Chills During Hemodialysis: Prediction and Prevalence of Bacterial Infections – A Retrospective Cohort Study

Introduction

Chills are a complication of patients undergoing hemodialysis. The rate of infection among hemodialysis patients presenting with chills is not well established, and empirical broad-spectrum antibiotics are usually the rule.

Influence of Gender on Epidemiology and Clinical Manifestations of Sarcoidosis: A Population-Based Retrospective Cohort Study 1976–2013

Purpose

The influence of ethnicity on epidemiology and clinical manifestations of sarcoidosis is well recognized. However, data on the role of sex are limited.

Methods

The current study utilized the resource of the Rochester Epidemiology Project to identify all residents of Olmsted County, Minnesota, United States, with new diagnosis of sarcoidosis from 1976 to 2013. Diagnosis was verified by medical record and histopathological report review.

Results

345 incident cases of sarcoidosis were identified: 174 (50 %) were female and 171 (50 %) were male. The age at diagnosis was significantly higher among females than males (48.3 vs. 42.8 years; p < 0.001). Intra-thoracic disease was seen in the great majority of patients (98 % among females and 96 % among males; p = 0.50). However, pulmonary symptoms were significantly more frequent among males than females (51 vs. 36 %; p = 0.006). The frequency of individual extra-thoracic organ involvement was not significantly different between females and males except for cutaneous involvement and uveitis that were significantly more common among females (6 vs. 1 % for uveitis, p = 0.012 and 25 vs. 12 % for cutaneous involvement, p = 0.002). The frequency of elevate angiotensin-converting enzyme level and hypercalcemia was not significantly different between the two sexes.

Conclusions

Females tended to be older at the age they developed sarcoidosis, and had more uveitis and cutaneous involvement than males.

     

Smoking Impairs Rectal Mucosal Bloodflow—A Pilot Study: Possible Implications for Transanal Advancement Flap Repair

ABSTRACT Transanal advancement flap repair has been advocated as the treatment of choice for transsphincteric perianal fistulas, because it enables the healing of almost all fistulas without sphincter damage and consequent continence disturbance. After initial promising reports, recently less favorable results have been reported. It remains unclear why there is such a large variety in the reported healing rates. Recently, it has been suggested that impaired wound healing caused by a diminished rectal mucosal perfusion in patients who smoke may lead to the breakdown of the advancement flap in patients undergoing flap repair for perianal fistulas. This study was designed to investigate the difference in blood flow in rectal mucosa between patients who smoke and those who do not smoke. Furthermore, we assessed the impact of the creation of a mucosa advancement flap and the difference in blood flow in the flap between smoking and nonsmoking patients. Between July 2001 and July 2002, 23 consecutive patients (19 males; median age, 46 (range, 26–69) years) with a perianal fistula of cryptoglandular origin underwent surgery for a perianal fistula. Among them were 13 patients who smoked cigarettes. All patients underwent intraoperative laser Doppler flowmetry. Median blood flow before transanal advancement flap repair was 35 (range, 8–70) volts in patients who did not smoke. In patients who smoked the median blood flow before transanal advancement flap repair was 18 (range, 7–35) volts. Blood flow was significantly lower in patients who smoked (P = 0.018; Mann-Whitney). In conclusion, it seems likely that impaired wound healing caused by a diminished rectal mucosal perfusion is a contributing factor in the breakdown of advancement flaps in patients who smoke cigarettes.Read at the meeting of The American Society of Colon and Rectal Surgeons, New Orleans, Louisiana, June 21 to 26, 2003.Reprints are not available.     

Rate of Progression of Aortic Stenosis and its Impact on Outcomes in Patients With Radiation-Associated Cardiac Disease: A Matched Cohort Study

Objectives

The aim of this study was to study differences in progression of aortic stenosis (AS) in patients with mediastinal radiotherapy (XRT)-associated moderate AS versus a matched cohort during the same time frame, and to ascertain need for aortic valve replacement (AVR) and longer-term survival.

Rectocele or stool quality: what matters more for symptoms of obstructed defecation?

Background  

Rectocele is a common condition seen in patients presenting with symptoms of obstructed defecation. We designed a prospective observational study to investigate the relative roles of rectocele and stool quality for such symptoms.     

Transanal electroresection of small rectal cancer: A sole treatment?

PURPOSE: Because abdominoperineal resection is associated with high morbidity and mortality, there is interest in local treatment of distal rectal carcinoma. Our technique of transanal electroresection ensures full-thickness tumor excision and complete histopathologic examination. METHODS: From July 1983 to July 1990, 227 patients underwent surgery. Criteria for cure were no extramural invasion (61 exclusions) and negative margins (34 exclusions). Six patients underwent postoperative radiotherapy and, therefore, were excluded. RESULTS: Among those included were 126 patients (66 men), who had a mean age of 68±11 (median, 68) years. Median tumor size was 35 mm. Distance from anal verge was less than 6 cm for 68 percent and 6–10 cm for 30 percent of patients. Deepest layer invaded was as follows: submucosa (T1), 35 percent; inner muscular layer (T2a), 42 percent; outer muscular layer (T2b), 23 percent. There was one postoperative death. Immediate postoperative course was uneventful for 94 percent of patients; at long-term, five cases of incontinence and two stenoses were noted (6 patients). Median follow-up was 88 (1–137) months. Global survival was 71 and 46 percent, and cancer-specific survival was 85 and 81 percent at 5 and 10 years, respectively. Of 35 patients (28 percent) with recurrence, 24 were treated. Global survival after recurrence was 72 and 50 percent at one and two years, respectively. The only pejorative prognostic factors isolated for survival or recurrence were mucinous contingent and intratumoral vascular invasion. CONCLUSION: Results of local treatment for rectal carcinoma in selected patients are favorable (5-year specific survival, 85 percent). Decisive prognostic factors are seldom isolated, but some patients would benefit from an adjuvant therapy.     

Calprotectin — A Marker of Mortality in COPD? Results from a Prospective Cohort Study

Abstract

Calprotectin comprises more than 45% of the cytosolic content of neutrophil granulocytes. Because pathogenesis, disease activity and disease progression in COPD are believed to be partly dependent of neutrophil driven inflammation we decided to investigate whether plasma level of calprotectin (p-calprotectin) was associated with all-cause mortality in patients with COPD. We measured p-calprotectin in blood samples from 460 patients with moderate to very severe COPD in stable phase. Patients were stratified into three groups according to p-calprotectin level. Outcome measure was all-cause mortality. Analyses were adjusted for factors known to influence mortality using a Cox regression analysis. We found a time dependent correlation between p-calprotectin levels and mortality during the first 5 years of follow-up. Increasing levels of p-calprotectin were associated with concomitant increases in mortality from HR 1.56 (CI 95%: 1.03 –2.38) at calprotectin between 100 –200 ng/ml to HR 2.02 (CI 95%: 1.27-3.19) at calprotectin >200 ng/ml. P-calprotectin could be a useful marker of all-cause mortality in patients suffering from moderate to very severe COPD.     

Factors Predicting Abnormal Liver Function Tests Induced by Graves’ Disease Alone: A Retrospective Cohort Study

Abnormal liver function tests (LFTs) are often observed in patients with Graves’ disease (GD). To date, there are limited data demonstrating the factors or biochemical indexes contributing to LFT abnormalities in this patient population. The aim of this study was to explore factors predicting abnormal LFTs induced by GD alone. This was a retrospective study of 289 consecutive cases of newly diagnosed and untreated patients with GD. All patients were divided into abnormal LFTs (group A) and normal LFTs (group B). In total, 205 (70.9%) cases were found to have at least 1 LFT abnormality. Among them, the frequencies of ALT, AST, ALP, γ-GTP, TBIL and DBIL abnormalities were 52.7%, 32.2%, 45.9%, 38.5%, 23.4%, 2.9%, respectively, and the number of patients with 1 to 6 hepatic variable abnormalities were 89, 64, 30, 16, 6 and 0, respectively. Logistic regression analysis was used to determine predictive factors contributing to abnormal LFTs. A receiver operating characteristic (ROC) curve was also plotted to verify the accuracy of predictors. In the univariate analysis, patients in group A had significantly higher FT3 concentration (37.5 vs 33.4 pmol/L, P = 0.009), FT4 concentration (85.7 vs 77.4 pmol/L, P = 0.002) and TRAb level (22.2 vs 17.4 IU/L, P < 0.001) when compared with those in group B. Binary logistic regression analysis identified higher FT4 concentration (odds ratio [OR]: 1.017, 95% confidence interval [CI]: 1.005–1.030, P = 0.006) and higher TRAb value (OR: 1.038, 95% CI:1.013–1.064, P = 0.003) to be independent risk factors predicting abnormal LFTs. The optimal cutoffs for FT4 and TRAb to predict abnormal LFTs were 75 pmol/L and 15 IU/L, respectively, based on ROC analysis.     

Laparoscopic resection of pancreatic adenocarcinoma: Dream or reality?

Laparoscopic pancreatic surgery is in its infancy despite initial procedures reported two decades ago. Both laparoscopic distal pancreatectomy(LDP) and laparoscopic pancreaticoduodenectomy(LPD) can be performed competently; however when minimally invasive surgical(MIS) approaches are implemented the indication is often benign or low-grade malignant pathologies. Nonetheless, LDP and LPD afford improved perioperative outcomes, similar to those observed when MIS is utilized for other purposes. This includes decreased blood loss, shorter length of hospital stay, reduced post-operative pain, and expedited time to functional recovery. What then is its role for resection of pancreatic adenocarcinoma? The biology of this aggressive cancer and the inherent challenge of pancreatic surgery have slowed MIS progress in this field. In general, the overall quality of evidence is low with a lack of randomized control trials, a preponderance of uncontrolled series, short follow-up intervals, and small sample sizes in the studies available. Available evidence compiles heterogeneous pathologic diagnoses and is limited by case-by-case follow-up, which makes extrapolation of results difficult. Nonetheless, shortterm surrogate markers of oncologic success, such as margin status and lymph node harvest, are comparable to open procedures. Unfortunately disease recurrence and long-term survival data are lacking. In this review we explore the evidence available regarding laparoscopic resection of pancreatic adenocarcinoma, a promising approach for future widespread application.     

Does Diffuse Esophageal Spasm Progress to Achalasia? A Prospective Cohort Study

Diffuse esophageal spasm (DES) and achalasia share both clinical and manometric characteristics. Some reports support the notion of progression of DES to achalasia. However, there are currently no prospective data in support of this theory. To assess prospectively the rate of manometric progression of DES to achalasia. Manometry tracings of DES patients diagnosed between 1992 and 2003 were independently reviewed blindly and agreed on by two esophageal experts. Patients with DES who agreed to undergo repeat esophageal manometry constituted the study cohort. Follow-up manometry tracings were evaluated blindly and independently by the same two interpreters to determine the rate of manometric progression to achalasia. Predictors of manometric progression were assessed. A total of 32 patients were diagnosed with DES between 1992–2003. Twelve patients (9M/3F; median age 62 years) agreed to participate and underwent second manometry (mean ± SD follow-up of 4.8± 3.4 years). Achalasia was diagnosed on follow-up manometry in one patient (8%), seven (58%) patients continued to have DES, three (25%) had normal motility, and one (8%) had nutcracker esophagus. There were no predictors of progression to achalasia based on the initial manometry parameters. A subgroup of DES patients with initial low esophageal body amplitude developed increase in esophageal simultaneous contractions on follow-up similar to the patient who evolved to achalasia. Following were the results. 1) Progression from DES to achalasia is uncommon. 2) DES patients with low esophageal body amplitude may develop increased simultaneous contractions over time. 3) DES remains an elusive diagnosis clinically and manometrically.     

MELD Scores and Child–Pugh Classifications Predict the Outcomes of ERCP in Cirrhotic Patients With Choledocholithiasis: A Retrospective Cohort Study

Endoscopic retrograde cholangiopancreatography (ERCP) is challenging in cirrhotic patients with choledocholithiasis. We evaluated the safety and efficacy of ERCP in cirrhotic patients with choledocholithiasis and accessed the model for end-stage liver disease (MELD) scores and Child–Pugh classifications for prediction of morbidity and mortality.From January 2000 to June 2014, 77 ERCP operations were performed in cirrhotic patients with choledocholithiasis. The data on operative complications were analyzed. MELD scores and Child–Pugh classifications were calculated and associated with operative outcomes and survival. Telephone follow-up was performed to determine survival situations.No death, perforation, or hemorrhage caused by gastroesophageal varices occurred as a result of the procedure. The rate of intraoperative hemorrhage was 13.0%, and the rate of postoperative morbidity was 27.3% including hemorrhage (18.2%), post-ERCP pancreatitis (6.1%), aggravated infection of the biliary tract (1.3%), hepatic encephalopathy (1.3%), and respiratory failure (1.3%). Four (5.2%) patients had both intraoperative and postoperative hemorrhage. Receiver operating characteristic analysis identified MELD scores higher than 11.5 as the best cutoff value for predicting complication incidence (95% confidence interval = 0.63–0.87). Twenty-one (44.7%) patients with a MELD score above 11.5 developed a complication, and 3 (10%) patients who had a lower MELD score developed a complication (P = 0.001). Both MELD score and Child–Pugh classification had prognostic value in patients without jaundice, although sex may result in different prognostic values based on the 2 scores. The rate of complications was not significantly different among patients with different Child–Pugh classifications. No significant difference was observed in patients with different MELD scores or Child–Pugh classifications in terms of median survival times.ERCP is an effective and safe procedure in cirrhotic patients with choledocholithiasis. MELD scores can predict the risk of operative complications, but Child–Pugh classification system scores do not predict the risk of complications.     

Laparoscopic Repair of Parastomal Hernias: A Single Surgeon’s Experience in 66 Patients

Introduction The repair of parastomal hernias represents a surgical problem with high complication and failure rates. A basic principle is the necessity of mesh-based techniques. The study was performed to evaluate a laparoscopic approach, primarily based on the intraperitoneal on lay mesh technique. Methods Sixty-six patients with a symptomatic parastomal hernia were enrolled in the prospective study between November 1999 and February 2006. After complete adhesiolysis, the mesh was introduced to cover the fascial defect of the hernia and the original midline incision. In special cases, a two-mesh technique was used. First, an incised mesh was placed around the stoma sling. The second mesh was used to cover the abdominal wall with the first mesh; the stoma sling was placed between the two meshes for at least 5 cm. Results The two-mesh technique proved to be superior in terms of recurrence rate especially in cases with a lateral fascial defect. Conclusions The laparoscopic repair of parastomal hernias is a surgically challenging procedure with promising results when using the two-mesh technique. Therefore, two meshes should be used in all cases of parastomal hernias. Polyvinylidene fluoride was revealed to be the most suitable material for the sandwich repair in terms of possible ingrowth and infection resistance.     

Do Alcohol Misuse,Smoking, and Depression Vary Concordantly or Sequentially? A Longitudinal Study of HIV-Infected and Matched Uninfected Veterans in Care

We analyzed temporal patterns of alcohol misuse, smoking, and depression among veterans in care to determine whether these conditions vary concordantly or sequentially. Using the Veterans Aging Cohort Study, harmful alcohol use (AUDIT-C ≥ 4), current smoking, and depression (PHQ-9 ≥ 8), were measured. In regression analyses, predictors included each outcome condition at baseline, the other two conditions in the same survey, the other two conditions in the immediately preceding survey, number of years since enrollment, and HIV status. We found that current smoking and depression were more common among HIV infected individuals. Harmful alcohol use was more common among uninfected individuals. Temporal analyses suggested a concurrent pattern: each condition was associated with the other two conditions (p < 0.03, OR 1.12–1.66) as well as with the prior presence of the same condition (p < 0.0001; OR 6.38?22.02). Smoking was associated with prior depression after controlling for current depression (OR 1.16; p = 0.003). In conclusion, alcohol misuse, smoking, and depression were temporally concordant and persistent, raising the question of whether they constitute a common syndrome in HIV infected patients and others with chronic diseases.     

Trastuzumab-Induced Cardiomyopathy: Not as Benign as it Looks? A Retrospective Study

BackgroundOne of the recent advances in the treatment of breast cancer is trastuzumab. However, a major side effect of this medication is cardiomyopathy. Our objective was to determine the incidence of trastuzumab-induced cardiomyopathy and the rate of discontinuation of trastuzumab in a clinical setting.Methods and ResultsWe retrospectively reviewed the records of all women treated with trastuzumab at the Moffitt Cancer Center between 2003 and 2007. Cardiomyopathy was defined as symptomatic heart failure or a decrease of ejection fraction by ≥10% from baseline or to <50%. Statistical analysis was done with Fisher exact test, t-test test, and Wilcoxon signed rank test. Cardiomyopathy developed in 52 of 156 (33.3%) of patients being treated with trastuzumab. In the adjuvant group, 23 (19.5%) of women permanently or temporarily discontinued therapy secondary to cardiomyopathy.ConclusionsCardiomyopathy is a common side effect of trastuzumab that leads to discontinuation of treatment in a significant proportion of patients. Further studies are indicated to establish the ways to predict, prevent, and treat cardiomyopathy to provide patients with maximal therapeutic benefit of trastuzumab.     

Fibromyalgia and Risk of Dementia—A Nationwide,Population-Based,Cohort Study

Background

Fibromyalgia is a syndrome of chronic pain and other symptoms and is associated with patient discomfort and other diseases. This nationwide matched-cohort population-based study aimed to investigate the association between fibromyalgia and the risk of developing dementia, and to clarify the association between fibromyalgia and dementia.