The prevalence of dysplasia in the ileoanal pouch following restorative proctocolectomy for ulcerative colitis with associated dysplasia

Aim A recent systematic review indicated that dysplasia present before restorative proctocolectomy is a predictor of subsequent dysplasia in the pouch. This prospective study was carried out to assess the prevalence of dysplasia in the ileal pouch in patients having RPC for ulcerative colitis with co‐existing dysplasia in the operation specimen. Method Eligible patients were invited for a surveillance endoscopy. The afferent and blind efferent ileal loop, ileoanal pouch and rectal cuff were examined by standard endoscopy using a dye‐spray technique with methylene blue. Mucosal abnormalities were biopsied and random biopsies were taken from the afferent and blind ileal loop, pouch and rectal cuff. Results Fourty‐four patients (25 male, mean 49 years) underwent pouch endoscopy at a mean interval from RPC of 8.6 years. Dysplasia was detected in two (4.5%) patients. In one, low‐grade dysplasia was found in the rectal cuff and in the other low‐grade dysplasia was detected in random biopsies from the pouch and the efferent ileal loop. Conclusion This prospective pouch‐endoscopy study detected dysplasia in < 5% of patients over nearly 10 years. The benefit of routine surveillance for dysplasia in the pouch is uncertain, as the significance of low‐grade dysplasia in the pouch is not clear.     

Early ileal pouch anal anastomosis for ulcerative colitis in children: Similar outcome to delayed pouch construction despite higher comorbidity

BackgroundChildren with ulcerative colitis (UC) may undergo a staged approach for restorative proctocolectomy and ileal pouch anal anastomosis (IPAA). Previous studies in adults suggest a decreased morbidity with delayed pouch creation, but pediatric studies are limited. We compared outcomes for delayed versus early pouch construction in children.MethodsPatients with UC undergoing IPAA were selected from the National Surgical Quality Improvement Program Pediatric database from 2012 to 2018. Patients were categorized as early (2-stage) or delayed (3-stage) pouch construction based on Current Procedural Terminology codes. Our primary outcome was any adverse event. We used a multivariable logistic regression model to assess the relationship between timing of pouch creation and adverse events.ResultsWe identified 371 children who underwent IPAA: 157 (42.3%) had early pouch creation and 214 (57.6%) had a delayed pouch. Those with an early pouch creation were more likely to have exposure to immunosuppressants (11% vs. 5%, p = 0.017) and steroids (30% vs. 10%, p < 0.001) at the time of surgery. After controlling for patient characteristics, there were no significant differences in adverse events between the two groups.ConclusionsChildren undergoing early pouch creation have increased exposure to steroids and immune suppressants; nevertheless, no differences in adverse events were identified.Level of evidenceII     

The changing face of mild head injury: Temporal trends and patterns in adolescents and adults from 1997 to 2008

Objective

To explore the temporal trend of incidence, causes of injury and main characteristics of adolescent and adult subjects with mild head injury (MHI).

Design

This study had a retrospective design.

Setting

The study was conducted in a longitudinal database of an Italian Emergency Department (ED).

Participants

The study comprised 19 124 consecutive subjects who visited and were managed within 24 h from the event, according to a predefined protocol for MHI from 1997 to 2008.

Main outcome measures

Incidence, demography, cause of injury and characteristics of any post-traumatic intracranial lesion within 7 days from MHI.

Results

The number of subjects with MHI decreased from 2019 per year (1997-1999) to 1232 per year (2006-2008; P for linear trend <0.001), without differences in the total number of subjects visited in the ED. The decrease was observed in all age-decades, in particular, in subjects in the age ranges of 20-29 and 30-39 years. Over time, the age of subjects with MHI lost a bimodal distribution, and the mean age increased from 43 (25-69) years (median (interquartile range)) in 1997-1999 to 56 (33-78) years in 2006-2008 (P < 0.001). The prevalence of falls increased from 36.5% to 55.0%, whereas crashes fell from 53.2% to 31.9%. The incidence of subdural haematoma (SDH) and epidural haematoma (EDH) did not change over time, whereas traumatic subarachnoid haemorrhage (t-SAH) and intra-cerebral haematoma/brain contusion (ICH) increased (from 0.7% to 1.9% and from 2.5% to 3.2%; P for trend: <0.001 for both.

Conclusions

The incidence and the clinical characteristics of MHI subjects are rapidly changing in our setting. These data need to be considered in defining the effectiveness of preventive measures and deciding resource allocation.     

Long-term survival and five year hospital resource usage following traumatic brain injury in Scotland from 1997 to 2015: A population-based retrospective cohort study

Background

It is unclear if traumatic brain injury (TBI) results in excess mortality compared with head injury without injury to neural structures (HI). Because TBI populations exhibit significant demographic differences from uninjured populations, to determine the effect of TBI on survival, it is essential that a similarly injured control population be used. We aimed to determine if survival and hospital resource usage differ following TBI compared with HI.

Elective surgery for diverticular disease in U.S. veterans: A VASQIP study of national trends and outcomes from 2004 to 2018

BackgroundTreatment for diverticular disease has evolved over time. In the United States, there has been a trend towards minimally invasive surgical approaches and fewer postoperative complications, but no study has investigated this subject in the Veterans Health Administration.MethodsThis retrospective review identified patients undergoing elective surgery for diverticular disease from 2004 to 2018. Demographics, comorbidities, operative approach, rates of ostomy creation, and 30-day outcomes were compared. The 15-year time period was divided into 3-year increments to assess changes over time.Results4198 patients were identified. Complication rate decreased significantly over time (28.1%–15.7%, p < 0.001), as did infectious complications (21.5–6.3%, p < 0.001). Median hospital length-of-stay decreased from 7 to 5 days (p < 0.001). Rates of laparoscopic surgery increased over time (17.7%–48.1%, p < 0.001).ConclusionsIncreased utilization of laparoscopy in veterans undergoing elective surgery for diverticular disease coincided with fewer complications and a shorter length-of-stay. These trends mirror outcomes reported in non-veterans.     

Increase in hospital admissions for childhood asthma: trends in referral, severity, and readmissions from 1970 to 1985 in a health region of the United Kingdom.

Admissions to hospital for childhood asthma have continued to increase, but the reasons are unknown. Because the incidence of acute asthmatic attacks in the community greatly exceeds the admission rate, this increase could be a result of changes in medical practice shifting the balance of care towards the hospital without there being any underlying change in morbidity. In the South West Thames Region (population 2.9 million) over the eight years 1978-85 the number of hospital admissions among those aged 0-4 and 5-14 rose by 186% and 56%. A random sample of case notes from all hospitals in the region was examined for evidence of changes in mode of referral, severity on admission (duration of episode, vital signs on admission), and readmission ratio. The findings indicate that there has been no reduction in severity on admission or increase in readmission rate since 1978. The findings for the 5-14 age group contrast with those from an earlier study (1970-8) in the same region, in which a substantial increase in self referral was observed together with an increase in readmissions and a reduction in the duration of the attack; pulse and respiration rates on admission have, however, remained unchanged over the 16 year period. Overall, these findings indicate that the increase in admissions cannot be satisfactorily explained by changes in medical practice alone and may be due to an increase in the number of asthmatic children experiencing severe attacks. This points to a change in the epidemiology of childhood asthma.     

The difference in the outcome of surgery for traumatic extradural hematoma between patients who are admitted directly to the neurosurgical unit and those referred from another hospital

In this study of 120 cases that had surgery for traumatic extradural hematoma (EDH) at Frenchay Hospital, England, between 1975 and 1987, the author attempts to outline the influence on the outcome of surgery for EDH of whether the patient is admitted directly to the neurosurgical unit or via another hospital. Only 15% of the patients were admitted directly, while 85% were referred. The results show that although the directly admitted patients included significantly more unconscious patients exhibiting clinical signs of herniation, their outcome was not significantly worse. Therefore, in support of previous reports, it is recommended that all head injured patients be admitted to the primary care of neurosurgeons.     

Impact of bone morphogenetic proteins on frequency of revision surgery,use of autograft bone,and total hospital charges in surgery for lumbar degenerative disease: review of the Nationwide Inpatient Sample from 2002 to 2008

Background contextBone morphogenetic proteins (BMPs) were developed with the goal of improving clinical outcomes through the promotion of bony healing and reducing morbidity from iliac crest bone graft harvest.PurposeTo complete a population-based assessment of the impact of BMP on use of autograft, rates of operative treatment for lumbar pseudoarthrosis, and hospital charges.Study designNationwide Inpatient Sample (NIS) retrospective cohort assessment of 46,452 patients from 2002 to 2008.Patient sampleAll patients who underwent lumbar arthrodesis procedures for degenerative spinal disease.Outcome measuresUse of BMP, revision surgery status as a percentage of total procedures, and autograft harvest in lumbar fusion procedures completed for degenerative diagnoses.MethodsDemographic and geographic/practice data, hospital charges, and length of stay of all NIS patients with thoracolumbar and lumbosacral procedure codes for degenerative spinal diagnoses were recorded. Codes for autograft harvest, use of BMP, and revision surgery were included in multivariable regression analysis.ResultsThe assessment found 46,452 patients from 2002 to 2008 undergoing thoracolumbar or lumbar arthrodesis procedures for degenerative disease. Assuming a representative sample, this cohort models more than 200,000 US patients. There was steady growth in lumbar spine fusion and in the use of BMP. The use of BMP increased from 2002 to 2008 (odds ratio [OR], 1.50; 95% confidence interval [CI], 1.48–1.52). Revision procedures decreased over the study period (OR, 0.94; 95% CI, 0.91–0.96). The use of autograft decreased substantially after introduction of BMP but then returned to baseline levels; there was no net change in autograft use from 2002 to 2008. The use of BMP correlated with significant increases in hospital charges ($13,362.39; standard deviation±596.28, p<.00001). The use of BMP in degenerative thoracolumbar procedures potentially added more than $900 million to hospital charges from 2002 to 2008.ConclusionsThere was an overall decrease in rates of revision fusion procedures from 2002 to 2008. Introduction of BMP did not correlate with decrease in use of autograft bone harvest. Use of BMP correlated with substantial increase in hospital charges. The small decrease in revision surgeries recorded, combined with lack of significant change in autograft harvest rates, may question the financial justification for the use of BMP.