Primary Ciliary Dyskinesia Due to Microtubular Defects is Associated with Worse Lung Clearance Index

Purpose

Primary ciliary dyskinesia (PCD) is characterised by repeated upper and lower respiratory tract infections, neutrophilic airway inflammation and obstructive airway disease. Different ultrastructural ciliary defects may affect lung function decline to different degrees. Lung clearance index (LCI) is a marker of ventilation inhomogeneity that is raised in some but not all patients with PCD. We hypothesised that PCD patients with microtubular defects would have worse (higher) LCI than other PCD patients.

Methods

Spirometry and LCI were measured in 69 stable patients with PCD. Age at testing, age at diagnosis, ethnicity, ciliary ultrastructure, genetic screening result and any growth of Pseudomonas aeruginosa was recorded.

Results

Lung clearance index was more abnormal in PCD patients with microtubular defects (median 10.24) than those with dynein arm defects (median 8.3, p?=?0.004) or normal ultrastructure (median 7.63, p?=?0.0004). Age is correlated with LCI, with older patients having worse LCI values (p?=?0.03, r?=?0.3).

Conclusion

This study shows that cilia microtubular defects are associated with worse LCI in PCD than dynein arm defects or normal ultrastructure. The patient’s age at testing is also associated with a higher LCI. Patients at greater risk of obstructive lung disease should be considered for more aggressive management. Differences between patient groups may potentially open avenues for novel treatments.

     

Hemodynamic impact of percutaneous left atrial appendage closure in patients with paroxysmal atrial fibrillation

Purpose

Percutaneous left atrial appendage (LAA) closure has become a valid alternative to anticoagulation therapy for the prevention of thromboembolic events in patients with atrial fibrillation (AF). However, scarce data exist on the impact of LAA closure on left atrial and ventricular function. We sought to assess the acute hemodynamic changes associated with percutaneous LAA closure in patients with paroxysmal AF.

Methods

The study population consisted of 31 patients (mean age 73?±?10 years; 49% women) with paroxysmal AF who underwent successful percutaneous LAA closure. All patients were in sinus rhythm and underwent 2D transthoracic echocardiography at baseline and the day after the procedure. A subset of 14 patients underwent preprocedural cardiac computed tomography (CT) with 3D LA and LAA reconstruction.

Results

Left ventricular systolic function parameters and LA volumetric indexes remained unchanged after the procedure. No significant changes in left ventricular stroke volume (72.4?±?16.0 vs. 73.3?±?15.7 mL, p?=?0.55) or LA stroke volume (total 15.6?±?4.2 vs. 14.6?±?4.2 mL, p?=?0.21; passive 9.0?±?2.8 vs. 8.3?±?2.6 mL, p?=?0.31; active 10.3?±?5.6 vs. 10.0?±?6.4 mL, p?=?0.72) occurred following LAA closure. Mean ratio of LAA to LA volume by 3D CT was 10.2?±?2.3%. No correlation was found between LAA/LA ratio and changes in LA stroke volume (r?=?0.35, p?=?0.22) or left ventricular stroke volume (r?=?0.28, p?=?0.33).

Conclusions

The LAA accounts for about 10% of the total LA volume, but percutaneous LAA closure did not translate into any significant changes in LA and left ventricular function.

     

Endoscopic submucosal resection with an endoscopic variceal ligation device for the treatment of rectal neuroendocrine tumors

Background

Endoscopic resection is recommended for rectal neuroendocrine tumors <?1 cm in diameter; the three techniques (mucosal resection, submucosal dissection, and mucosal resection with variceal ligation device) of endoscopic resection of neuroendocrine tumor were reported; however, the optimal endoscopic technique remains unclear.

Purpose

We compared the efficacy and safety of three endoscopic rectal neuroendocrine tumor resection methods.

Methods

We retrospectively enrolled 52 patients with rectal neuroendocrine tumors treated by endoscopy at Aichi Medical University Hospital and Nagoya City University Hospital between May 2003 and June 2017. We compared clinical outcomes in three groups based on the endoscopic treatment method.

Results

Fifty-two patients underwent endoscopic rectal neuroendocrine tumor treatment (mucosal resection, 14; submucosal dissection, 19; mucosal resection with an endoscopic variceal ligation device, 19). In the endoscopic mucosal resection, submucosal dissection, and mucosal resection with variceal ligation device groups, R0 resection occurred in 50.0, 94.7, and 89.5%, respectively (mucosal resection vs. mucosal resection with variceal ligation device, p <?0.05; mucosal resection vs. submucosal dissection, p <?0.01), while the median procedure times were 6.5, 43, and 6.0 min, respectively (submucosal dissection vs. mucosal resection with variceal ligation device procedure times, p?<?0.01; mucosal resection vs. submucosal resection procedure times, p <?0.01). Postoperative bleeding occurred after endoscopic mucosal resection (1/14) and endoscopic submucosal dissection (4/19), but not after endoscopic mucosal resection with a ligation device.

Conclusion

Endoscopic mucosal resection with an endoscopic variceal ligation device was a safe, effective treatment for rectal neuroendocrine tumors.

     

The short-term outcomes of robotic sphincter-preserving surgery for rectal cancer: comparison with open and laparoscopic surgery using a propensity score analysis

Purpose

The aim of this study is to clarify the short-term outcomes of robotic sphincter-preserving surgery for rectal cancer in a retrospective study.

Methods

The short-term outcomes of robotic sphincter-preserving surgery (n?=?130) were retrospectively compared to open (n?=?234) and laparoscopic surgery (n?=?318) by a propensity score analysis.

Results

Robotic surgery was performed more frequently for patients with lower rectal cancer (55%) than open (30%, p?<?0.0001) or laparoscopic surgery (36%, p?<?0.0001). None of the robotic surgery cases were converted to open surgery. After propensity score matching, robotic surgery was found to be associated with a longer operation time (342 vs. 230 min, p?<?0.0001) and less blood loss (7 vs. 420 mL, p?<?0.0001) than open surgery. The overall complication rate of robotic surgery was lower than that of open surgery (13 vs. 28%, p?=?0.032). Robotic surgery was associated with a lower incidence of surgical site infections (SSIs) than laparoscopic surgery (0 vs. 7%, p?=?0.028). There were no cases of anastomotic leakage after robotic surgery. The circumferential resection margin was involved in 0.8% of the patients who underwent robotic surgery; the incidence did not differ among the treatment groups.

Conclusions

Although robotic surgery for rectal cancer was associated with a longer operation time, it was associated with a very low incidence of SSIs. The degree of safety was comparable to both open and laparoscopic surgery.

     

Ratio of Circulating Estrogen Receptors Beta and Alpha (ERβ/ERα) Indicates Endoscopic Activity in Patients with Crohn’s Disease

Background

Data supporting a role of female hormones and/or their receptors in inflammatory bowel disease (IBD) are increasing, but most of them are derived from animal models. Estrogen receptors alpha (ERα) and beta (ERβ) participate in immune and inflammatory response, among a variety of biological processes. Their effects are antagonistic, and the net action of estrogens may depend on their relative proportions.

Aim

To determine the possible association between the balance of circulating ERβ and ERα (ERβ/ERα) and IBD risk and activity.

Methods

Serum samples from 145 patients with IBD (79 Crohn’s disease [CD] and 66 ulcerative colitis [UC]) and 39 controls were retrospectively studied. Circulating ERα and ERβ were measured by ELISA. Disease activities were assessed by clinical and endoscopic indices specific for CD and UC.

Results

Low values of ERβ/ERα ratio were directly associated with clinical (p = 0.019) and endoscopic (p = 0.002) disease activity. Further analyses by type of IBD confirmed a strong association between low ERβ/ERα ratio and CD clinical (p = 0.011) and endoscopic activity (p = 0.002). The receiver operating curve (ROC) analysis showed that an ERβ/ERα ratio under 0.85 was a good marker of CD endoscopic activity (area under the curve [AUC]: 0.84; p = 0.002; sensitivity: 70%; specificity: 91%). ERβ/ERα ratio was not useful to predict UC activity.

Conclusions

An ERβ/ERα ratio under 0.85 indicated CD endoscopic activity. The determination of serum ERβ/ERα might be a useful noninvasive screening tool for CD endoscopic activity.

     

Feasibility of directional percutaneous epicardial ablation with a partially insulated catheter

Purpose

To demonstrate the feasibility of directional percutaneous epicardial ablation using a partially insulated catheter.

Methods

Partially insulated catheter prototypes were tested in 12 (6 canine, 6 porcine) animal studies in two centers. Prototypes had interspersed windows to enable visualization of epicardial structures with ultrasound. Epicardial unipolar ablation and ablation between two electrodes was performed according to protocol (5–60 W power, 0–60 mls/min irrigation, 78 s mean duration).

Results

Of 96 epicardial ablation attempts, unipolar ablation was delivered in 53.1%. Electrogram evidence of ablation, when analyzable, occurred in 75 of 79 (94.9%) therapies. Paired pre/post-ablation pacing threshold (N?=?74) showed significant increase in pacing threshold post-ablation (0.9 to 2.6 mA, P?<?.0001). Arrhythmias occurred in 18 (18.8%) therapies (11 ventricular fibrillation, 7 ventricular tachycardia), mainly in pigs (72.2%). Coronary artery visualization was variably successful. No phrenic nerve injury was noted during or after ablation. Furthermore, there were minimal pericardial changes with ablation.

Conclusions

Epicardial ablation using a partially insulated catheter to confer epicardial directionality and protect the phrenic nerve seems feasible. Iterations with ultrasound windows may enable real-time epicardial surface visualization thus identifying coronary arteries at ablation sites. Further improvements, however, are necessary.

     

Diverticulitis recurrence after percutaneous abscess drainage

Purpose

Recurrent diverticulitis has been reported in 30–50% of patients who recover from an episode of diverticular-associated abscess. Our aim was to review the outcomes of patients who underwent non-operative management after percutaneous drainage (PD) of colonic diverticular abscess.

Methods

All patients with a diverticular-associated abscess were identified between 2001 and 2012. Individual charts were queried for peri-procedural data and follow-up. The most recent follow-up data were acquired via the electronic medical record or telephone call.

Results

A total of 165 patients underwent PD of diverticular-associated abscesses. Abscess locations were pelvic (n = 122), abdominal (n = 36), and both (n = 7), while median abscess size was 6.1 ± 2.2 cm. One hundred eighteen patients clinically improved following non-operative management, and 81 of these patients did not undergo subsequent colonic resection within 4 months of PD. Of these, 8 died within 12 months. Among the remaining 73 patients, there were no significant differences in demographics or abscess variables compared to those who underwent elective surgery within 4 months. Only 7 of 73 patients had documented episodes of recurrences, while 22 patients later had elective surgery (1.1 ± 1.2 years from the index case). Five-year colectomy-free survival was 55% (95%CI 42–66%), while the recurrence-free survival at 5 years was 77% (95%CI 65–86%). All recurrences were managed non-operatively initially and one patient went on to have elective resection.

Conclusion

A sizable number of patients successfully recover from complicated diverticulitis following PD. Subsequent non-operative management carries an acceptable risk for recurrent episodes and may be considered as a reasonable management option.

     

Obstructive sleep apnea increases the risk of cardiac events after percutaneous coronary intervention: a meta-analysis of prospective cohort studies

Purpose

Recent studies have shown an association between obstructive sleep apnea (OSA) and coronary artery disease; however, the association between OSA and cardiac outcomes in patients after percutaneous coronary intervention (PCI) remains undetermined.

Methods

PubMed, EMBASE, and CENTRAL were searched from inception to July 2016 for cohort studies that followed up with patients after PCI, and evaluated their overnight sleep patterns within 1 month for major adverse cardiac events (MACEs) as primary outcomes including cardiac death, non-fatal myocardial infarction (MI), and coronary revascularization and secondary outcomes including re-admission for heart failure and stroke. Outcomes data were pooled using fixed-effect meta-analysis, and heterogeneity was assessed with the I ² statistics. The methodological quality of the studies was assessed using the Newcastle-Ottawa Scale checklist, and publication bias was evaluated by a visual investigation of funnel plots.

Results

We identified seven pertinent studies including 2465 patients from 178 related articles. OSA was associated with MACEs (odds ratio [OR], 1.52, 95% confidence interval [CI], 1.20–1.93, I ² = 29%), which included cardiac death (OR 2.05, 95% CI, 1.15–3.65, I ² = 0%), non-fatal MI (OR 1.59, 95% CI, 1.14–2.23, I ² = 15%), and coronary revascularization (OR 1.69, 95% CI, 1.28–2.23, I ² = 0%). However, OSA was not associated with re-admission for heart failure (OR 1.71, 95% CI, 0.99–2.96, I ² = 0%) and/or stroke (OR 1.68, 95% CI, 0.91–3.11, I ² = 0%) according to the pooled results.

Conclusions

In patients after PCI, OSA appears to increase the risk of cardiac death, non-fatal MI, and coronary revascularization.

     

Proton pump inhibitors and other disease-based factors in the recurrence of adverse cardiovascular events following percutaneous coronary angiography: A long-term cohort

Background

Dual aspirin-clopidogrel antiplatelet therapy (DAPT) has been shown to decrease the risk of adverse cardiac events after percutaneous coronary intervention (PCI). Proton pump inhibitors (PPIs) are used in these patients to decrease the risk of gastrointestinal bleeding and several studies have reported potential interaction and conflicting clinical outcomes with their use. We aim to assess the effect of different PPIs and other factors on the recurrence of cardiovascular (CV) events in patients following PCI.

Methods

We performed a retrospective cohort on patients who underwent PCI in the last 5 years and were discharged with or without PPIs. Strict inclusion criteria were adopted, outcome measures were defined, and patient follow up up to 2 years was collected.

Results

Out of 740 patients, 453 (61.2 %) had received PPIs and 287 (38.8 %) were discharged without PPIs. Ninety-five (12.8 %) patients were readmitted due to adverse CV events. Statistically, there was no significant difference in the recurrence of CV events with the use of different PPIs (p?=?0.384) and PPI use had an overall protective effect (p?=?0.009, HR 0.58 (CI 0.39–0.88). Patients with history of diabetes mellitus (p?=?0.048) had an increased risk of adverse CV events.

Conclusion

We conclude that pharmacokinetic interaction between PPIs and antiplatelet therapy is not associated with adverse CV events. A comprehensive, multicenter, open-label trial including all PPI subclasses and patient and disease-based factors is warranted for a fair evaluation.

     

Combined NOTES total mesorectal excision and single-incision laparoscopy principles for conservative proctectomy: a single-centre study

Background

Surgery for low rectal cancer remains a challenge when a standard laparoscopic approach is used. Transanal endoscopic total mesorectal excision (TME) has been shown to be feasible and to be associated with a low conversion rate. Combining the transanal and transabdominal single-port approaches (with an abdominal single port implanted in the future stoma and extraction site) could allow TME with minimal wound trauma, low morbidity, and faster recovery. The aim of the current study was to assess the short- and mid-term results of this technique.

Methods

We conducted a prospective single-centre study of consecutive patients presenting with low rectal cancer requiring a conservative proctectomy with a manual coloanal anastomosis between January 2012 and April 2015.

Results

During the study period, 41 patients were recruited. Conversion to open surgery was required in only one patient (2.4%). The median operating time was 358.5 min (range 300–600 min). Partial intersphincteric resection was necessary for 15 patients (36.6%). The specimens were mostly extracted via the abdominal access (n = 34) without wound complications. The mean number of lymph nodes harvested was 12.7 (range 6–24 lymph nodes). Specimens were graded as complete (n = 31) or nearly complete (n = 10) in all of the patients, and the circumferential resection margin positivity was 4.9%. Intraoperative morbidity rate was 4.9%, and the 30-day morbidity rate was 24.4% (n = 10). Sixty per cent (n = 6) of the patients with 30-day morbidity were Dindo I–II. At a median follow-up of 29 months, overall and disease-free survival rates were 97.5 and 80.5%, respectively. The stoma-free survival rate was 95.1%.

Conclusions

Combining an endoscopic transanal TME and a single laparoscopic ileostomy-site proctectomy is a promising minimally invasive approach for the treatment of low rectal cancer.

     

Patient–Family Agenda Setting for Primary Care Patients with Cognitive Impairment: the SAME Page Trial

Background

Establishing priorities for discussion during time-limited primary care visits is challenging in the care of patients with cognitive impairment. These patients commonly attend primary care visits with a family companion.

Objective

To examine whether a patient–family agenda setting intervention improves primary care visit communication for patients with cognitive impairment

Design

Two-group pilot randomized controlled study

Participants

Patients aged 65?+ with cognitive impairment and family companions (n?=?93 dyads) and clinicians (n?=?14) from two general and one geriatrics primary care clinic

Intervention

A self-administered paper-pencil checklist to clarify the role of the companion and establish a shared visit agenda

Measurements

Patient-centered communication (primary); verbal activity, information disclosure including discussion of memory, and visit duration (secondary), from audio recordings of visit discussion

Results

Dyads were randomized to usual care (n?=?44) or intervention (n?=?49). Intervention participants endorsed an active communication role for companions to help patients understand what the clinician says or means (90% of dyads), remind patients to ask questions or ask clinicians questions directly (84% of dyads), or listen and take notes (82% of dyads). Intervention dyads identified 4.4 health issues for the agenda on average: patients more often identified memory (59.2 versus 38.8%; p?=?0.012) and mood (42.9 versus 24.5%; p?=?0.013) whereas companions more often identified safety (36.7 versus 18.4%; p?=?0.039) and personality/behavior change (32.7 versus 16.3%; p?=?0.011). Communication was significantly more patient-centered in intervention than in control visits at general clinics (p?<?0.001) and in pooled analyses (ratio of 0.86 versus 0.68; p?=?0.046). At general clinics, intervention (versus control) dyads contributed more lifestyle and psychosocial talk (p?<?0.001) and less biomedical talk (p?<?0.001) and companions were more verbally active (p?<?0.005). No intervention effects were found at the geriatrics clinic. No effect on memory discussions or visit duration was observed.

Conclusion

Patient–family agenda setting may improve primary care visit communication for patients with cognitive impairment.

Trial Registration

ClinicalTrials.gov: NCT02986958

     

Gefahr der Anastomoseninsuffizienz nach laparoskopischer und offener kolorektaler Resektion

Background

Anastomotic leak following colorectal surgery is associated with significant morbidity and mortality. With the widespread adoption of laparoscopy, data from initial clinical trials evaluating the efficacy of laparoscopic when compared to open surgery may not currently be generalizable. We assess the risk of anastomotic leak after laparoscopic versus open colorectal resection using a nationwide database with standardized definitions.

Methods

The 2012–2013 ACS-NSQIP targeted colectomy data were queried for all elective colorectal resections. Characteristics were compared for those patients undergoing laparoscopic versus open operations. Univariable and multivariable analyses, followed by a propensity score-matched analysis, were performed to assess the impact of laparoscopy on the development of an anastomotic leak.

Results

Of 23,568 patients, 3.4% developed an anastomotic leak. Laparoscopic surgery was associated with a leak rate of 2.8% (n = 425) and open surgery, 4.5% (n = 378, p <0.0001). Patients who developed a leak were more likely to die within 30 days of surgery (5.7 vs 0.6%, p <0.0001). Patients who underwent laparoscopic surgery compared to open were younger (61 vs 63 years, p = 0, p = 0.045) and with fewer comorbidities. On univariable analysis laparoscopic surgery was associated with reduced odds of developing an anastomotic leak (OR 0.60, p <0.0001), and this remained after adjusting for all significant preoperative and disease-related confounders (OR 0.69, 95% CI 0.58–0.82). A propensity score-matched analysis confirmed benefit of laparoscopic surgery over open surgery for anastomotic leak.

Conclusion

Laparoscopic colectomy is safe and associated with reduced odds of developing an anastomotic leak following colectomy when controlling for patient-, disease and procedure-related factors.

     

Is the Care Transitions Measure Associated with Readmission Risk? Analysis from a Single Academic Center

BACKGROUND

It is widely hypothesized that improvement in transitions of care will reduce unplanned hospital readmissions. However, the association between the Care Transitions Measure, the national quality metric for transitions of care and readmission risk, has not been established.

OBJECTIVE

We aimed to determine the association between the Care Transition Measure and readmission.

DESIGN

This was a single-center, prospective cohort study.

PARTICIPANTS

Convenience sample of 2,963 patients enrolled in the “Bridging the Divides” program, a longitudinal care management program for patients with coronary revascularization, from 2013 to 2014. Of these, 1594 (54 %) patients completed a post-discharge Care Transition Measure questionnaire.

INTERVENTION

Care Transition Measure scores were collected by trained research staff blinded to study hypothesis, by telephone, within 30 days of discharge. Higher Care Transition Measure scores reflect a higher quality transition of care.

MAIN MEASURES

30-day readmission was measured.

KEY RESULTS

Of the1594 patients that completed the Care Transition Measure survey, 1216 (76 %) received percutaneous coronary intervention and 378 (24 %) received coronary artery bypass grafting. Mean Care Transition Measure scores were significantly lower among patients who had a prior admission (77.2 vs. 82.1, p?<?0.001) and those with ≥ 5 comorbidities (77 vs. 82.6 vs. 81.6, p?<?0.001). Mean scores were significantly lower among patients who were readmitted within the percutaneous coronary intervention subgroup (73 vs. 80.9, p?<?0.001) and the total study population (74.6 vs. 81.1, p?<?0.001) compared to those who were not readmitted. This was not the case in the coronary artery bypass grafting subgroup (78.5 vs. 81.7, p?=?0.29). After multivariable adjustment, every ten-point increase in the Care Transition Measure score was associated with a 14 % reduction in readmission risk (adjusted odds ratio 0.86, 95 % CI 0.78–0.95).

CONCLUSIONS

The Care Transition Measure is strongly associated with readmissions, which strengthens its validity. However, its association with patient variables linked with readmission and its inconsistent association with readmission across clinical groups raises concerns that scores may be influenced by patient characteristics.

     

TIMP-1 Promotes the Immune Response in Influenza-Induced Acute Lung Injury

Introduction

Influenza infects millions of people each year causing respiratory distress and death in severe cases. On average, 200,000 people annually are hospitalized in the United States for influenza related complications. Tissue inhibitor of metalloproteinase-1 (TIMP-1), a secreted protein that inhibits MMPs, has been found to be involved in lung inflammation. Here, we evaluated the role of TIMP-1 in the host response to influenza-induced lung injury.

Methods

Wild-type (WT) and Timp1-deficient (Timp1^?/?) mice that were 8–12 weeks old were administered A/PR/8/34 (PR8), a murine adapted H1N1 influenza virus, and euthanized 6 days after influenza installation. Bronchoalveolar lavage fluid and lungs were harvested from each mouse for ELISA, protein assay, PCR, and histological analysis. Cytospins were executed on bronchoalveolar lavage fluid to identify immune cells based on morphology and cell count.

Results

WT mice experienced significantly more weight loss compared to Timp1^?/? mice after influenza infection. WT mice demonstrated more immune cell infiltrate and airway inflammation. Interestingly, PR8 levels were identical between the WT and Timp1^?/? mice 6 days post-influenza infection.

Conclusion

The data suggest that Timp1 promotes the immune response in the lungs after influenza infection facilitating an injurious phenotype as a result of influenza infection.

     

Contrast-induced acute kidney injury and adverse clinical outcomes risk in acute coronary syndrome patients undergoing percutaneous coronary intervention: a meta-analysis

Background

Recent studies have shown associations between contrast-induced acute kidney injury (CI-AKI) and increased risk of adverse clinical outcomes in acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI); however, the estimates are inconsistent and vary widely. Therefore, this meta-analysis aimed to evaluate the precise associations between CI-AKI and adverse clinical consequences in patients undergoing PCI for ACS.

Methods

EMBASE, PubMed, Web of Science? and Cochrane Library databases were systematically searched from inception to December 16, 2016 for cohort studies assessing the association between CI-AKI and any adverse clinical outcomes in ACS patients treated with PCI. The results were demonstrated as pooled risk ratios (RRs) with 95% confidence intervals (CI). Heterogeneity was explored by subgroup analyses.

Results

We identified 1857 articles in electronic search, of which 22 (n?=?32,781) were included. Our meta-analysis revealed that in ACS patients undergoing PCI, CI-AKI significantly increased the risk of adverse clinical outcomes including all-cause mortality (18 studies; n?=?28,367; RR?=?3.16, 95% CI 2.52–3.97; I²?=?56.9%), short-term all-cause mortality (9 studies; n?=?13,895; RR?=?5.55, 95% CI 3.53–8.73; I²?=?60.1%), major adverse cardiac events (7 studies; n?=?19,841; RR?=?1.49, 95% CI: 1.34–1.65; I² =?0), major adverse cardiovascular and cerebrovascular events (3 studies; n?=?2768; RR?=?1.86, 95% CI: 1.42–2.43; I² =?0) and stent restenosis (3 studies; n?=?130,678; RR?=?1.50, 95% CI: 1.24–1.81; I² =?0), respectively. Subgroup analyses revealed that the studies with prospective cohort design, larger sample size and lower prevalence of CI-AKI might have higher short-term all-cause mortality risk.

Conclusions

CI-AKI may be a prognostic marker of adverse outcomes in ACS patients undergoing PCI. More attention should be paid to the diagnosis and management of CI-AKI.

     

Endoscopic management of pancreatic pseudocysts and walled-off pancreatic necrosis: A two-decade experience

Aim

To determine long-term outcome of endoscopic management of pancreatic pseudocyst/walled-off pancreatic necrosis (WOPN) without necrosectomy.

Methods

One-hundred and sixty-five pancreatic pseudocysts/WOPN managed endoscopically over a period of 22 years were analyzed retrospectively for technical success, complications, and recurrence.

Results

Symptomatic 118 males and 47 females with mean age of 35.8 years were included. Alcohol was the most common etiology (41.2 %). Transmural endoscopic drainage was done in 144 patients, while 21 patients underwent transpapillary drainage. All the patients were subjected to contrast computed tomography (CT) abdomen or routine/Doppler ultrasound. Endoscopic ultrasound was done in last 11 patients. One or two double pigtail 7 Fr stents were placed when clear watery fluid came out from cyst (130 patients, 78.8 %), and nasocystic drainage (NCD) tubes were placed in addition to two 7 Fr stents when there were frank pus, thick dark fluid, or solid components inside the cyst (35 patients). All these patients settled on this treatment. Thirty-three of 35 patients of WOPN could be managed endoscopically without necrosectomy. Complications occurred in 9.2 % of pseudocysts and 40 % of WOPN. Thirty-five patients were followed up for more than 5 years (3 patients more than 10 years), and 130 patients were followed up for up to 5 years. Recurrence occurred in 8.1 % of pseudocysts and 5.7 % of WOPN.

Conclusion

Majority of pancreatic pseudocysts/WOPN can be managed with endoscopic drainage without necrosectomy with high success, low complication, and recurrence rates.

     

Teaching Medical Students to Help Patients Quit Smoking: Outcomes of a 10-School Randomized Controlled Trial

Background

Early in medical education, physicians must develop competencies needed for tobacco dependence treatment.

Objective

To assess the effect of a multi-modal tobacco dependence treatment curriculum on medical students’ counseling skills.

Design

A group-randomized controlled trial (2010–2014) included ten U.S. medical schools that were randomized to receive either multi-modal tobacco treatment education (MME) or traditional tobacco treatment education (TE).

Setting/Participants

Students from the classes of 2012 and 2014 at ten medical schools participated. Students from the class of 2012 (N?=?1345) completed objective structured clinical examinations (OSCEs), and 50 % (N?=?660) were randomly selected for pre-intervention evaluation. A total of 72.9 % of eligible students (N?=?1096) from the class of 2014 completed an OSCE and 69.7 % (N?=?1047) completed pre and post surveys.

Interventions

The MME included a Web-based course, a role-play classroom demonstration, and a clerkship booster session. Clerkship preceptors in MME schools participated in an academic detailing module and were encouraged to be role models for third-year students.

Measurements

The primary outcome was student tobacco treatment skills using the 5As measured by an objective structured clinical examination (OSCE) scored on a 33-item behavior checklist. Secondary outcomes were student self-reported skills for performing 5As and pharmacotherapy counseling.

Results

Although the difference was not statistically significant, MME students completed more tobacco counseling behaviors on the OSCE checklist (mean 8.7 [SE 0.6] vs. mean?8.0 [SE 0.6], p?=?0.52) than TE students. Several of the individual Assist and Arrange items were significantly more likely to have been completed by MME students, including suggesting behavioral strategies (11.8 % vs. 4.5 %, p?<?0.001) and providing information regarding quitline (21.0 % vs. 3.8 %, p?<?0.001). MME students reported higher self-efficacy for Assist, Arrange, and Pharmacotherapy counseling items (ps?≤0.05).

Limitations

Inclusion of only ten schools limits generalizability.

Conclusions

Subsequent interventions should incorporate lessons learned from this first randomized controlled trial of a multi-modal longitudinal tobacco treatment curriculum in multiple U.S. medical schools.NIH Trial Registry Number: NCT01905618

     

Laparoscopic versus open surgery for rectal cancer: a meta-analysis of 3-year follow-up outcomes

purpose

We wished to evaluate the effectiveness of laparoscopic and open surgery for patients with rectum cancer through a meta-analysis.

Methods

We searched PubMed, EMBASE, and Cochrane database until June 30, 2015, to identify eligible studies. Randomized controlled trials comparing laparoscopic with open surgery for rectum cancer were included. Meta-analysis was performed using the search strategy following the requirement of the Cochrane Library Handbook. Three-year overall survival (OS) and disease-free survival (DFS) were the main endpoints.

Results

Eight randomized controlled trials comprising 3145 patients matched the selection criteria. Meta-analysis showed no significant difference between laparoscopic and open surgery in 3-year overall survival (OS) and disease-free survival (DFS) (hazard ratio (HR)_{3-year OS} = 0.83, 95 % CI [0.68–1.01]; P = 0.06; HR_{3-year DFS} = 0.89, 95 % CI [0.75,1.05]; P = 0.16). No evidence of publication bias was observed.

Conclusion

Our meta-analysis supported the notion that based on the 3-year DFS and OS, oncological outcomes are comparable after laparoscopic and open surgery for rectal cancer.

     

Ten-year outcomes following laparoscopic colorectal resection: results of a randomized controlled trial

Purpose

To evaluate the impact of laparoscopy compared to open surgery on long-term outcomes in a large series of patients who participated in a randomized controlled trial comparing short-term results of laparoscopic (LPS) versus open colorectal resection.

Methods

This is a retrospective review of a prospective database including 662 patients with colorectal disease (526, 79 % cancer patients) who were randomly assigned to LPS or open colorectal resection and followed every 6 months by office visits. The primary endpoint of the study was long-term morbidity. Secondary outcomes included 10-year overall, cancer-specific, and disease-free survivals. All patients were analyzed on an intention-to-treat basis.

Results

Fifty-eight (8.8 %) patients were lost to follow-up. Median follow-up was 131 (IQR 78–153) months in the LPS group and 126 (IQR 52–152) months in the open group (p?=?0.121). Overall, long-term morbidity rate was 11.8 % (36/309) in the LPS versus 12.6 % (37/295) in the open group (p?=?0.770). Incisional hernia rate was 5.8 % (18/309) in the LPS group versus 8.1 % (24/295) in the open group (p?=?0.264). Adhesion-related small-bowel obstruction occurred in five (1.6 %) patients in the LPS versus four (1.4 %) patients in the open group (p?=?1.000). In 497 cancer patients, 10-year overall survival was 45.3 % in the LPS group and 40.9 % in the open group (p?=?0.160). No difference was found in cancer-specific and disease-free survivals, also when patients were stratified according to cancer stage.

Conclusion

In this series, LPS colorectal resection was not associated with a lower long-term morbidity rate when compared to open surgery. Overall, cancer-specific and disease-free survivals were similar in cancer patients who were treated with LPS and open surgeries.