscopy international open Chandan, S., Bapaye, J., Khan, S. R., Deliwala, S., Mohan, B. P., Ramai, D., Dhindsa, B. S., Goyal, H., Kassab, L. L., Aziz, M., Kamal, F., Facciorusso, A., Adler, D. G. 2022; 10 (11): E1462-E1473

  Abstract

  Background and study aims  Barrett's esophagus (BE) is a precursor condition to esophageal adenocarcinoma (EAC), resulting in transformation of the squamous epithelium of distal esophagus to columnar-lined epithelium with intestinal metaplasia (IM). Liquid nitrogen spray cryotherapy (LNSC) is a non-contact method of BE eradication and has been used both as primary and salvage therapy. We conducted a systematic review and meta-analysis to assess the safety and efficacy of LNSC. Methods  We searched multiple databases from inception through December 2021 to identify studies on use of LNSC for Barrett's neoplasia. Pooled estimates were calculated using random-effects model and results were expressed in terms of pooled proportions with relevant 95 % confidence intervals (CIs) of complete eradication (CE) of dysplasia(D), high grade dysplasia (HGD) and IM. Results  Fourteen studies with 707 patients were included in our final analysis. Overall pooled rates of CE-D, CE-HGD and CE-IM were 80.8 % (CI 77.4-83.8; I 2 62), 90.3 % (CI 85.2-93.7; I 2 33) and 55.8 % (CI 51.7-59.8; I 2 73) with follow up ranging from 4.25 months to 69.7 months. In patients with follow up beyond 24 months, the rates of CE-D and CE-IM were 83.6 % (CI 77.6-88.2; I 2 60) and 54.7 % (CI 47.6-61.6; I 2 81). Among LNSC naïve patients with prior history of endoscopic resection, the rates were 79.9 % (CI 73.3-85.2; I 2 50) and 67.1 % (CI 59.5-73.8; I 2 0). Pooled rate of therapeutic failures, defined as lack of response to LNSC therapy, was 23.6 % (CI 19.4-28.3; I 2 73). Post LNSC strictures and perforation pooled rates were 4 % and 0.8 %, respectively, which are similar to those previously reported for RFA. Conclusions  Our analysis suggests that liquid nitrogen spray cryotherapy is an acceptable treatment for BE in both ablation naïve and experienced patients.

  View details for DOI 10.1055/a-1906-4967

  View details for PubMedID 36397870

  View details for PubMedCentralID PMC9666080

• Safety and efficacy of over-the-scope clips versus standard therapy for high-risk nonvariceal upper GI bleeding: systematic review and meta-analysis. Gastrointestinal endoscopy Bapaye, J., Chandan, S., Naing, L. Y., Shehadah, A., Deliwala, S., Bhalla, V., Chathuranga, D., Okolo, P. I. 2022; 96 (5): 712-720.e7

  Abstract

  Upper GI bleeding (UGIB) is a common condition associated with significant morbidity and mortality. Endoscopic hemostasis remains the mainstay of therapy and is mainly aimed at effective hemostasis and prevention of rebleeding. Lesions with high-risk stigmata can have rebleeding rates of as high as 26.3%. Rebleeding is associated with increased mortality and reduced success rates of endoscopic retreatment. The over-the-scope-clip (OTSC) is a device with widespread endoscopic indications including hemostasis for nonvariceal UGIB (NVUGIB). The current study presents a systematic review and meta-analysis comparing OTSCs versus standard therapy (STD) for NVUGIB.Multiple databases were searched through April 2022 for studies comparing OTSCs and STD for NVUGIBs. Primary outcomes were clinical success rates, rebleeding rates, and procedure times, and secondary outcomes were mortality rates and length of hospitalization. Meta-analysis was performed to determine pooled odds ratios to compare outcomes between the OTSC and STD groups.Ten studies, including 4 randomized controlled trials, with 914 patients were included in the final analysis. Of patients with NVUGIB, 431 were treated with OTSCs and 483 with STD. Patients treated with OTSCs had an overall lower risk of 7-day (risk ratio [RR], .41; 95% confidence interval [CI], .24-.68; I2 = 0%) and 30-day rebleeding (RR, .46; 95% CI, .31-.65; I2 = 0%). Clinical success rates were higher with OTSCs compared with STD (RR, 1.36; 95% CI, 1.06-1.75). Mean procedure time was shorter in the OTSC group by 6.62 minutes (95% CI, 2.58-10.67) versus the STD group (I2 = 84%). There was no statistically significant difference in terms of mortality between the OTSC and STD groups (RR, .55; 95% CI, .24-1.24; I2 = 0%). Length of hospitalization was comparable between both groups, with a pooled mean difference for OTSCs versus STD of .87 days (95% CI, -1.62 to 3.36 days; I2 = 71%).Although our study was limited to high-risk NVUGIB, our analysis showed that hemostasis with OTSCs is associated with a lower 7-day and 30-day rebleeding rates, higher clinical success rates, and shorter procedure time with similar mortality rates and length of hospital stay as compared with STD.

  View details for DOI 10.1016/j.gie.2022.06.032

  View details for PubMedID 35803307

• The Natural History of Pancreatic Cystic Lesions in Liver Transplant Recipients: A Systematic Review and Meta-analysis. Pancreas Canakis, A., Vittal, A., Deliwala, S., Twery, B., Canakis, J., Patel, P., Chahal, P. 2022; 51 (9): 1160-1166

  Abstract

  The management of incidentally discovered pancreatic cystic lesions (PCLs) with surveillance or resection often requires shared decision-making. Patients with cirrhosis are more likely to have PCLs discovered due to increased imaging, and those undergoing liver transplantations (LTs) may be at increased risk of carcinogenesis due to immunosuppressive medications. Our study aimed to characterize the outcomes and risk of malignant progression of PCLs in post-LT patients.Multiple databases were searched for studies looking at PCLs in post-LT patients from inception until February 2022. Primary outcomes were the incidence of PCLs in LT recipients and progression to malignancy. Secondary outcomes included development of worrisome features, outcomes of surgical resection for progression, and change in size.A total of 12 studies with 17,862 patients with 1411 PCLs were included. The pooled proportion of new PCL development in post-LT patients was 68% (95% confidence interval [CI], 42-86; I2 = 94%) over the follow-up of 3.7 (standard deviation, 1.5) years. The pooled progression of malignancy and worrisome features was 1% (95% CI, 0-2; I2 = 0%) and 4% (95% CI, 1-11; I2 = 89%), respectively.Compared with nontransplant patients, incidental PCLs do not carry a higher risk of malignancy.

  View details for DOI 10.1097/MPA.0000000000002155

  View details for PubMedID 37078940

  View details for PubMedCentralID PMC10119747

• Safety and Efficacy of the Novel EndoRotor Device for the Treatment of Walled-Off Pancreatic Necrosis (WOPN): A Systematic Review and Meta-Analysis Ramai, D., Ahmed, Z., Deliwala, S., Mozell, D., Facciorusso, A., Morgan, A., Anderloni, A., Barakat, M., Alastal, Y., Adler, D. G. LIPPINCOTT WILLIAMS & WILKINS. 2022: S815

  View details for Web of Science ID 000897916002324

• The diagnostic performance of probe-based confocal laser endomicroscopy in the detection of gastric cancer: a systematic review and meta-analysis. Annals of gastroenterology Canakis, A., Deliwala, S. S., Kadiyala, J., Bomman, S., Canakis, J., Bilal, M. 2022; 35 (5): 496-502

  Abstract

  Gastric cancer (GC) represents a significant global health burden with high morbidity and mortality, especially when diagnosed at advanced stages. Therefore, early detection of GC is critical. Probe-based confocal laser endomicroscopy (pCLE) is a new evolving technology that uses real-time, high-resolution imaging to inspect the mucosa at the cellular and microvascular level, using a confocal probe. Widespread studies using pCLE are limited at the current time. We aimed to investigate the diagnostic efficacy of this modality for the detection of GC.Multiple databases were searched from inception until November 2021. The diagnostic performance of pCLE was assessed by calculating its sensitivity, specificity and accuracy for the detection of GC, using pooled proportions and 95% confidence intervals (CI) with a random-effects model. Heterogeneity was assessed using I2.Seven studies were included, with a total of 567 patients (mean age 61.7 years, 364 males). Pooled performance metrics of pCLE included a sensitivity of 87.9% (95%CI 81.4-92.4; P<0.001; I2=0%), specificity 96.5% (95%CI 91.5-98.6; P<0.001; I2=51.84%), and an accuracy of 94.7% (95%CI 89.5-97.4; P<0.001; I2=65.44%).pCLE is a highly effective diagnostic modality for detecting GC. Larger, randomized controlled studies are needed to determine its role in daily practice compared to conventional endoscopic practices.

  View details for DOI 10.20524/aog.2022.0741

  View details for PubMedID 36061161

  View details for PubMedCentralID PMC9399575

• Spontaneous bacterial empyema in cirrhosis: A systematic review and meta-analysis. World journal of hepatology Reiche, W., Deliwala, S., Chandan, S., Mohan, B. P., Dhindsa, B., Ramai, D., Perisetti, A., Rangray, R., Mukherjee, S. 2022; 14 (6): 1258-1268

  Abstract

  Spontaneous bacterial empyema (SBE) occurs when a hepatic hydrothorax becomes infected and runs a course similar to spontaneous bacterial peritonitis (SBP). It remains underdiagnosed as patients with cirrhosis do not routinely undergo diagnostic thoracentesis. Current understanding is limited by small cohorts, while studies reporting its association with ascites/SBP are conflicting.To explore the incidence of SBE, to determine its association with ascites, and to summarize what is known regarding treatment and outcomes for patients with SBE.Major databases were searched until June 2021. Outcomes include the incidence of SBE in pleural effusions, SBP in peritoneal fluid, and SBE in patients without ascites within our cohort of patients with cirrhosis. We performed a meta-analysis using a random-effects model with pooled proportions and 95% confidence intervals (CI). We assessed heterogeneity using I 2 and classic fail-safe to determine bias.Eight studies with 8899 cirrhosis patients were included. The median age ranged between 41.2 to 69.7 years. The majority of the patients were Child-Pugh B and C. Mean MELD score was 18.6 ± 8.09. A total of 1334 patients had pleural effusions and the pooled incidence of SBE was 15.6% (CI 12.6-19; I 2 50). Amongst patients diagnosed with SBE, the most common locations included right (202), left (64), and bilateral (8). Amongst our cohort, a total of 2636 patients had ascites with a pooled incidence of SBP of 22.2% (CI 9.9-42.7; I 2 97.8). The pooled incidence of SBE in patients with cirrhosis but without concomitant ascites was 9.5% (CI 3.6-22.8; I 2 82.5).SBE frequently occurs with concurrent ascites/SBP; our results suggest high incidence rates of SBE even in the absence of ascites. The pleura can be an unrecognized nidus and our findings support the use of diagnostic thoracentesis in patients with decompensated cirrhosis after exclusion of other causes of pleural effusion. Thoracentesis should be considered particularly in patients without ascites and when there is a high suspicion of infection. The need for diagnostic thoracentesis will continue to be important as rates of multi-drug resistant bacterial infections increase and antibiotic susceptibility information is required for adequate treatment.

  View details for DOI 10.4254/wjh.v14.i6.1258

  View details for PubMedID 35978675

  View details for PubMedCentralID PMC9258251

• Risk of Hepatocellular Carcinoma in Patients with Porphyria: A Systematic Review. Cancers Ramai, D., Deliwala, S. S., Chandan, S., Lester, J., Singh, J., Samanta, J., di Nunzio, S., Perversi, F., Cappellini, F., Shah, A., Ghidini, M., Sacco, R., Facciorusso, A., Giacomelli, L. 2022; 14 (12)

  Abstract

  Acute porphyrias are a group of metabolic disorders resulting in defective porphyrin synthesis and reduced heme production, which carries a risk of malignancy. Porphyrias are inborn defects in the heme biosynthesis pathway resulting in neurovisceral manifestations and cutaneous photosensitivity attacks with multi-systemic involvement. Its estimated prevalence nears 5 per 100,000 patients worldwide. Subclinical liver disease is common, which can progress into transaminitis, fibrosis, cirrhosis, and malignancy. However, data on the incidence of primary liver cancer are lacking. We aim to determine the risk of hepatocellular carcinoma (HCC) in patients with porphyria. A systematic review and pooled analysis were conducted through 2021 on studies assessing blood tests, imaging, cancer development, liver transplant, surgical resection, and outcomes in porphyria. In total, 19 studies, which included 7381 patients with porphyria (3476 females), were considered for the final review. In eight studies, alpha-fetoprotein levels were elevated between 200 and 1000 IU/mL. Of the total cohort of patients with porphyria, primary liver cancer was diagnosed in 351 patients (4.8%), of whom 243 (3.3% of the total) were found to have HCC. A subset of patients was found to have cholangiocarcinoma (n = 18; 0.3% of the total). Interestingly, advanced liver disease or cirrhosis was not a prerequisite for the formation of HCC in a small group of patients. Of the total cohort, 30 patients underwent liver resection, 48 patients underwent liver transplantation, and 327 patients died. Patients with porphyria are at risk of developing primary liver malignancy. Further studies should aim to develop diagnostic and prognostic models aimed at the early detection of HCC in porphyria.

  View details for DOI 10.3390/cancers14122947

  View details for PubMedID 35740611

  View details for PubMedCentralID PMC9221430

• Meta-analysis and systematic review of randomized controlled trials assessing the role of thromboprophylaxis after vascular surgery JOURNAL OF VASCULAR SURGERY-VENOUS AND LYMPHATIC DISORDERS Haykal, T., Zayed, Y., Kerbage, J., Deliwala, S., Long, C. A., Ortel, T. L. 2022; 10 (3): 767-+

  Abstract

  Venous thromboembolism (VTE) is a well-known complication associated with surgical procedures. The implementation of thromboprophylaxis in this population has become a vital aspect of perioperative care to decrease VTE-associated morbidity and mortality risk. However, data assessing the role of thromboprophylaxis for patients undergoing vascular surgery are sparse. Assessing the role of thromboprophylaxis by low-molecular-weight heparin or unfractionated heparin in vascular surgery.We searched MEDLINE, Embase, and the Cochrane Collaboration Central Register of Controlled Trials from inception until December 2020, for randomized controlled trials assessing the role of thromboprophylaxis in vascular surgery.Eight randomized controlled trials met inclusion criteria, including 3130 patients, with a mean age of 55.35 years and 45% were females. Compared with placebo, anticoagulant use was associated with a decrease in deep venous thrombosis (DVT) (risk ratio [RR], 0.34; 95% confidence interval [CI], 0.11-1.05; P = .06; I2 = 68%) and pulmonary embolism (PE) (RR, 0.17; 95% CI, 0.02-1.22; P = .08; I2 = 41%), but this trend did not attain statistical significance. There was no difference for bleeding outcomes between anticoagulants and placebo (RR, 0.90; 95% CI, 0.05-15.01; P = .94; I2 = 76%). There was no significant difference in outcomes when low-molecular-weight heparin was compared directly with unfractionated heparin. In a sensitivity analysis, anticoagulant use was associated with a significant decrease in DVT or PE in patients undergoing venous surgeries, but was not associated with a significant decrease in DVT or PE in patients undergoing arterial surgeries, although this analysis was limited by the small number of studies in each group.Among patients undergoing vascular surgery, thromboprophylaxis with anticoagulants showed a trend toward a lesser incidence of VTE when compared with placebo, although this difference was not statistically significant. Bleeding outcomes were comparable between both treatment groups.

  View details for DOI 10.1016/j.jvsv.2021.08.019

  View details for Web of Science ID 000792468600028

  View details for PubMedID 34508872

• Acute organoaxial gastric volvulus-A dangerous twist. Clinical case reports Chinnappan, J., Hussain, M. S., Deliwala, S. S., Bachuwa, G. 2022; 10 (4): e05785

  Abstract

  Acute gastric volvulus is a rare yet life-threatening condition with mortality ranging from 30% to 50% if not treated promptly. The stomach rotates on itself causing strangulation precipitating necrosis, cameron lesions, and perforation. Long-standing paraesophageal hernia is a common cause of organoaxial gastric volvulus.

  View details for DOI 10.1002/ccr3.5785

  View details for PubMedID 35498355

  View details for PubMedCentralID PMC9040557

• Direct percutaneous endoscopic jejunostomy (DPEJ) and percutaneous endoscopic gastrostomy with jejunal extension (PEG-J) technical success and outcomes: Systematic review and meta-analysis. Endoscopy international open Deliwala, S. S., Chandan, S., Kumar, A., Mohan, B., Ponnapalli, A., Hussain, M. S., Kaushal, S., Novak, J., Chawla, S. 2022; 10 (4): E488-E520

  Abstract

  Background and study aims  Endoscopic methods of delivering uninterrupted feeding to the jejunum include direct percutaneous endoscopic jejunostomy (DPEJ) or PEG with jejunal extension (PEG-J), validated from small individual studies. We aim to perform a meta-analysis to assess their effectiveness and safety in a variety of clinical scenarios. Methods  Major databases were searched until June 2021. Efficacy outcomes included technical and clinical success, while safety outcomes included adverse events (AEs) and malfunction rates. We assessed heterogeneity using I 2 and classic fail-safe to assess bias. Results  29 studies included 1874 patients (983 males and 809 females); mean age of 60 ± 19 years. Pooled technical and clinical success rates with DPEJ were 86.6 % (CI, 82.1-90.1, I 2 73.1) and 96.9 % (CI, 95.0-98.0, I 2 12.7). The pooled incidence of malfunction, major and minor AEs with DPEJ were 11 %, 5 %, and 15 %. Pooled technical and clinical success for PEG-J were 94.4 % (CI, 85.5-97.9, I 2 33) and 98.7 % (CI, 95.5-99.6, I 2  < 0.001). The pooled incidence of malfunction, major and minor AEs with DPEJ were 24 %, 1 %, and 25 %. Device-assisted DPEJ performed better in altered gastrointestinal anatomy. First and second attempts were 87.6 % and 90.2 %. Conclusions  DPEJ and PEG-J are safe and effective procedures placed with high fidelity with comparable outcomes. DPEJ was associated with fewer tube malfunction and failure rates; however, it is technically more complex and not standardized, while PEG-J had higher placement rates. The use of balloon enteroscopy was found to enhance DPEJ performance.

  View details for DOI 10.1055/a-1774-4736

  View details for PubMedID 35433212

  View details for PubMedCentralID PMC9010104

• Serotonin Surge: Intravenous Escitalopram as a Rare Cause of Drug-Induced Aplastic Anaemia. European journal of case reports in internal medicine Hussain, M., Boyer, K., Ponnapalli, A., Awuah, D., Khaneki, S., Deliwala, S., Bachuwa, G. 2022; 9 (3): 003228

  Abstract

  Escitalopram is a commonly prescribed medication that has infrequently been implicated in drug-induced thrombocytopenia (DITP) but has never been associated with aplastic anaemia in the literature. We present an extremely rare case of hypoproliferative pancytopenia due to self-administered intravenous (IV) injection of escitalopram. The crux of this case is the unusual trilineage cytopenia. Our patient was managed with steroids and supportive care with subsequent clinical and blood count recovery. This case sheds light on this uncommon but important association.Escitalopram is an uncommon medication that could lead to drug-induced aplastic anaemia.The adverse effects of escitalopram on red cell, white cell and platelet counts may be exacerbated on intravenous administration of the medication.Timely diagnosis is vital for the effective treatment of severe aplastic anaemia, avoiding complications and preventing recurrence.

  View details for DOI 10.12890/2022_003228

  View details for PubMedID 35402326

  View details for PubMedCentralID PMC8988496

• Proton Pump Inhibitors Versus Histamine-2-Receptor Antagonists for Stress Ulcer Prophylaxis in Critically Ill Patients A Meta-analysis and Trial Sequential Analysis JOURNAL OF CLINICAL GASTROENTEROLOGY Deliwala, S. S., Hamid, K., Goyal, H., Ponnapalli, A., Zayed, Y., Bala, A., Lakshman, H., Malladi, S., Jones, S., Santana, M., Leon, B., An, M. T., Chawla, S. 2022; 56 (3): 204-217

  Abstract

  Stress ulcer prophylaxis has been shown to lower gastrointestinal bleeding (GIB) rates. Various agents have been studied, and the optimal strategy continues to be contested. This study evaluates the efficacy between proton pump inhibitors (PPIs) and histamine-2-receptor antagonists. Small sample sizes and methodology flaws limited prior studies.A systematic search of MEDLINE, EMBASE, CENTRAL, Web of Science, and ClinicalTrials.gov for randomized controlled trials reporting the use of PPI and histamine-2-receptor antagonist reporting rates of GIB and standardized intensive care outcomes. Risk ratios (RR) and standardized mean difference (SMD) with 95% confidence intervals (CIs). A trial sequential analysis was performed to guard against errors.A total of 14 randomized controlled trials of 28,526 patients with a mean age of 57.83±17.35 years and 30.82% females. In our pooled analysis, PPI outperformed its comparator (RR: 0.68; 95% CI: 0.57-0.82) in clinically significant GIB. PPI re-demonstrated significant reduction in overt GIB (RR: 0.61; 95% CI: 0.39-0.97). No differences between groups was noted toward all-cause mortality (RR: 1.05; 95% CI: 1.00-1.10) or incidence of pneumonia (RR: 1.11; 95% CI: 0.82-1.51). Duration of stay (SMD: 0.07; 95% CI: -0.04-0.17) and ventilator days (SMD: 0.01; 95% CI: -0.01-0.04) were indifferent between the groups.Among critically ill patients, PPI was associated with reduced clinically significant or overt GIB. No differences in pneumonia were seen with the use of either agent. Trial sequential analysis for clinically significant GIB ruled out the risk for false-positive results, and thereby it is unlikely that future trials will affect our conclusions.

  View details for DOI 10.1097/MCG.0000000000001562

  View details for Web of Science ID 000757534700011

  View details for PubMedID 34049377

• Acute Renal Failure and Nephrotic Syndrome Secondary to Collapsing Glomerulopathy Associated With Hepatitis C. Cureus Wiggins, B., Deliwala, S., Banno, F., Knight, K., Minaudo, M. 2022; 14 (3): e23175

  Abstract

  Collapsing glomerulopathy (CG) is a rare variant of focal segmental glomerulosclerosis (FSGS) that commonly presents as nephrotic syndrome in patients. CG is almost always associated with human immunodeficiency virus (HIV) infection but is rarely from other infectious sources such as parvovirus, Epstein-Barr virus, cytomegalovirus, and SARS-CoV-2. CG has also been reported to be related to other etiologies such as genetic disorders, lupus, malignancy, and post-renal transplant but is exceedingly rare when related to hepatitis C virus (HCV). In this report, we describe the case of a patient presenting with nephrotic syndrome secondary to CG caused by newly diagnosed HCV.

  View details for DOI 10.7759/cureus.23175

  View details for PubMedID 35444880

  View details for PubMedCentralID PMC9009271

• R0 resection rates with underwater EMR better than conventional EMR: an updated analysis Response GASTROINTESTINAL ENDOSCOPY Chandan, S., Deliwala, S., Kochhar, G. S. 2022; 95 (3): 596-597

  View details for DOI 10.1016/j.gie.2021.11.021

  View details for Web of Science ID 000756742300035

  View details for PubMedID 35180945

• Development of Venous Thromboembolism After COVID-19 mRNA-1273 Vaccine Inoculation CUREUS JOURNAL OF MEDICAL SCIENCE Mahgoub, A. E., Awuah, D., Hussain, M., Deliwala, S., Bachuwa, G., Younas, M. 2022; 14 (2): e22179

  Abstract

  A 79-year-old man suddenly developed right lower extremity (RLE) pain and swelling a few days after receiving his 1st dose of the mRNA-1273 COVID-19 vaccine. Despite this, he proceeded to receive the 2nd dose of his mRNA-1273 COVID-19 vaccine. Investigations confirmed extensive acute deep venous thrombosis and a concurrent acute pulmonary embolism. Therapeutic anticoagulation was initiated and he was eventually discharged home on supplemental oxygen. The overall benefits of the vaccine in curbing severe disease overwhelmingly outweigh the handful of cases of reported adverse events. To our knowledge, this is one of the first few cases of provoked venous thrombosis after receiving the mRNA-1273 COVID-19 vaccine during the pharmacovigilance period.

  View details for DOI 10.7759/cureus.22179

  View details for Web of Science ID 000757966900013

  View details for PubMedID 35308698

  View details for PubMedCentralID PMC8923564

• Refractory familial hypokalaemic periodic paralysis leading to cardiovascular compromise BMJ CASE REPORTS Awuah, D. O., Hussain, M. S., Ponnapalli, A., Deliwala, S., Seedahmed, E. M., Bachuwa, G. 2022; 15 (2)

  Abstract

  Familial hypokalaemic periodic paralysis (FHPP) is a rare neuromuscular disorder that is classified under periodic paralysis (PP), which is characterised by episodes of muscle weakness. Common triggers include intense exercise, fasting or consumption of carbohydrate-rich meals. Hypokalaemic PP has an incidence of 1 in 100 000; despite the temporal association, cardiac manifestations are exceedingly rare. We present a case of FHPP, a channelopathy presenting with severe refractory hypokalaemia. The challenges with our patient were maintaining potassium levels within normal ranges and initiating a close follow-up plan. Due to the lack of clinical guidance in our case, many aspects of care, including surveillance, medications and genetic testing, remain unaddressed. Medical management includes aggressive correction with supplements, potassium-sparing diuretics and carbonic anhydrase inhibitors. Severe cases of dysrhythmias, especially ventricular fibrillation, require electrophysiology evaluation and possible implantation of a defibrillator to prevent sudden cardiac death.

  View details for DOI 10.1136/bcr-2021-246674

  View details for Web of Science ID 000753989600013

  View details for PubMedID 35131788

  View details for PubMedCentralID PMC8823031

• Ballooning Your Way in Altered Anatomy ERCP: Ready for Deductive Learning DIGESTIVE DISEASES AND SCIENCES Deliwala, S. S., Chawla, S. 2022; 67 (7): 2696-2698

  View details for DOI 10.1007/s10620-021-07348-w

  View details for Web of Science ID 000740596800003

  View details for PubMedID 35001243

• Advanced Endoscopic Resection Techniques in Cirrhosis-A Systematic Review and Meta-Analysis of Outcomes DIGESTIVE DISEASES AND SCIENCES Chandan, S., Deliwala, S., Khan, S. R., Ramai, D., Mohan, B. P., Bilal, M., Facciorusso, A., Kassab, L. L., Kamal, F., Dhindsa, B., Perisetti, A., Adler, D. G. 2022; 67 (10): 4813-4826

  Abstract

  While safety and effectiveness of advanced endoscopic resection techniques such as endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) has been well established in general population, data regarding their utility in patients with cirrhosis is limited.We searched multiple databases from inception through July 2021 to identify studies that reported on outcomes of EMR and/or ESD in patients with cirrhosis. Meta-analysis was performed to determine pooled rates of immediate and delayed bleeding, perforation, death as well as rates of successful en bloc and R0 resection. Pooled relative risk (RR) was calculated for each outcome between patients with and without cirrhosis.Ten studies with a total of 3244 patients were included in the final analysis. Pooled rates of immediate & delayed bleeding, perforation, and death during EMR and/or ESD in patients with cirrhosis were 9.5% (CI 4.0-21.1), 6.6% (CI 4.2-10.3), 2.1% (CI 1.1-3.9) and 0.6% (CI 0.2-1.7), respectively. Pooled rates of successful en bloc and R0 resection were 93% (CI 85.9-96.7) and 90.8% (CI 86.5-93.8), respectively. While incidence of immediate bleeding was higher in patients with cirrhosis, there was no statistically significant difference in any of the other outcomes between the patient groups.Our study shows that performing EMR and ESD for gastrointestinal lesions in patients with cirrhosis is both safe and effective. The risks of procedural complications parallel those reported in general population.

  View details for DOI 10.1007/s10620-021-07364-w

  View details for Web of Science ID 000739790100002

  View details for PubMedID 34993682

  View details for PubMedCentralID 4949078

• Association of <i>BRCA</i> Mutations and Pancreatic Cancer <i>Review of Literature and Meta</i>-<i>analysis</i> PANCREAS Chandan, S., Deliwala, S. S., Facciorusso, A., Mohan, B. P., Ramai, D., Kochhar, G. S. 2022; 51 (1): E8-E10

  View details for Web of Science ID 000759723600008

  View details for PubMedID 35195609

• The Management of Acute Onset Complete Heart Block and Atrial Flutter in a Patient with COVID-19. European journal of case reports in internal medicine Hussain, M., Awuah, D., Deliwala, S., Alkotob, M. L., Seedahmed, E., Bachuwa, G. 2022; 9 (2): 003026

  Abstract

  Coronavirus disease (COVID-19) has infected millions of people worldwide. Its cardiac presentations include myocarditis, arrhythmias and structural heart changes even in young and healthy individuals. The long-term sequelae of these manifestations are unknown. We describe a unique combination of complete heart block and atrial flutter in the setting of COVID-19. SARS-CoV-2 virulence mechanisms can cause fibrosis in the myocardium resulting in loss of sinus node dominance. The paradoxical finding of atrial flutter and complete heart block is very rare. Prompt cardiac evaluation and electrophysiological testing are important. Cardiac magnetic resonance imaging (cMRI) and endomyocardial biopsies are the gold standard investigations. Anticoagulation should be administered until atrioventricular synchrony is achieved.LEARNING POINTS: Simultaneous atrial flutter and third-degree atrioventricular block (AVB) caused by COVID-19 infection should be treated with a pacemaker according to heart block guidelines.During the COVID-19 pandemic, we recommend leadless pacemaker implantation for third-degree AVB as it has a lower risk of infection compared with traditional percutaneous procedures.Due to a lack of long-term data, patients with cardiac manifestations from COVID-19 require close follow-up with individualized surveillance schedules.

  View details for DOI 10.12890/2022_003026

  View details for PubMedID 35265539

• Postvaccination SARS-CoV-2 infection among healthcare workers: A systematic review and meta-analysis JOURNAL OF MEDICAL VIROLOGY Chandan, S., Khan, S. R., Deliwala, S., Mohan, B. P., Ramai, D., Chandan, O. C., Facciorusso, A. 2022; 94 (4): 1428-1441

  Abstract

  Healthcare workers (HCWs) remain on the front line of the battle against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and coronavirus disease 2019 (COVID-19) infection and are among the highest groups at risk of infection during this raging pandemic. We conducted a systematic review and meta-analysis to assess the incidence of postvaccination SARS-CoV-2 infection among vaccinated HCWs. We searched multiple databases from inception through August 2021 to identify studies that reported on the incidence of postvaccination SARS-CoV-2 infection among HCWs. Meta-analysis was performed to determine pooled proportions of COVID-19 infection in partially/fully vaccinated as well as unvaccinated individuals. Eighteen studies with 228 873 HCWs were included in the final analysis. The total number of partially vaccinated, fully vaccinated, and unvaccinated HCWs were 132 922, 155 673, and 17 505, respectively. Overall pooled proportion of COVID-19 infections among partially/fully vaccinated and unvaccinated HCWs was 2.1% (95% confidence interval [CI] 1.2-3.5). Among partially vaccinated, fully vaccinated and unvaccinated HCWs, pooled proportion of COVID-19 infections was 2.3% (CI 1.2-4.4), 1.3% (95% CI 0.6-2.9), and 10.1% (95% CI 4.5-19.5), respectively. Our analysis shows the risk of COVID-19 infection in both partially and fully vaccinated HCWs remains exceedingly low when compared to unvaccinated individuals. There remains an urgent need for all frontline HCWs to be vaccinated against SARS-CoV-2 infection.

  View details for DOI 10.1002/jmv.27457

  View details for Web of Science ID 000721810100001

  View details for PubMedID 34783055

  View details for PubMedCentralID PMC8661690

• Black oesophagus, upside-down stomach and cameron lesions: cascade effects of a large hiatal hernia BMJ CASE REPORTS Deliwala, S., Hussain, M. S., Ponnapalli, A., Bachuwa, G., Gurvits, G. E. 2021; 14 (11)

  Abstract

  Acute oesophageal necrosis, black oesophagus (BE) or Gurvits syndrome (GS) is a rare form of severe oesophagitis appearing as a striking circumferential discolouration of distal mucosa with various proximal extensions abruptly terminating at the gastro-oesophageal junction. It is most commonly associated with acute exacerbations of medical comorbidities, while associations with altered gut anatomy are rare. We present a unique constellation of BE, Cameron ulcers (CU), and gastric volvulus from a large paraesophageal hiatal hernia. Our patient recently recovered from COVID-19 and was malnourished and frail, while the expanding paraesophageal hiatal hernia turned into an acute organoaxial gastric volvulus with accompanying outlet obstruction. In low-flow post-COVID coagulopathic states, compensatory mechanisms may lack against gastric stunning and sudden massive reflux on the oesophagus. We additionally performed a systematic review and discovered additional cases with coexistent volvulus and paraesophageal hernia, although there are no previous reports of BE with CU, which makes this study the first.

  View details for DOI 10.1136/bcr-2021-246496

  View details for Web of Science ID 000718989900002

  View details for PubMedID 34772683

  View details for PubMedCentralID PMC8593710

• Acute Esophageal Necrosis in a Patient With COVID-19 AMERICAN JOURNAL OF GASTROENTEROLOGY Deliwala, S. S., Gurvits, G. E. 2021; 116 (10): 1977

  View details for DOI 10.14309/ajg.0000000000001207

  View details for Web of Science ID 000711689500005

• Pseudomelanosis Duodeni After Dialysis Initiation in Long-Standing Kidney Disease ACG CASE REPORTS JOURNAL Deliwala, S. S., Hussain, M. S., Ponnapalli, A., Wiggins, B., Beere, T., Kunaprayoon, L., Lakshman, H., Gurvits, G. E. 2021; 8 (9): e00658

  View details for DOI 10.14309/crj.0000000000000658

  View details for Web of Science ID 000711684700009

  View details for PubMedID 34611528

  View details for PubMedCentralID PMC8487778

• Accelerated balloon-retrograde transvenous obliteration (BRTO): an effective tool in the Arsenal against isolated gastric varices (IGV) BMJ CASE REPORTS Deliwala, S., Hussain, M., Ponnapalli, A., Igbinedion, S. O., Bachuwa, G., Bansal, A. 2021; 14 (9)

  Abstract

  Gastric and oesophageal variceal bleeding poses high morbidity and mortality in cirrhosis. Amongst all types, isolated gastric varices (IGV) carry the highest propensity to bleed. Successful outcomes combine endoscopic and interventional radiology approaches using ligation, coils, glue or sclerosants. Transjugular intrahepatic portosystemic shunt success is only seen in a subset of patients, while balloon-retrograde transvenous obliteration (BRTO) has demonstrated high efficacy in preventing rebleeding and morbidity in patients with a myriad of anatomies and shunts. The American Association for the Study of Liver disease guidelines do not favour any particular modality; however, recent trials and meta-analyses support BRTO as the first-line therapy. Despite promising results, BRTO adoption is limited by procedural time, patient length-of-stay and equipment compatibilities hindering scalability in academic and community settings. To address these concerns, we present a successfully treated case of IGV with a revised technique called accelerated BRTO.

  View details for DOI 10.1136/bcr-2021-244405

  View details for Web of Science ID 000698721000006

  View details for PubMedID 34489255

  View details for PubMedCentralID PMC8422294

• Line it up-Inadvertent placement of nasogastric tube in pleural space resulting in iatrogenic empyema CLINICAL CASE REPORTS Hussain, M. S., Deliwala, S. S., Awuah, D., Valvani, A. 2021; 9 (9): e04729

  Abstract

  Dobhoff tubes, used for post-pyloric feedings, have a weighted metal end with a small diameter that enhances their flexibility to traverse the gastrointestinal tract. Unfortunately, the metal stylet can iatrogenically perforate surrounding structures in patients with diminished cough and gag (1), and extreme caution should be considered before its utilization.

  View details for DOI 10.1002/ccr3.4729

  View details for Web of Science ID 000700003300127

  View details for PubMedID 34484764

  View details for PubMedCentralID PMC8405423

• Reduced left atrial strain can predict stroke in atrial fibrillation - A meta analysis IJC HEART & VASCULATURE Sachdeva, S., Desai, R., Andi, K., Vyas, A., Deliwala, S., Sachdeva, R., Kumar, G. 2021; 36: 100859

  View details for DOI 10.1016/j.ijcha.2021.100859

  View details for Web of Science ID 000704387000010

  View details for PubMedID 34485678

  View details for PubMedCentralID PMC8391018

• Blowing off steam-Identifying bowel perforation after routine colonoscopy CLINICAL CASE REPORTS Hussain, M. S., Deliwala, S. S., Gupta, R., Berrou, M. 2021; 9 (7): e04515

  Abstract

  Colonoscopy is an effective procedure for colorectal cancer (CRC) screening. Perforation is a rare yet the most severe complication, identified by landmarks-double dolphin, triangle, or double-wall sign signifying air and intracolonic contents leaking into the peritoneal space. Prompt recognition and surgical intervention are imperative to avoid high mortality.

  View details for DOI 10.1002/ccr3.4515

  View details for Web of Science ID 000678684500037

  View details for PubMedID 34322261

  View details for PubMedCentralID PMC8299273

• Important reminder: nitrous oxide (N₂O) as a cause of functional vitamin B₁₂ deficiency BMJ CASE REPORTS Mahgoub, A., Deliwala, S., Bachuwa, G. 2021; 14 (7)

  Abstract

  A 32-year-old woman who misused multiple substances, including nitrous oxide (N2O), sought medical advice after she subacutely developed bilateral lower extremity weakness without a sensory level but with ataxia-her significant other developed similar symptoms with vitamin B12 deficiency due to N2O intake. Laboratory results revealed macrocytic anaemia despite normal B12 and folate levels, with serum markers pointing towards functional cobalamin deficiency. Spinal MRIs and cerebrospinal fluid analysis were unremarkable. Our patient was treated with vitamin B12 supplementation with an encouraging response.

  View details for DOI 10.1136/bcr-2020-241414

  View details for Web of Science ID 000677605300032

  View details for PubMedID 34290005

  View details for PubMedCentralID PMC8296808

• Splenic Injury After a Colonoscopy: Threading the Scope Carefully in Heritable Connective Tissue Disorders CUREUS JOURNAL OF MEDICAL SCIENCE Wiggins, B., Lamarche, C., Gupta, R., Deliwala, S., Minaudo, M. 2021; 13 (6): e15444

  Abstract

  Colonoscopies have reduced colorectal cancer (CRC) burden in the United States, and their utility has expanded to include various diagnostic and therapeutic indications. Complications are seen in up to 1% and increase with age and polypectomy. As colonoscopies become widespread, specific populations seem to be at a much higher risk; notably patients with heritable connective tissue disorders (HCTD). As life expectancy increases, these patients undergo routine screenings and require careful peri-endoscopic care to reduce adverse outcomes. Amongst HCTD, Ehlers-Danlos syndrome (EDS) is commonly implicated, however, no reports of Marfan syndrome (MS) exist. We present a unique case of splenic injury after colonoscopy in a patient with MS. Successful outcomes require early suspicion and emergent surgical evaluation in patients with hemodynamic instability after a colonoscopy. Increased ligament laxity and bowel fragility are the most likely mechanisms. Alternative CRC strategies like fecal immunochemical test (FIT), fecal occult, Cologuard, or virtual colonography can be considered.

  View details for DOI 10.7759/cureus.15444

  View details for Web of Science ID 000658413400011

  View details for PubMedID 34113526

  View details for PubMedCentralID PMC8184110

• Is the use of warfarin becoming obsolete? JOURNAL OF COMMUNITY HOSPITAL INTERNAL MEDICINE PERSPECTIVES Haykal, T., Deliwala, S. S., Ortel, T. L. 2021; 11 (3): 418-419

  View details for DOI 10.1080/20009666.2021.1918474

  View details for Web of Science ID 000648740100028

  View details for PubMedID 34234920

  View details for PubMedCentralID PMC8118434

• Artificial intelligence (AI) real-time detection vs. routine colonoscopy for colorectal neoplasia: a meta-analysis and trial sequential analysis INTERNATIONAL JOURNAL OF COLORECTAL DISEASE Deliwala, S. S., Hamid, K., Barbarawi, M., Lakshman, H., Zayed, Y., Kandel, P., Malladi, S., Singh, A., Bachuwa, G., Gurvits, G. E., Chawla, S. 2021; 36 (11): 2291-2303

  Abstract

  Studies analyzing artificial intelligence (AI) in colonoscopies have reported improvements in detecting colorectal cancer (CRC) lesions, however its utility in the realworld remains limited. In this systematic review and meta-analysis, we evaluate the efficacy of AI-assisted colonoscopies against routine colonoscopy (RC).We performed an extensive search of major databases (through January 2021) for randomized controlled trials (RCTs) reporting adenoma and polyp detection rates. Odds ratio (OR) and standardized mean differences (SMD) with 95% confidence intervals (CIs) were reported. Additionally, trial sequential analysis (TSA) was performed to guard against errors.Six RCTs were included (4996 participants). The mean age (SD) was 51.99 (4.43) years, and 49% were females. Detection rates favored AI over RC for adenomas (OR 1.77; 95% CI: 1.570-2.08) and polyps (OR 1.91; 95% CI: 1.68-2.16). Secondary outcomes including mean number of adenomas (SMD 0.23; 95% CI: 0.18-0.29) and polyps (SMD 0.23; 95% CI: 0.17-0.29) detected per procedure favored AI. However, RC outperformed AI in detecting pedunculated polyps. Withdrawal times (WTs) favored AI when biopsies were included, while WTs without biopsies, cecal intubation times, and bowel preparation adequacy were similar.Colonoscopies equipped with AI detection algorithms could significantly detect previously missed adenomas and polyps while retaining the ability to self-assess and improve periodically. More effective clearance of diminutive adenomas may allow lengthening in surveillance intervals, reducing the burden of surveillance colonoscopies, and increasing its accessibility to those at higher risk. TSA ruled out the risk for false-positive results and confirmed a sufficient sample size to detect the observed effect. Currently, these findings suggest that AI-assisted colonoscopy can serve as a useful proxy to address critical gaps in CRC identification.

  View details for DOI 10.1007/s00384-021-03929-3

  View details for Web of Science ID 000647547200001

  View details for PubMedID 33934173

  View details for PubMedCentralID 7045775

• Human Immunodeficiency Virus (HIV) Masquerading as Myopathy and Rhabdomyolysis CUREUS JOURNAL OF MEDICAL SCIENCE Ranabhat, K., Deliwala, S., Hussain, M., Haykal, T., Bachuwa, G. 2021; 13 (4): e14559

  Abstract

  Human immunodeficiency virus (HIV) characteristically presents as a mononucleosis-like prodrome; rhabdomyolysis as a sole manifestation remains a rare finding from infection to seroconversion. A young male with a vague sexual history presented with myopathy progressing rapidly to rhabdomyolysis and renal failure. Acute HIV rarely presents with classic features, and rhabdomyolysis seems to manifest more in younger patients. Our case also demonstrates the importance of keeping a strong suspicion for HIV in the right setting despite false-negative results in the pre-seroconversion phase. The variability in HIV presentation and stigma of sexual history taking represents a diagnostic challenge. The astute clinician must be privy to these peculiarities to formulate a prompt diagnosis.

  View details for DOI 10.7759/cureus.14559

  View details for Web of Science ID 000642569700007

  View details for PubMedID 34026376

  View details for PubMedCentralID PMC8133517

• Sarcoidosis Masquerading as Long-Standing Cholestasis GASTROENTEROLOGY RESEARCH Deliwala, S. S., Hussain, M., Ponnapalli, A., Khanal, R., Goyal, H., Abdalla, A., Elbedawi, M. M. 2021; 14 (2): 112-115

  Abstract

  Hepatic sarcoidosis is an exceedingly rare extrapulmonary manifestation of sarcoidosis, with the majority remaining stable for years without clinical clues, only displaying biochemical abnormalities. Amongst the literature, the timeline to cirrhosis has not been parsed out; hepatomegaly develops in 50% and cirrhosis in 33% of all hepatic sarcoidosis patients, making this an essential issue in this patient population. Interestingly, the risk for hepatocellular carcinoma remains high regardless of cirrhosis development. Corticosteroids and biologics remain the mainstay of therapy, although refractory cases may require deeper immunosuppression. Liver transplantation is seen in a handful of cases with promising results. We present an interesting case of cholestatic pattern livery injury in our outpatient setting that was eventually discovered to be hepatic sarcoidosis. Mild biochemical derangements or sole elevations in alkaline phosphatase are under-recognized, and patients often progress to cirrhosis and end-stage liver disease. This diagnostic miss has significant implications and represents an opportunity to treat liver disease with a reversible cause. Consensus guidelines recommend alkaline phosphatase screening in newly diagnosed cases of sarcoidosis.

  View details for DOI 10.14740/gr1360

  View details for Web of Science ID 000642374600007

  View details for PubMedID 34007353

  View details for PubMedCentralID PMC8110232

• When Variants Collide: An Unusual Presentation of Metastatic Gastric Mixed Neuroendocrine-Non-Neuroendocrine Neoplasm ACG CASE REPORTS JOURNAL Deliwala, S. S., Ponnapalli, A., Gakhal, I., Modi, V., Haykal, T., Bachuwa, G., Chawla, S. 2021; 8 (4): e00569

  Abstract

  Gastrointestinal neuroendocrine neoplasms were recently reclassified into the 2019 World Health Organization schema into well-differentiated neuroendocrine tumors, poorly differentiated neuroendocrine carcinomas, and mixed neuroendocrine-non-neuroendocrine neoplasms (MiNENs). Among these, gastric MiNENs are exceedingly rare and often metastasize quickly without diagnostic clues. We present a refractory gastric MiNEN with unique presenting features. This case highlights the clinical spectrum of these tumors, the importance of accurate histochemical interpretation, and clinical management in the absence of formalized guidelines. Future therapies looking at novel targets and palliative symptom relief are needed.

  View details for DOI 10.14309/crj.0000000000000569

  View details for Web of Science ID 000711685500005

  View details for PubMedID 34476269

  View details for PubMedCentralID PMC8389938

• Serrating through vascular access catheters: a great masquerader with severe systemic manifestations BMJ CASE REPORTS Deliwala, S., Hussain, M., Ponnapalli, A., Awuah, D., McDonald, P., Bachuwa, G. 2021; 14 (4)

  Abstract

  Serratia marcescens, time and again, has demonstrated its ability to easily adhere and infect vascular access catheters, making them a bona fide source of hospital outbreaks and contributing to adverse patient outcomes. We present a unique case of a severe recurrent Serratia infection, leading to persistent bacteria in the blood, haematogenous dissemination and subsequent development of abscesses, to a degree not reported in the literature before. These infections are exceedingly challenging to eradicate, owing to multiple virulence mechanisms and the deep seeding ability of this microorganism. Serratia infections require a multifaceted approach with intricacies in identification, therapeutics and surveillance, all of which are sparsely reported in the literature and reviewed in this report.

  View details for DOI 10.1136/bcr-2021-242013

  View details for Web of Science ID 000648560300085

  View details for PubMedID 33827881

  View details for PubMedCentralID PMC8030668

• Acute confusional state as a prognostic sign of COVID-19 large-vessel occlusion (LVO) BMJ CASE REPORTS Deliwala, S., Hussain, M., Ponnapalli, A., Awuah, D., Dawood, T., Bachuwa, G. 2021; 14 (2)

  Abstract

  COVID-19 is well known for its respiratory symptoms, but severe presentations can alter haemostasis, causing acute end-organ damage with poor outcomes. Among its various neurological presentations, cerebrovascular events often present as small-vessel strokes. Although uncommon, in predisposed individuals, large-vessel occlusions (LVOs) can occur as a possible consequence of direct viral action (viral burden or antigenic structure) or virus-induced cytokine storm. Subtle presentations and complicated stroke care pathways continue to exist, delaying timely care. We present a unique case of COVID-19 LVO manifesting as an acute confusional state in an elderly man in April 2020. CT angiography revealed 'de novo' occlusions of the left internal carotid artery and proximal right vertebral artery, effectively blocking anterior and posterior circulations. Delirium can lead to inaccurate stroke scale assessments and prolong initiation of COVID-19 stroke care pathways. Future studies are needed to look into the temporal relationship between confusion and neurological manifestations.

  View details for DOI 10.1136/bcr-2020-240536

  View details for Web of Science ID 000661575500285

  View details for PubMedID 33622754

  View details for PubMedCentralID PMC7907863

• Pericardial effusion uncovering underlying hypothyroidism CLINICAL CASE REPORTS Ponnapalli, A., Deliwala, S. S., Zayed, Y., Bachuwa, G. 2021; 9 (3): 1816-1818

  Abstract

  Pericardial effusion may be the tipping point to unravel hypothyroidism. Large effusions may not correlate with severity of cardiovascular compromise. Medical therapy over surgical intervention is appropriate if no evidence of cardiac tamponade.

  View details for DOI 10.1002/ccr3.3857

  View details for Web of Science ID 000611163700001

  View details for PubMedID 33768953

  View details for PubMedCentralID PMC7981775

• Thromboprophylaxis for orthopedic surgery; An updated meta-analysis THROMBOSIS RESEARCH Haykal, T., Adam, S., Bala, A., Zayed, Y., Deliwala, S., Kerbage, J., Ponnapalli, A., Malladi, S., Samji, V., Ortel, T. L. 2021; 199: 43-53

  Abstract

  Venous thromboembolism (VTE) is a serious complication of orthopedic surgery. Low molecular weight heparin (LMWH) has been the standard of care for thromboprophylaxis in this population. However, direct oral anticoagulants (DOACs) are increasingly being used as alternatives.To assess the efficacy and safety of DOACs versus LMWH for thromboprophylaxis in orthopedic surgery.We searched MEDLINE, Embase, and the Cochrane Collaboration Central Register of Controlled Trials from inception until April 2020, for randomized controlled trials (RCTs) comparing DOACs with LMWH for thromboprophylaxis in orthopedic surgery.Twenty-five RCTs met inclusion criteria, including 40,438 patients, with a mean age of 68 years and 50% were males. Compared to LMWH, DOACs were associated with a significant reduction of major VTE; defined as the composite events of proximal deep vein thrombosis (DVT), pulmonary embolism (PE), and VTE-related mortality (RR 0.33; 95% CI: 0.20-0.53; P<0.01), and total DVT (RR: 0.59; 95% CI: 0.48-0.73; P<0.01), but not PE (RR 0.81; 95% CI: 0.49-1.34; P=0.42). There was no statistically significant difference between both groups on the incidence of major bleeding (RR 0.99; 95% CI: 0.77-1.27; P=0.92), clinically relevant non-major bleeding (RR 1.04; 95% CI: 0.92-1.17; P=0.52), all-cause mortality (RR 1.06; 95% CI: 0.64-1.76; P=0.83), VTE-related mortality (RR 0.84; 95% CI: 0.40-1.74; P=0.64) and bleeding-related mortality (RR 1.24; 95% CI: 0.30-5.18; P=0.77).For patients undergoing orthopedic surgery, thromboprophylaxis with DOACs is associated with a significant reduction of major VTE and DVT, compared to LMWH. Safety outcomes were not significantly different between both treatment groups.

  View details for DOI 10.1016/j.thromres.2020.12.007

  View details for Web of Science ID 000631711000009

  View details for PubMedID 33422802

• Cyclical Hemoptysis and Pelvic Pain in a Young Female: A Sign of Thoracic Endometriosis Syndrome CUREUS JOURNAL OF MEDICAL SCIENCE Bala, A., Salim, R. A., Deliwala, S., Obeid, M., Bachuwa, G. 2020; 12 (10): e11078

  Abstract

  Distant autoimplantation of endometrial implants presents with signs and symptoms specific to the affected site. The constellation of cyclical hemoptysis, pleuritic chest pain, dyspnea, or cough in the right gynaecologic setting should raise concern for thoracic endometriosis syndrome (TES). Although extra-pelvic implications of endometriosis are well known, TES is exceedingly rare. We present an unusual case of aggressive TES that re-emerged after a period of latency despite suppressive therapy, making the case for future studies to establish surveillance schedules and advanced therapies. As these implants become sizable, they require a combination of medical and surgical therapies often with psychological support. This case illustrates the importance of prompt diagnosis and a multidisciplinary approach to TES.

  View details for DOI 10.7759/cureus.11078

  View details for Web of Science ID 000580960800007

  View details for PubMedID 33224672

  View details for PubMedCentralID PMC7678763

• Direct oral anticoagulant versus low-molecular-weight heparin for treatment of venous thromboembolism in cancer patients: An updated meta-analysis of randomized controlled trials THROMBOSIS RESEARCH Haykal, T., Zayed, Y., Deliwala, S., Kerbage, J., Ponnapalli, A., Malladi, S., Goranta, S., Samji, V., Adam, S. 2020; 194: 57-65

  Abstract

  Cancer associated venous thromboembolism (VTE) results in significant morbidity and mortality. Low molecular weight heparin (LMWH) has been standard of care for treatment of cancer-associated VTE, however direct oral anticoagulants (DOACs) are emerging as alternative treatment options.To compare the benefits and harms of DOACs versus LMWH for treatment of VTE in cancer.MEDLINE, Embase, and the Cochrane Collaboration Central Register of Controlled Trials from inception to April 2020.Randomized controlled trials (RCT) comparing DOACs with LMWH for treatment of VTE in cancer patients.Four good-quality RCTs, met inclusion criteria. Compared with LMWH, DOACs were associated with lower rates of VTE recurrence (RR 0.62; 95% CI: 0.44-0.87; P = 0.006), and DVT recurrence (RR 0.61; 95% CI: 0.4-0.94; P = 0.02) but not PE recurrence (RR 0.73; 95% CI: 0.51-1.04; P = 0.08), in cancer patients. However, the risk of clinically relevant non-major bleeding (CRNMB) (RR 1.58; 95% CI: 1.11-2.24; P = 0.01), and major bleeding in gastrointestinal cancer (RR 2.55; 95% CI 1.24-5.27, P = 0.01), were higher with DOACs. The risk of overall major bleeding (RR 1.33; 95% CI: 0.84-2.1; P = 0.22), all-cause mortality (RR 0.99; 95% CI: 0.84-1.17; P = 0.92), VTE-related mortality (RR: 1; 95% CI: 0.29-3.44; P = 1) and bleeding-related mortality (RR: 0.71; 95% CI: 0.17-2.91; P = 0.63), were similar in both treatment groups.Among cancer patients with VTE, treatment with DOACs is associated with a significant reduction of VTE and DVT recurrence, compared to LMWH. These benefits were offset by an increased risk of CRNMB, and major bleeding in gastrointestinal cancer.

  View details for DOI 10.1016/j.thromres.2020.06.025

  View details for Web of Science ID 000568490100011

  View details for PubMedID 32788122

• Acute Esophageal Necrosis (Gurvits Syndrome) Presenting as Globus and Altered Phonation. The American journal of case reports Deliwala, S. S., Bala, A., Haykal, T., Elbedawi, M. M., Bachuwa, G., Gurvits, G. E. 2020; 21: e926019

  Abstract

  BACKGROUND Acute esophageal necrosis (AEN), also known as black esophagus or Gurvits syndrome, is an infrequently seen clinical condition distinguishable by a visually striking endoscopic appearance of necrotic esophageal mucosa that involves the distal esophagus with proximal extensions ending at the gastroesophageal junction. Since its early recognition pathologically in the 1960s and endoscopically in the 1990s, AEN, despite its rarity, is being increasingly recognized as a demonstratable cause of upper gastrointestinal bleeding. Cases of pan-esophageal necrosis are sparsely reported, leaving management guidance to isolated case reports. CASE REPORT An 80-year-old female smoker with advanced chronic obstructive pulmonary disease presented with signs and symptoms of acute pharyngitis and globus sensation that had been evolving over the preceding weeks. An esophagogastroduodenoscopy revealed circumferential necrotic mucosa encircling the entire lumen of the esophagus. The patient was made nil-per-os and started on high-dose anti-reflux therapy with adequate hemodynamic resuscitation. CONCLUSIONS AEN is multifactorial but primarily a combination of decreased tissue perfusion and a massive influx of gastric contents in settings of impaired local defense barriers. Despite its dramatic presentation, the majority of cases resolve with conservative medical management, foregoing surgical interventions.

  View details for DOI 10.12659/AJCR.926019

  View details for PubMedID 32881843

• A 29-Year-Old Male with a Fatal Case of COVID-19 Acute Respiratory Distress Syndrome (CARDS) and Ventilator-Induced Lung Injury (VILI) AMERICAN JOURNAL OF CASE REPORTS Deliwala, S. S., Ponnapalli, A., Seedahmed, E., Berrou, M., Bachuwa, G., Chandran, A. 2020; 21: e926136

  Abstract

  BACKGROUND COVID-19 patients that develop acute respiratory distress syndrome (ARDS) "CARDS" behave differently compared to patients with classic forms of ARDS. Recently 2 CARDS phenotypes have been described, Type L and Type H. Most patients stabilize at the milder form, Type L, while an unknown subset progress to Type H, resembling full-blown ARDS. If uncorrected, phenotypic conversion can induce a rapid downward spiral towards progressive lung injury, vasoplegia, and pulmonary shrinkage, risking ventilator-induced lung injury (VILI) known as the "VILI vortex". No cases of in-hospital phenotypic conversion have been reported, while ventilation strategies in these patients differ from the lung-protective approaches seen in classic ARDS. CASE REPORT A 29-year old male was admitted with COVID-19 pneumonia complicated by severe ARDS, multi-organ failure, cytokine release syndrome, and coagulopathy during his admission. He initially resembled CARDS Type L case, although refractory hypoxemia, fevers, and a high viral burden prompted conversion to Type H within 8 days. Despite ventilation strategies, neuromuscular blockade, inhalation therapy, and vitamin C, he remained asynchronous to the ventilator with volumes and pressures beyond accepted thresholds, eventually developing a fatal tension pneumothorax. CONCLUSIONS Patients that convert to Type H can quickly enter a spiral of hypoxemia, shunting, and dead-space ventilation towards full-blown ARDS. Understanding its nuances is vital to interrupting phenotypic conversion and entry into VILI vortex. Tension pneumothorax represents a poor outcome in patients with CARDS. Further research into monitoring lung dynamics, modifying ventilation strategies, and understanding response to various modes of ventilation in CARDS are required to mitigate these adverse outcomes.

  View details for DOI 10.12659/AJCR.926136

  View details for Web of Science ID 000554479300001

  View details for PubMedID 32701934

  View details for PubMedCentralID PMC7405922

• Use of glucocorticoids in patients with acute respiratory distress syndrome: a meta-analysis and trial sequential analysis JOURNAL OF INTENSIVE CARE Zayed, Y., Barbarawi, M., Ismail, E., Samji, V., Kerbage, J., Rizk, F., Salih, M., Bala, A., Obeid, M., Deliwala, S., Demian, S., Al-Sanouri, I., Reddy, R. 2020; 8 (1): 43

  Abstract

  Acute respiratory distress syndrome (ARDS) is a common and disabling disease with high rates of mortality and morbidity. The role of steroids in treating ARDS remains controversial. We aim to examine the evidence behind using glucocorticoids in the management of ARDS from the available studies.We performed a literature review of major electronic databases for randomized controlled trials (RCTs) comparing glucocorticoids versus placebo in treating patients with ARDS. Our primary outcome was hospital mortality. Other outcomes included ICU mortality, number of ventilator-free days at day 28, incidence of nosocomial infections, and hyperglycemia. We performed a meta-analysis using a random effects model to calculate risk ratios (RR) and mean difference (MD) with their corresponding 95% confidence intervals (CI). A subsequent trial sequential analysis was performed to examine the strength of evidence and to guard against statistical type I and type II errors for our results.Eight RCTs were included in the final analysis totaling of 1091 patients, with a mean age of 57 ± 16, and 56.2% were male. In our pooled analysis, use of glucocorticoids was associated with a significant reduction in hospital mortality (RR 0.79; 95% CI 0.64-0.98; P = 0.03) and ICU mortality (RR 0.64; 95% CI 0.42-0.97; P = 0.04). Furthermore, glucocorticoid use was associated with an increased number of ventilator-free days at day 28 (MD 4.06 days; 95% CI 2.66-5.45; P < 0.01). Regarding adverse events, glucocorticoids use was not associated with an increased risk for nosocomial infections (RR 0.82; 95% CI 0.68-1.00; P = 0.05); however, it was associated with an increased risk of hyperglycemia (RR 1.11; 95% CI 1.01-1.24; P = 0.04). In our trial sequential analysis, the required diversity-adjusted information size (sample size = 2692 patients) was not reached, and the evidence was insufficient from the available RCTs.Among patients with ARDS, use of glucocorticoids is associated with a significant reduction in mortality and duration of mechanical ventilation, without increased risk of hospital-acquired infections. However, based on a trial sequential analysis, these findings may be secondary to a false-positive (type I) error. Further studies are needed for a firm conclusion with guarding against possible statistical errors.

  View details for DOI 10.1186/s40560-020-00464-1

  View details for Web of Science ID 000550646900001

  View details for PubMedID 32612838

  View details for PubMedCentralID PMC7324774

• Meta-Analysis of the Role of Intermittent Pneumatic Compression of the Lower Limbs to Prevent Venous Thromboembolism in Critically Ill Patients INTERNATIONAL JOURNAL OF LOWER EXTREMITY WOUNDS Haykal, T., Zayed, Y., Dhillon, H., Miran, M., Kerbage, J., Bala, A., Samji, V., Deliwala, S., Bachuwa, G. 2022; 21 (1): 31-40

  Abstract

  Critically ill patients (patients treated in a medical or surgical intensive care unit) are at high risk of venous thromboembolism (VTE) development (deep vein thrombosis [DVT] and/or pulmonary embolism). Multiple thromboprophylaxis strategies have been used for the prevention of VTE in this population with various outcomes. Therefore, we aimed to evaluate the efficacy of intermittent pneumatic compression (IPC) prophylaxis in the lower limb compared with no treatment, anticoagulant use, or their combinations in reducing risk. A comprehensive electronic database search was conducted for all randomized clinical trials (RCTs) comparing the clinical outcomes of IPC versus anticoagulants or no treatment or their combinations for the prevention of VTE for critically ill patients. The primary outcome was VTE. The secondary outcome was DVT. We performed a Bayesian network meta-analysis to calculate odds ratios (ORs) and 95% credible intervals (CrIs). We included 5 RCTs with 3133 total patients, represented by a mean age of 49.61 ± 18 years, while 60.28% were male. There was a significant reduction of the primary outcome (incidence of VTE events) when no treatment was compared with IPC (OR = 0.36; 95% CrI = 0.18-0.71), anticoagulation alone (OR = 0.30; 95% CrI = 0.12-0.68), or anticoagulation with IPC (OR = 0.34; 95% CrI = 0.13-0.81). In addition, there was a significant reduction in DVT when no treatment was compared with IPC (OR = 0.45; 95% CrI = 0.21-0.9), anticoagulation alone (OR = 0.16; 95% CrI = 0.03-0.66), or anticoagulation with IPC (OR = 0.18; 95% CrI = 0.03-0.84). However, there were no significant differences between other comparisons (IPC vs anticoagulation alone, anticoagulation alone vs anticoagulation with IPC, or anticoagulation with IPC vs IPC alone) regarding VTE or DVT incidence. Among critically ill patients, IPC alone, anticoagulation alone, and IPC with anticoagulation were associated with a significant reduction of VTE and DVT incidence compared with no treatment. However, there was no significant difference between these modalities when compared together. Therefore, further larger studies comparing those different thromboprophylaxis modalities and their combinations are needed to provide more robust results for future clinical recommendations.

  View details for DOI 10.1177/1534734620925391

  View details for Web of Science ID 000539855000001

  View details for PubMedID 32527203

• Severe primary refractory thrombotic thrombocytopenic purpura (TTP) in the post plasma exchange (PEX) and rituximab era BMJ CASE REPORTS Goranta, S., Deliwala, S. S., Haykal, T., Bachuwa, G. 2020; 13 (6)

  Abstract

  Acute acquired thrombotic thrombocytopenic purpura (TTP) requires prompt recognition and initiation of plasma exchange (PEX) therapy and immunosuppression. When PEX fails, mortality nears 100%, making finding an effective treatment crucial. Primary refractory TTP occurs when initial therapies fail or if exacerbations occur during PEX therapy, both signifying the need for treatment intensification to achieve clinical remission. Rituximab helps treat most of the refractory TTP cases, except those that are severely refractory. A paucity of studies guiding severely refractory TTP makes management arbitrary and individualised, highlighting the value of isolated reports. We present an extremely rare case of primary refractory TTP with an insufficient platelet response to numerous types of treatments, including emerging therapies such as caplacizumab, on the background of repeated PEX and immunosuppressive therapies.

  View details for DOI 10.1136/bcr-2019-234091

  View details for Web of Science ID 000661532200038

  View details for PubMedID 32532908

  View details for PubMedCentralID PMC7295375

• Encephalopathy as the Sentinel Sign of a Cortical Stroke in a Patient Infected With Coronavirus Disease-19 (COVID-19) CUREUS JOURNAL OF MEDICAL SCIENCE Deliwala, S., Abdulhamid, S., Abusalih, M., Al-Qasmi, M. M., Bachuwa, G. 2020; 12 (5): e8121

  Abstract

  The novel coronavirus has challenged medical systems worldwide to provide optimal medical care in the setting of limited resources. Although we are uncovering many facets of its disease spectrum, with rapidly emerging data, there is still limited knowledge of the sequelae of this infection, making treatment guidelines incomplete and resulting in serious unpredictable outcomes in patients at seemingly low risk, especially ones afflicted by neurological consequences. We present a case of a cortical stroke in a 31-year-old coronavirus disease-19 (COVID-19) positive female with otherwise no stroke risk factors. We noted a correlation between cytokine release, encephalopathy, and the onset of stroke symptoms. Patients with marked pro-thrombotic and inflammatory markers may benefit from closer neurological monitoring and thromboprophylaxis at therapeutic doses. The establishment of acute care pathways to manage critically ill patients with neurological consequences may reverse the suboptimal outcome trends seen during the pandemic.

  View details for DOI 10.7759/cureus.8121

  View details for Web of Science ID 000532618300015

  View details for PubMedID 32426200

  View details for PubMedCentralID PMC7228791

• Black Esophagus in the Setting of Alcohol Abuse after External Beam Radiation CASE REPORTS IN GASTROENTEROLOGY Deliwala, S., Lakshman, H., Congdon, D., Elbedawi, M., Bachuwa, G., Gurvits, G. 2020; 14 (2): 443-447

  Abstract

  Acute esophageal necrosis (AEN), black esophagus, or Gurvits syndrome is a rare clinical disorder characterized by a striking endoscopic appearance of necrotic esophageal mucosa, universally affecting the distal esophagus and ending abruptly at the gastroesophageal junction. It has been gaining traction as a demonstrable cause of upper gastrointestinal bleeding in the 21st century. Its pathophysiology is multifactorial affecting men and the elderly disproportionally, with a mortality rate nearing 36%. AEN has been associated with numerous conditions in the past, and we aim to present an unusual case of AEN on the setting of chronic alcohol use.

  View details for DOI 10.1159/000508852

  View details for Web of Science ID 000744678800027

  View details for PubMedID 32999646

  View details for PubMedCentralID PMC7506255

• When Zoonotic Organisms Cross Over-Trueperella pyogenes Endocarditis Presenting as a Septic Embolic Stroke CUREUS JOURNAL OF MEDICAL SCIENCE Deliwala, S., Beere, T., Samji, V., Mcdonald, P. J., Bachuwa, G. 2020; 12 (4): e7740

  Abstract

  Infective endocarditis (IE) remains a significant cause of morbidity and mortality worldwide, with numerous pathogens as culprits. We present a case of IE that evolved to a septic embolic stroke caused by an extremely rare bacteria Trueperella (T.) pyogenes that primarily infects non-humans. In contrast to most cases occurring outside the United States (US), this is the second case of T. pyogenes-associated endocarditis and the first to present as a stroke in the US. T. pyogenes has undergone numerous taxonomic revisions over the years since first being reported and characterized as Bacillus pyogenes in the 1800s. T. pyogenes is a zoonotic infection, and despite advancements in chemotaxonomic detection methods, Trueperella is often misidentified and under-diagnosed. Although epidemiological data is scarce, T. pyogenes infections have the propensity to cause endocarditis, and we aim to summarize all isolated reports of T. pyogenes infections that have been reported in the literature thus far.

  View details for DOI 10.7759/cureus.7740

  View details for Web of Science ID 000526848800004

  View details for PubMedID 32455060

  View details for PubMedCentralID PMC7241225

• ST-elevation Myocardial Infarction and Complete Heart Block in a Nitrate-free Patient using a New Emerging Substance called Rhino CUREUS JOURNAL OF MEDICAL SCIENCE Deliwala, S., Haykal, T., Dhillon, H., Shafi, S., Bachuwa, G. 2020; 12 (4): e7601

  Abstract

  The pervasive use of counterfeit sexual enhancement supplements is increasing worldwide. There are thousands of vendors on the internet while local gas stations and convenience stores are selling it across the United States (US). We report a case of right coronary artery ST-segment elevation and complete heart block in a nitrate-free patient shortly after consuming three 950 mg pills of a sexual enhancer known as rhino and completing sexual intercourse. Coronary angiography revealed 100% occlusion of the right coronary artery and a drug-eluting stent was inserted with a transvenous pacer that he tolerated well, and recovered without complications. The counterfeit drug has gained traction for its high user satisfaction and low cost among recreational customers. The Food and Drug Administration (FDA), through its MedWatch program, has frequently released citations to consumers warning them against rhino since 2015, while their labs have recognized two prime ingredients: sildenafil and tadalafil. Although adverse cardiac risk with this therapeutic class is low, we aim to parse out its temporal relationship with rhino, an enhancer containing 14-200 times the prescription limits of sildenafil and tadalafil.

  View details for DOI 10.7759/cureus.7601

  View details for Web of Science ID 000525179200007

  View details for PubMedID 32399335

  View details for PubMedCentralID PMC7212751

• E-cigarette, or Vaping, Product Use-associated Lung Injury (EVALI): Acute Lung Illness within Hours of Switching from Traditional to E-cigarettes CUREUS JOURNAL OF MEDICAL SCIENCE Deliwala, S., Sundus, S., Haykal, T., Theophilus, N., Bachuwa, G. 2020; 12 (4): e7513

  Abstract

  2019 has been a landmark year in the world of electronic nicotine delivery systems (ENDS), specifically e-cigarette and vaping. Numerous state health departments across the United States have voiced their concerns in the growing number of lung injury cases from e-cigarettes and vaping. Over the past few decades, many agencies have brought into light the harmful effects of smoking cigarettes, and despite popular belief, a growing movement has started to recognize the harmful effects of ENDS. The Centers for Disease Control and Prevention have released recommendations and provided health practitioners a methodology to identify and diagnose e-cigarette, or vaping, product use-associated lung injury (EVALI). EVALI is a diagnosis of exclusion and comprises a variety of respiratory illnesses, with intubation rates nearing 32%. The most critical risk factor remains product use in the preceding 90 days, although a timeline on the development of symptoms or notable structural changes remains unknown. We present a case of acute lung injury in a traditional cigarette smoker that evolved within hours of switching to e-cigarettes.

  View details for DOI 10.7759/cureus.7513

  View details for Web of Science ID 000523461700008

  View details for PubMedID 32373415

  View details for PubMedCentralID PMC7195202

• Small Duct Primary Sclerosing Cholangitis: An Underdiagnosed Cause of Chronic Liver Disease and Cirrhosis CUREUS JOURNAL OF MEDICAL SCIENCE Deliwala, S., Sundus, S., Haykal, T., Elbedawi, M. M., Bachuwa, G. 2020; 12 (3): e7298

  Abstract

  Classic or large duct primary sclerosing cholangitis (PSC) is part of the PSC spectrum. It is diagnosed on clinical and biochemical findings of cholestasis supported by biliary tree changes on cholangiography, forgoing the need for an invasive liver biopsy. The spectrum contains various PSC variants with distinct clinical courses and outcomes. We present a case of small duct PSC, a rare variant that manifested insidiously with clinical and objective cholestasis but appeared negative on diagnostic cholangiography. Eventually, a liver biopsy was obtained that revealed chronic bilious disease of the small and microscopic ducts with simultaneous changes consistent with liver cirrhosis. Despite presenting like its classical counterpart, small duct PSC can remain undetectable on cholangiography due to the diminutive size of the bile ducts requiring histological confirmation. In contrast to classic PSC, small duct PSC portends a much better prognosis. However, it eventually progresses to the classic form or end-stage liver disease, requiring patients to receive timely surveillance and transplantation referrals. Due to the limited understanding of this disease process, patients with similar presentations often pose a diagnostic dilemma due to the clinical and cholangiographic mismatch. This case aims to reaffirm that a negative cholangiography does not rule out the PSC spectrum and that small duct disease is a rare but growing entity. The paucity in cases emphasizes the importance of isolated reports in guiding workup and management, especially since surveillance schedules and transplantation guidelines have not been formally established.

  View details for DOI 10.7759/cureus.7298

  View details for Web of Science ID 000520023400003

  View details for PubMedID 32313739

  View details for PubMedCentralID PMC7163339

• Angiotensin-Converting Enzyme (ACE) Inhibitors and Pancreatitis: A Potential Dose-dependent Relationship. European journal of case reports in internal medicine Hussain, M. S., Deliwala, S. S., Ponnapalli, A., Modi, V., Kanugula, A., Elbedawi, M. M., Bachuwa, G. 2020; 7 (12): 001956

  Abstract

  Acute pancreatitis (AP) remains one of the most common causes of emergency department visits in the USA. The literature supports an association between angiotensin-converting enzyme inhibitors (ACEi), mainly at steady-state doses, and AP[1]. We present a case of recurrent AP and pseudocyst formation following multiple ACEi dose adjustments after a steady-state period lasting for over a decade. Previous reports have rarely described ACEi-induced pancreatitis and pseudocyst development. ACEi can cause significant ductal obstruction[2] and fluid retention due to its angioedema effects. Consequently, it may trigger AP complicated by pseudocyst formation. Therefore, ACEi administration must be considered in the appropriate clinical context.LEARNING POINTS: Although rare, ACEi is an emerging cause of drug-induced pancreatitis and often goes unrecognized.Multiple dose changes within a short period of time can lead to acute drug-induced pancreatitis (DIP), in addition to classic DIP caused by steady-state doses.ACEi-induced angioedema damages the ductal architecture and also has longer-lasting effects such as pseudocyst formation.

  View details for DOI 10.12890/2020_001956

  View details for PubMedID 33457354