Prevalence, predictors, and service utilization of patients with recurrent use of Veterans Affairs substance use disorder specialty care

Although substance use disorders (SUDs) are chronic conditions for many patients, the prevalence, predictors, and health care utilization patterns of those who reenter SUD specialty care are understudied. We identified 1,640 patients who initiated SUD specialty care at 1 Veterans Affairs (VA) medical center and categorized them, using their subsequent 24 and prior 60 months receipt of VA SUD care, as index episode only (35.7%, 33.5–38.1), index and prior episode(s) (24.6%, 22.5–22.7), and index and postindex episodes (39.6%, 37.3–42.0). Compared with the index episode-only group, the postindex episode(s) group had modestly higher percentages of men, divorced/separated, and alcohol use, cocaine use, bipolar disorder, and psychotic disorders. Patients with postindex episodes averaged 2 times more postindex emergency visits and mental health hospitalizations than patients with an index only episode. Results document the prevalence, overall health care utilization, and limited predictability of SUD treatment reentry and support development of new models of care for these complex patients.     

Prosthetic valve endocarditis: importance of surgical treatment

Surgical therapy of prosthetic valve endocarditis (PVE) is still associated with a high mortality of up to 80 %. Further risk analysis and characterization of clinical features are important for a further improvement of surgical results. The aim of this retrospective study was a risk analysis of clinical features of the pre-, intra-, and postoperative period. Between February 1998 and December 2004, 70 patients (52 male, 18 female, age 62 +/- 11 years) were referred to our institution for surgical therapy of PVE. This cohort included 16 patients with early PVE and 54 patients with late PVE. Preoperative, intraoperative and postoperative features were evaluated with respect to their influence on the early postoperative course and the midterm follow-up. The aortic valve was affected in 41 patients (58.6 %) and the mitral valve in 15 patients (21.4 %). Double valve infection was recorded in 14 patients (20.0 %). Staphylococci (n = 36, 51.4 %), Streptococci (n = 9, 12.9 %) and others (n = 24, 14.5 %) were identified as causative agents in blood cultures. The hospital mortality rate was 20.0 % (n = 14), during follow-up (mean follow up: 3.3 +/- 2.5 years), a further 11 patients (15.7 %) died, resulting in an overall mortality of 35.7 %. The main predictors for hospital mortality were preoperative heart failure ( P = 0.01) and Staphylococci infection ( P = 0.01). Predictors of overall mortality were Staphylococci infection ( P = 0.01), heart failure ( P = 0.02) and abscess formation ( P = 0.02). Surgical therapy of prosthetic valve endocarditis is still associated with quite a high mortality during the early and midterm follow-up. Predictors of outcome particularly include preoperative risk constellations (heart failure, Staphylococci infection).     

Saving the red baby: Successful allogeneic cord blood transplantation in Omenn syndrome

Haematopoietic stem cell transplantation is the treatment of choice for severe primary immunodeficiencies, but only has moderate prognosis in Omenn syndrome as it is complicated by highly activated Omenn T-cells resulting in delayed T-cell engraftment and a high rate of graft failure. A 6 1/2 months old patient with a previously unknown compound heterozygous defect within the RAG1 gene (R474C; R975W) underwent 8/10 HLA-matched cord blood transplantation after myeloablative conditioning. Immune reconstitution was impressive with T-, B- and NK-cells reaching the median of age-dependent reference values within twelve, four and two months respectively. With a continuous decrease of activated Omenn T-cells there was a steady increase of naive, probably thymus-derived T-cells. Polyclonal B-cell activation and hypergammaglobulinaemia disappeared with B-cell engraftment. This case emphasizes that, despite their naive status and HLA-barriers, cord blood T-cells were apparently able to achieve T-effector function resulting in the elimination of all activated Omenn T-cells.     

Koronarchirurgie im akuten Koronarsyndrom

Background:

The objective of the present study was to analyze the outcome and predictors of in-hospital mortality in patients (pts) referred to CABG with acute coronary syndrome (ACS).

Patients and methods:

Between January 2003 and May 2005, a total of 3127 pts underwent primary isolated CABG at our institution, including 220 pts with ACS. UAP was present in 88 pts (group I), 97 pts (group II) had NSTEMI, whereas 35 pts (group III) had STEMI. Clinical data, inhospital mortality was studied, retrospectively.

Results:

Overall in-hospital mortality was 6.4 % (n = 14), being 2.2 % in group I (n = 2), 9.2 % in group II (n = 9) and 8.5 % (n = 3) in group III (p < 0.05). Logistic regression identified age, NYHA, EF, catecholamine support, cardiogenic shock, COPD, renal disease and EuroSCORE (p < 0.0001) as significant predictors related to in-hospital mortality. The mean time from the onset of symptoms to revascularization differed significantly between survivors (5.1 ± 2.7 h) and no survivors (11.4 ± 3.2 h) (p < 0.0007) in the STEMI group. Preoperative cTnI did not provide any prognostic information.

Conclusion:

CABG in pts with ACS can be performed with good clinical results. The clinical outcome is dependent on the ACS group. Therefore an individual risk stratification of each pt in ACS is necessary. The time interval of 6 h seems to be crucial as a prognostic variable in the STEMI group.     

Do thymidylate synthase gene promoter polymorphism and the C/G single nucleotide polymorphism predict effectiveness of adjuvant 5-fluorouracil-based chemotherapy in stage III colonic adenocarcinoma?

Since 5-fluorouracil (5-FU)-based chemotherapy has become standard adjuvant treatment for patients with node-positive colonic adenocarcinoma, there has arisen the need for predictive factors. Thymidylate synthase (TS) is a major target of 5-FU's action, and high TS expression in carcinoma cells could reduce its cytostatic effect. Both, a 28-base pair repeat polymorphism and a cytosine vs. guanine single nucleotide polymorphism in the promoter region of the TS gene are known to modulate its expression. All patients with a single, non-metachronous node-positive colonic adenocarcinoma who underwent a potentially curative resection at this institution in the years 1994-2002, and who received adjuvant 5-FU (n=95) were included in this study. Ninety-four of the 95 patients were successfully genotyped: 70 patients were classified as TS gene low-expressors (2R-2R, 2R-3C and 3C-3C), and 24 patients were classified as high-expressors (2R-3G, 3C-3G and 3G-3G). Contrary to the hypothesis, Kaplan-Meier survival analysis did not reveal any differences between the groups (power of 0.8 to detect an absolute survival difference >30%). In a Cox model, venous angioinvasion and the infiltrative pattern of tumour invasion were strong adverse factors. These results argue against a practical role for the TS gene repeat polymorphism or the C/G single nucleotide polymorphism as a predictive factor. However, by careful histopathological examination a high-risk group of node-positive patients can be defined that could be candidates for studies of alternative (more aggressive) adjuvant treatment.