Importace: There is conflicting evidence about the role of angiotensin converting enzymes inhibitors (ACEIs) and angiotensin receptors blockers (ARBs) in the pathogenesis and outcome of patients infected with acute severe respiratory syndrome coronavirus 2 (SASR-CoV-2) virus and growing public concern. Methods: We systematically reviewed the literature and performed a meta-analysis using inverse variance random effect models including all studies that evaluate the role of ACEIs/ARBs and reported adjusted odds ratio. Results: Nine studies met our eligibility criteria that enrolled a population of 58615 patients infected with SASR-CoV-2. Prior use of ACEIs/ARBs were associated with significant reduction of inpatient mortality among infected patients with SASR-CoV-2, adjusted odds ratio from 4 studies 0.33, 95% confidence interval ( 0.22,0.49) with zero in between studies heterogeneity and with significant reduction of critical or fatal outcome , pooled adjusted odds ratio from 5 studies 0.32,95% confidence interval ( 0.22,0.46) with no in between studies heterogeneity. Conclusion: Our findings suggest that prior use ACEIs /ARBs is associated with a decreased risk of death or critical outcome among SASR-CoV-2 infected patients.This findings is limited by the observational nature of included studies.However, it provides a reassurance to the public not to stop prescribed ACEIs /ARBs due to fear of severe COVID-19. It also calls upon investigators and ethics committee to reconsider the ongoing randomized trials of discontinuation of these drugs.

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Background: Angiotensin converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) are known to increase the expression of angiotensin converting enzyme 2 receptor, which has been shown to be the receptor for the acute severe respiratory syndrome coronavirus 2 (SARS-CoV-2). Areas of Uncertainty: Based on these observations, speculations raised the concerns that ACEIs/ARBs users would be more susceptible to SARS-CoV-2 infection and would be at higher risk for severe COVID-19 disease and death. Therefore, we systematically reviewed the literature and performed a meta-analysis of the association between prior use of ACEIs and ARBs and mortality due to COVID-19 disease. Data Sources: A comprehensive search of several databases from November 2019 to June 18, 2020 was conducted. The databases included Ovid MEDLINE(R) and Epub Ahead of Print, In-Process and Other Non-Indexed Citations and Daily, Ovid Embase, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, Web of Science, and Scopus. Medrxiv.org was also searched for unpublished data. Therapeutic Advances: Nine studies with a total of 18,833 patients infected with SARS-CoV-2 met our eligibility criteria. Prior use of ACEIs and/or ARBs was associated with reduced mortality among SARS-CoV-2-infected patients, with a pooled adjusted relative risk (aRR) from 6 studies of 0.63, 95% confidence interval (CI) (0.42–0.94) (I2 = 65%). Three studies reported separately on ACEIs or ARBs and their association with survival among SARS-CoV-2-infected patients, with a pooled adjusted relative risk of 0.78, 95% CI (0.58–1.04) (I2 = 0%) and 0.97, 95% CI (0.73–1.30) (I2 = 0%) respectively. The results of sensitivity analyses were consistent with the main analysis. Conclusion: Our meta-analysis suggests that use of ACEIs/ARBs is associated with a decreased risk of death among SARS-CoV-2-infected patients. This finding provides a reassurance to the public not to stop prescribed ACEIs/ARBs because of fear of severe COVID-19.

e13093 Background: Angiotensin-converting enzyme inhibitors (ACEIs) are commonly prescribed medications for hypertension and heart failure. Generally, ACEIs are well-tolerated medications with reasonable safety profile making them a favorable choice by many clinicians. However, several studies with conflicting results have signaled an association between ACEIs use and the development of lung cancer. We sought to systematically review the literature and perform the first meta-analysis to study the risk of lung cancer among ACEI users. Methods: We performed a literature review by searching multiple databases. A random effect meta-analysis approach was used to pool the data and relative risk was used to calculate the overall effect estimate. Results: A total of 423 articles were identified but only 6 observational studies were included with a total of 872,220 patients (634,672. ACEIs users). The relative risk of lung cancer development among ACEIs users was 1.02 (CI 0.89-1.16) compared to non-ACEIs users. Conclusions: Current systematic review and meta-analysis show no significant association between ACEIs use and the development of lung cancer. The result of our meta-analysis provides further assurance to the health care providers regarding ACEIs use.

This case describes a 47-year-old man with a history of malignant hypertension and end-stage renal disease who had an in-hospital cardiac arrest…

Limited data exist that comprehensively describe the practical management, in-hospital outcomes, healthcare resource utilization, and rates of post-hospital readmission among patients with submassive and massive pulmonary embolism (PE). Consecutive discharges for acute PE were identified from a single health system over 3 years. Records were audited to confirm presence of acute PE, patient characteristics, disease severity, medical treatment, and PE-related invasive therapies. Rates of in-hospital major bleeding and death, hospital length of stay (LOS), direct costs, and hospital readmission are reported. From January 2016 to December 2018, 371 patients were hospitalized for acute massive or submassive PE. In-hospital major bleeding (12.1%) was common, despite low utilization of systemic thrombolysis (1.8%) or catheter-directed thrombolysis (3.0%). In-hospital death was 10-fold higher among massive PE compared to submassive PE (36.6% vs 3.3%, p < 0.001). Massive PE was more common during hospitalizations not primarily related to venous thromboembolism, including hospitalizations primarily for sepsis or infection (26.8% vs 8.2%, p = 0.001). Overall, the median LOS was 6.0 days (IQR, 3.0–11.0) and the median standardized direct cost of admissions was $10,032 (IQR, $4467–$20,330). Rates of all-cause readmission were relatively high throughout late follow-up but did not differ between PE subgroups. Despite low utilization of thrombolysis, in-hospital bleeding remains a common adverse event during hospitalizations for acute PE. Although massive PE is associated with high risk for in-hospital bleeding and death, those successfully discharged after a massive PE demonstrate similar rates of readmission compared to submassive PE into late follow-up.

INTRODUCTION: An NSAID is present in about 8% of all prescriptions written by primary care physicians. Among GI-related adverse drug events, 23.5% were related to NSAIDs, 45% were considered avoidable. Risk factors associated with peptic ulcer disease include: History of peptic ulcer or ulcer bleeding, positive status of H Pylori, age (>65 years), Concomitant use of warfarin, steroids, anti-platelets. Study in France, showed that gastroprotection was not prescribed in 16% of patients on NSAIDs and risk factors for GI toxicity. Misoprostol and PPI therapy are proved to reduce the risk of GI toxicity. Current guidelines recommend that high risk patients should be prescribed COX2 selective agents by itself or non-selective agents with gastroprotection. METHODS: We performed a retrospective chart review of patients at Truman Medical Center Hospital Hill, Missouri who were hospitalized for NSAID-related peptic ulcer disease from the time period of January 2013 till September 2018. We further included only patients with risk factors of peptic ulcer disease and should have been on gastroprotective agents prior to presentation. RESULTS: Our sample included 81 patients hospitalized for NSAID-related peptic disease with risk factors for peptic ulcer disease. Mean age was 58.2 years old. More than half of patients were male (56.8%). Around 47% were smokers and 41% were alcohol current users. Around third of patients were taking aspirin daily and only 13% were on anticoagulation. More than half of patient had History of peptic ulcer (52%) and 38% had history of bleeding ulcer. Only 44.4% of our patients were on gastroprotective agents prior to presentation. Significant portion of our sample presented with ulcer complication (i.e., bleeding, perforation) at 74.1% (60/81). About 60% of patient were anemic at presentation. 31% of patients presented with significant bleeding requiring more than 2 units of packed RBC. Gastroprotective agent prescription prior to presentation was significantly associated with aspirin use (P-value 0.038), anticoagulation (P-value 0.023), Hx coronary artery disease (P-value 0.023), history of peptic ulcer in the past (P-value 0.002) and anemia (P-value 0.003). CONCLUSION: Significant portion of patients who were hospitalized with peptic ulcer disease complications were not on gastroprotective agents although indicated. Risk stratification and PPI prescription when appropriate should be implemented more aggressively in outpatient setting.

INTRODUCTION: Advanced liver fibrosis is an important predictor of liver disease progression and mortality, and current guidelines recommend screening for complications of cirrhosis once patients develop F3 fibrosis. Our study looked into patients with stage 3 (F3) fibrosis on liver biopsy and who had EGD subsequently for screening for varices. METHODS: We conducted a retrospective review of the patients who had a liver biopsy between 1/1/2017 to 10/1/2018 in our tertiary care institution. It was determined how many of the patients with F3 fibrosis underwent EGD and the results of those investigations are presented here. Furthermore, laboratory findings as well as risk factors for cirrhosis were analyzed among the patients with F3 fibrosis. RESULTS: A total of 18 patients were found who had a liver biopsy as part of work up for underlying liver pathology. All of the 18 patients had F3 stage fibrosis and underwent an EGD subsequently. None of these patients had any evidence of portal hypertension evidenced by varices. Only 44.4% (n = 8) of the patients had underlying transaminitis. All of them had normal serum creatinine and only 1 patient had underlying coagulopathy with an elevated INR of 1.9. Only 5 patients were actively drinking alcohol. None of these patients had underlying Hepatitis C or Hepatitis B infection. CONCLUSION: Our case series concludes that screening of F3 fibrosis may not be of any benefit for patients irrespective of the cause of their advanced fibrosis. Larger studies would be needed to prove this is the case as this study is limited by its retrospective nature and small number of subjects.