Alcoholic liver disease (ALD), comprising a spectrum of diseases ranging from alcoholic fatty liver disease (AFLD) to advanced ALD (including alcoholic hepatitis, cirrhosis, and cirrhosis complications), 1 is a leading cause of mortality in the United States, with nearly 250 000 deaths attributed to ALD in 2010. 2,3 Overall US clinical burden of ALD remains unclear, perhaps because of lack of a definitive standard for identifying ALD. This study focused on the specific, more well-defined subset of AFLD to estimate national prevalence among US adults.
Aims Alcoholic hepatitis (AH) and alcoholic cirrhosis disproportionately affect ethnic minority and safety-net populations. We evaluate the impact of a hospital’s safety net burden (SNB) on in-hospital mortality and costs among patients with AH and alcoholic cirrhosis. Methods We performed a cross-sectional analysis of 2012–2016 National Inpatient Sample. SNB was calculated as percentage of hospitalizations with Medicaid or uninsured payer status. Associations between hospital SNB and in-hospital mortality and costs were evaluated with adjusted multivariable logistic regression and linear regression models. Results Among 21,898 AH-related hospitalizations, compared to low SNB hospitals (LBH), patients hospitalized in high SNB hospitals (HBH) were younger (44.4 y vs. 47.4 y, P < 0.001) and more likely to be African American (11.3% vs. 7.7%, P < 0.001) or Hispanic (15.4% vs. 8.4%, P < 0.001). AH-related hospitalizations in HBH had a non-significant trend towards higher odds of mortality (OR 1.27, 95% CI 0.98–1.65, P = 0.07) and higher mean hospitalizations costs. Among 108,669 alcoholic cirrhosis-related hospitalizations, patients in HBH were younger (53.3 y vs. 55.8 y, P < 0.001) and more likely to be African American (8.2% vs. 7.3%, P < 0.001) or Hispanic (24.4% vs. 12.0%, P < 0.001) compared to LBH. Compared to alcoholic cirrhosis-related hospitalizations in LBH, mortality was higher among medium SNB (OR 1.10, 95% CI 1.03–1.17, P = 0.007) and HBH (OR 1.07, 95% CI 1.00–1.15, P = 0.05). Mean hospitalization costs were not different by SNB status. Conclusions HBH hospitals predominantly serve ethnic minorities and underinsured/uninsured populations. The higher in-hospital mortality associated HBH particularly for alcoholic cirrhosis patients is alarming given its increasing burden in the USA.
Hepatocellular carcinoma (HCC) is a leading cause of cancer-related deaths worldwide and remains one of the most rapidly rising cancers among the US adults. While overall HCC survival is poor, early diagnosis via timely and consistent implementation of routine HCC surveillance among at-risk individuals leads to earlier tumor stage at diagnosis, which is directly correlated with improved options for potentially curative therapies, translating into improved overall survival. Despite this well-established understanding of the benefits of HCC surveillance, surveillance among cirrhosis patients remains suboptimal in a variety of practice settings. While the exact reasons underlying the unacceptably low rates of routine HCC surveillance are complex, it likely reflects multifactorial contributions at the patient, provider, and health care system levels. Furthermore, these multilevel challenges affect ethnic minorities disproportionately, which is particularly concerning given that ethnic minorities already experience existing barriers in timely access to consistent medical care, and these populations are disproportionately affected by HCC burden in the United States. In this review, we provide an updated evaluation of the existing literature on rates of HCC surveillance in the United States. We specifically highlight the existing literature on the impact of patient-specific, provider-specific, and health care system-specific factors in contributing to challenges in effective implementation of HCC surveillance.
A 70 year old man, a non-smoker, presented with a painful swelling over the right sternoclavicular joint and low grade continuous fever for a period of two months. The patient had been empirically started on antituberculous therapy on the suspicion of tuberculous osteomyelitis, but his fever and swelling persisted.On clinical examination, a hard and tender swelling was present over the right sternoclavicular joint. The swelling was fixed to the underlying bone, but not to the overlying skin. The patient did not have any skin lesions. Examination of his respiratory system revealed no abnormality. Examination of other systems was unremarkable.Blood investigations showed a haemoglobin concentration of 160 g/l. The total white blood cell count was 10.5 × 10 9 /l with 72% polymorphonuclear cells, 26% lymphocytes, and 2% eosinophils. ELISA testing for HIV infection was negative. Other haematological and biochemical parameters were within normal limits.Fine needle aspiration cytology of the swelling showed a few red blood cells, polymorphonuclear cells, lymphocytes, and a few epithelioid cells in a necrotic background. No granulomas or giant cells were seen.Computed tomography (plain and contrast) of the thorax revealed a right sternoclavicular and first costoclavicular joints arthropathy with subchondral sclerosis and abnormal periarticular soft tissue mass. A technetium-99 bone scan was done (shown in fig 1) which revealed the diagnosis. Questions(1) What does the bone scan show? (2) What is the diagnosis and name the associated syndrome.
INTRODUCTION: Recurrent hospitalizations due to alcoholic hepatitis (AH) contribute to significant morbidity, mortality, and economic burden. Underserved safety-net populations and ethnic minorities are disproportionately affected by recurrent AH hospitalizations. We aim to evaluate the impact of a hospital’s safety-net burden (SNB) on in-hospital mortality using a large U.S. inpatient database with a focus on ethnicity-specific disparities. METHODS: We retrospectively evaluated the 2012-2014 National Inpatient Sample database, the largest publicly available all-payer inpatient healthcare database in the U.S., to evaluate the impact of hospital SNB on in-hospital mortality among adults with AH. Hospital SNB was defined as the percentage of AH hospitalizations per hospital with Medicaid or uninsured payer status and was categorized into 3 groups (low SNB-lowest quartile, medium SNB-2nd and 3rd quartile, high SNB- 4th quartile). AH hospitalizations were identified using ICD-9 codes. Sex- and ethnicity-specific differences by SNB were evaluated with chi-squared testing. The odds of being hospitalized at a high SNB hospital (vs. low/medium) and the impact of SNB on in-hospital mortality were evaluated using adjusted multivariate logistic regression. RESULTS: Among 12,519 AH-related hospitalizations (63.2% male, 66.9% non-Hispanic white, 9.9% African American, 11.8% Hispanic), 30.6% were low SNB, 46.3% were medium SNB, and 23.0% were high SNB. Compared to men with AH, women were significantly more likely to be hospitalized at high SNB hospitals (24.1% vs. 22.4%; OR 1.13, 95% CI 1.03-1.25, P < 0.01). Compared to non-Hispanic whites, African Americans (29.6% vs. 21.1%; OR 1.31, 95% CI 1.10-1.57, P < 0.001) were significantly more likely to be hospitalized at a high SNB hospital, and Hispanics demonstrated a trend towards more likely to be hospitalized at a high SNB hospital (29.2% vs. 21.1%; OR 1.18, 95% CI 0.99-1.42, P = 0.067). Overall in-hospital mortality among AH-related hospitalizations was 2.63%. On multivariate regression, there was a trend towards higher odds of in-hospital mortality for AH-related hospitalizations at high SNB hospitals vs. low/medium SNB hospitals (2.78% vs. 2.58%; OR 1.41, 95% CI 0.95-2.08, P = 0.09). CONCLUSION: Among hospitalized adults with AH in the U.S., women and ethnic minorities were significantly more likely to be cared for at high SNB hospitals. High SNB hospitals demonstrated a trend towards higher in-hospital mortality for AH patients.
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