Dani Babbel, MD

Background: Acute cholangitis (AC) in its most severe form is associated with a high mortality rate. Most patients respond to medical management involving intravenous hydration and antibiotics, though a sizable portion require biliary drainage. Current guidelines advocate for urgent drainage depending on the severity of AC, though do not specify optimal timing. Existing literature is conflicting on when ERCP should ideally be done for AC.

Study design: Systematic review and meta-analysis.

Setting: Literature search involving PubMed, Medline, and Embase databases.

Synopsis: Nine studies with 7,534 patients were included in the final meta-analysis. Emergent ERCP was associated with a lower in-hospital mortality (IHM; odds ratio, 0.52; 95% confidence interval, 0.28-0.98) and shorter length of stay (LOS; mean difference, –2.87 days; 95% CI, –1.55 to –4.18), compared to urgent ERCP. The IHM mortality difference was true for both patients with severe AC (as defined by evidence of end-organ dysfunction) and mild-moderate AC. There was a trend toward lower 30-day mortality in patients who underwent emergent ERCP, though it did not reach statistical significance.

The studies included in the analysis were observational studies, so no causal relationship can be established. Only two of the nine studies reported outcome differences stratified by severity of presentation. Etiology of the AC was inconsistently reported amongst studies.

Bottom line: Emergent ERCP appears to be associated with reduced mortality and LOS in patients presenting with AC, though larger randomized controlled trials are needed to better delineate the optimal timing for biliary drainage in these patients.

Citation: Iqbal U et al. Emergent versus urgent ERCP in acute cholangitis: A systematic review and meta-analysis. Gastrointes Endosc. 2019 Oct 16. doi: 10.1016/j.gie.2019.09.040.

Dr. Babbel is a hospitalist and assistant professor of medicine at the University of Utah, Salt Lake City.

Background: Acute cholangitis (AC) in its most severe form is associated with a high mortality rate. Most patients respond to medical management involving intravenous hydration and antibiotics, though a sizable portion require biliary drainage. Current guidelines advocate for urgent drainage depending on the severity of AC, though do not specify optimal timing. Existing literature is conflicting on when ERCP should ideally be done for AC.

Study design: Systematic review and meta-analysis.

Setting: Literature search involving PubMed, Medline, and Embase databases.

Synopsis: Nine studies with 7,534 patients were included in the final meta-analysis. Emergent ERCP was associated with a lower in-hospital mortality (IHM; odds ratio, 0.52; 95% confidence interval, 0.28-0.98) and shorter length of stay (LOS; mean difference, –2.87 days; 95% CI, –1.55 to –4.18), compared to urgent ERCP. The IHM mortality difference was true for both patients with severe AC (as defined by evidence of end-organ dysfunction) and mild-moderate AC. There was a trend toward lower 30-day mortality in patients who underwent emergent ERCP, though it did not reach statistical significance.

The studies included in the analysis were observational studies, so no causal relationship can be established. Only two of the nine studies reported outcome differences stratified by severity of presentation. Etiology of the AC was inconsistently reported amongst studies.

Bottom line: Emergent ERCP appears to be associated with reduced mortality and LOS in patients presenting with AC, though larger randomized controlled trials are needed to better delineate the optimal timing for biliary drainage in these patients.

Citation: Iqbal U et al. Emergent versus urgent ERCP in acute cholangitis: A systematic review and meta-analysis. Gastrointes Endosc. 2019 Oct 16. doi: 10.1016/j.gie.2019.09.040.

Dr. Babbel is a hospitalist and assistant professor of medicine at the University of Utah, Salt Lake City.

Background: Acute cholangitis (AC) in its most severe form is associated with a high mortality rate. Most patients respond to medical management involving intravenous hydration and antibiotics, though a sizable portion require biliary drainage. Current guidelines advocate for urgent drainage depending on the severity of AC, though do not specify optimal timing. Existing literature is conflicting on when ERCP should ideally be done for AC.

Study design: Systematic review and meta-analysis.

Setting: Literature search involving PubMed, Medline, and Embase databases.

Synopsis: Nine studies with 7,534 patients were included in the final meta-analysis. Emergent ERCP was associated with a lower in-hospital mortality (IHM; odds ratio, 0.52; 95% confidence interval, 0.28-0.98) and shorter length of stay (LOS; mean difference, –2.87 days; 95% CI, –1.55 to –4.18), compared to urgent ERCP. The IHM mortality difference was true for both patients with severe AC (as defined by evidence of end-organ dysfunction) and mild-moderate AC. There was a trend toward lower 30-day mortality in patients who underwent emergent ERCP, though it did not reach statistical significance.

The studies included in the analysis were observational studies, so no causal relationship can be established. Only two of the nine studies reported outcome differences stratified by severity of presentation. Etiology of the AC was inconsistently reported amongst studies.

Bottom line: Emergent ERCP appears to be associated with reduced mortality and LOS in patients presenting with AC, though larger randomized controlled trials are needed to better delineate the optimal timing for biliary drainage in these patients.

Citation: Iqbal U et al. Emergent versus urgent ERCP in acute cholangitis: A systematic review and meta-analysis. Gastrointes Endosc. 2019 Oct 16. doi: 10.1016/j.gie.2019.09.040.

Dr. Babbel is a hospitalist and assistant professor of medicine at the University of Utah, Salt Lake City.

Background: National guidelines recommend CR after CVS. However, neither enrollment in CR nor its benefits have been well described in this population.

Study design: Observational cohort study.

Setting: Enrolled Medicare beneficiaries residing in the United States in 2014.

Synopsis: There were 41,369 Medicare patients who underwent CVS and met the study requirements; of these, 43.2% enrolled in CR programs. Those who had concomitant coronary artery bypass grafting (CABG) surgery or who resided in the Midwest region of the United States were more likely to enroll in CR. Asian, black, and Hispanic patients were less likely to enroll in CR. Enrollment in CR after CVS was associated with a decreased risk of 1-year hospitalization (hazard ratio, 0.66; 95% confidence interval, 0.63-0.69). CR utilization was also associated with a decrease in 1-year mortality after CVS (HR, 0.39; 95% CI, 0.35-0.44).

Enrollment rates in CR after CVS were lower than that of heart transplant patients, but higher than that for patients with systolic heart failure or after CABG. Major study limitations were the lack of generalizability to younger patients because all patients examined were older than 64 years.

Bottom line: Racial and geographic factors influence the rate of enrollment in CR for patients undergoing CVS. All patients should be encouraged to participate in CR after CVS because it is associated with reduced 1-year mortality and risk of hospitalization.

Citation: Patel DK et. al. Association of cardiac rehabilitation with decreased hospitalization and mortality risk after cardiac valve surgery. JAMA Cardiol. 2019 Oct 23. doi: 10.1001/jamacardio.2019.4032.
 

Dr. Babbel is a hospitalist and assistant professor of medicine at the University of Utah, Salt Lake City.

Background: National guidelines recommend CR after CVS. However, neither enrollment in CR nor its benefits have been well described in this population.

Study design: Observational cohort study.

Setting: Enrolled Medicare beneficiaries residing in the United States in 2014.

Synopsis: There were 41,369 Medicare patients who underwent CVS and met the study requirements; of these, 43.2% enrolled in CR programs. Those who had concomitant coronary artery bypass grafting (CABG) surgery or who resided in the Midwest region of the United States were more likely to enroll in CR. Asian, black, and Hispanic patients were less likely to enroll in CR. Enrollment in CR after CVS was associated with a decreased risk of 1-year hospitalization (hazard ratio, 0.66; 95% confidence interval, 0.63-0.69). CR utilization was also associated with a decrease in 1-year mortality after CVS (HR, 0.39; 95% CI, 0.35-0.44).

Enrollment rates in CR after CVS were lower than that of heart transplant patients, but higher than that for patients with systolic heart failure or after CABG. Major study limitations were the lack of generalizability to younger patients because all patients examined were older than 64 years.

Bottom line: Racial and geographic factors influence the rate of enrollment in CR for patients undergoing CVS. All patients should be encouraged to participate in CR after CVS because it is associated with reduced 1-year mortality and risk of hospitalization.

Citation: Patel DK et. al. Association of cardiac rehabilitation with decreased hospitalization and mortality risk after cardiac valve surgery. JAMA Cardiol. 2019 Oct 23. doi: 10.1001/jamacardio.2019.4032.
 

Dr. Babbel is a hospitalist and assistant professor of medicine at the University of Utah, Salt Lake City.

Background: National guidelines recommend CR after CVS. However, neither enrollment in CR nor its benefits have been well described in this population.

Study design: Observational cohort study.

Setting: Enrolled Medicare beneficiaries residing in the United States in 2014.

Synopsis: There were 41,369 Medicare patients who underwent CVS and met the study requirements; of these, 43.2% enrolled in CR programs. Those who had concomitant coronary artery bypass grafting (CABG) surgery or who resided in the Midwest region of the United States were more likely to enroll in CR. Asian, black, and Hispanic patients were less likely to enroll in CR. Enrollment in CR after CVS was associated with a decreased risk of 1-year hospitalization (hazard ratio, 0.66; 95% confidence interval, 0.63-0.69). CR utilization was also associated with a decrease in 1-year mortality after CVS (HR, 0.39; 95% CI, 0.35-0.44).

Enrollment rates in CR after CVS were lower than that of heart transplant patients, but higher than that for patients with systolic heart failure or after CABG. Major study limitations were the lack of generalizability to younger patients because all patients examined were older than 64 years.

Bottom line: Racial and geographic factors influence the rate of enrollment in CR for patients undergoing CVS. All patients should be encouraged to participate in CR after CVS because it is associated with reduced 1-year mortality and risk of hospitalization.

Citation: Patel DK et. al. Association of cardiac rehabilitation with decreased hospitalization and mortality risk after cardiac valve surgery. JAMA Cardiol. 2019 Oct 23. doi: 10.1001/jamacardio.2019.4032.
 

Dr. Babbel is a hospitalist and assistant professor of medicine at the University of Utah, Salt Lake City.