Rates and causes of emergency department revisits within 72 hours.

The purpose of this study was to determine the rates and causes of revisits to the emergency department (ED) of a 3,500-bed referral hospital, to identify areas for improvement, and to generate baseline data for the development of a computerized, automatic monthly audit system. We identified all patients returning within 72 hours of their initial ED visits, from 1 July 1995 to 30 June 1997, and monthly revisit rates were calculated. To determine the reasons for revisits, two independent reviewers examined the charts of revisit cases from 1 July 1996 to 30 June 1997. A one-in-three sampling method was used to select charts. A total of 485 revisit charts were reviewed. The monthly revisit rates ranged from 1.32% to 2.38%, with no particular seasonal or event-specific pattern. Most revisits were attributed to disease factors (79.0%). Those felt to be medical errors only accounted for 7.8% of the revisits but led to a higher hospital admission rate (73.7%) subsequently. By contrast, the overall hospital admission rates for revisit patients (36.5%) and all ED patients (36.2%) were similar. We suggest setting baseline monthly ED revisit rates at 2% for future computer-programmed audit filters. While this study indicates that most revisits are disease-related, further prospective studies are needed to evaluate the most common and serious causes of revisits to see if improvements can be made.     

A systematic review of the prevalence and attribution of human papillomavirus types among cervical, vaginal, and vulvar precancers and cancers in the United States

OBJECTIVES: To describe prevalence and estimated attribution of human papillomavirus (HPV) types in U.S. cervical, vaginal, and vulvar precancers and cancers. METHODS: U.S. studies reporting HPV typing for cervical intraepithelial neoplasia (CIN), vulvar intraepithelial neoplasia (VIN), and vaginal intraepithelial neoplasia (VaIN) and/or invasive cancers of those sites were gathered from the PubMed database (http://www.ncbi.nlm.nih.gov/sites/entrez/). Selected studies had PCR testing data for > or =10 cases for a disease endpoint. Analytic methods augmented prior reviews of cervical disease with an updated and expanded analysis (including vulvar and vaginal disease), new selection criteria for specimens, and adjustment for histologic type, where possible, among pooled cancer cases. In addition, for analyses of estimated attribution of HPV types, we incorporated accounting methods for lesions infected with multiple HPV types. RESULTS: Data from 22 U.S. studies meeting review eligibility criteria were tabulated. Following adjustment for the presence of multiple HPV types in a single specimen, the top two HPV types contributing to disease were CIN 1 (HPV 16/66; 15.3%), CIN 2/3 (HPV 16/31; 61.9%), cervical cancer (HPV 16/18; 79.2%), VIN 1 (HPV 6/11; 41.7%), VIN 3 (HPV 16/18; 84.0%), vulvar cancer (HPV 16/33; 55.5%), VaIN 3 (HPV 16/18; 65.1%), and vaginal cancer (HPV 16/18; 72.7%). CONCLUSIONS: The HPV type distribution and proportion of cases testing positive for any HPV type were observed to vary among U.S. cervical, vulvar, and vaginal neoplasias and by grade of disease. Adjustment for the presence of multitype HPV infections can have an important effect on the estimated attribution of HPV types to disease, particularly for types other than HPV 16.     

Pathophysiology of and prophylaxis against late ahmed glaucoma valve occlusion

PURPOSE: To understand the pathophysiology of late Ahmed Glaucoma Valve failures and devise strategies to minimize this problem. METHODS: One hundred sixty eyes that had undergone Ahmed Glaucoma Valve implants by one surgeon were retrospectively reviewed. Six eyes with late (greater than 3 months) Ahmed Glaucoma Valve occlusion requiring operative intervention were identified. Two of these eyes underwent initial successful transcameral drainage tube irrigation and four initially required Ahmed Glaucoma Valve exchange. Intraoperative images, postoperative histologic analysis, and Ahmed Glaucoma Valve handling experiments were performed. RESULTS: Two eyes with late occlusion (33%; 1.25% of total implants) were initially successfully treated with irrigation alone. A gap between the valve cover and valve body junction allowed fibrovascular ingrowth and produced valve failure ultimately in five of six eyes (83%; 3.1% of total implants). This gap could be produced by grasping the device along the center line, indenting the valve cover, and damaging the plastic rivets attaching the valve cover to the valve body. Handling the Ahmed Glaucoma Valve outside this "no touch zone" eliminated this problem. CONCLUSIONS: Leaflet adhesion has a low incidence and may be treated by transcameral drainage tube irrigation. Late onset distal occlusion is best treated by Ahmed Glaucoma Valve exchange with respect for the "no touch zone." Respecting the "no touch zone over the valve mechanism should avoid creation of gaps between the valve cover and valve body junction, which allow secondary fibrovascular ingrowth.     

Microangiopathic hemolytic anemia in a patient with recurrent anal cancer and liver metastasis

Microangiopathic hemolytic anemia (MAHA) is a late but fatal complication in advanced cancers (cancer-associated). It may also appear in complete remission after chemotherapy (chemotherapy-related). Mucin-producing adenocarcinoma has been extensively studied in relation to this phenomenon. Squamous cell carcinoma with MAHA, on the other hand, has not often been reported in the English literature. Because of the difficulty of case collection, understanding of the association of MAHA and anal squamous cell carcinoma remains vague. We present a 60-year-old woman with anal cancer and liver metastasis. This patient received chemotherapy (mitomycin C, 5-fluoruracil, and cisplatin) and reached a good partial response. MAHA developed 2 months later, and tumor recurrence with rapid deterioration appeared 5 months later. The patient died 5 months after MAHA was diagnosed. We consider that the MAHA in this patient is chemotherapy-related. However, the possibility of cancer-associated MAHA could not be excluded.     

Gingival metastasis from gallbladder cancer

Gallbladder cancer is generally diagnosed at an advanced stage. The liver is the most commonly invaded organ by direct extension and/or metastasis, followed by regional lymph nodes. Oral soft tissue metastasis is extremely unusual. This report describes the case of a 62-year-old woman diagnosed with advanced metastatic gallbladder cancer, who initially presented with abdominal pain. Diagnosis of gallbladder cancer was made about 3 months after her symptoms developed, when a laparoscopic cholecystectomy was performed because of the suspicion of gallstones. Liver metastasis was also discovered during surgery. A postoperative investigation revealed additional lung and bone metastases. A visible left gingival tumor was found on physical examination and was confirmed as gallbladder cancer metastasis by compatible histopathology 1 month after surgery. The patient responded poorly to chemotherapy and unfortunately died 5 months after the diagnosis. The clinical presentation of gallbladder cancer was relatively typical, apart from the unusual gingival metastasis. The medical literature contains quite a few examples of metastatic lesions located strictly in the oral soft tissue, however no case of gallbladder cancer metastasizing to the oral soft tissue has been previously reported.     

Increased risk for hepatitis B-related liver cirrhosis in relatives of patients with hepatocellular carcinoma in northern Taiwan

BACKGROUND: There is a tendency for familial aggregation of hepatocellular carcinoma (HCC). The aims of this study were to assess the degree to which familial aggregation of hepatitis B surface antigen (HBsAg) carriers accounts for familiality of HCC in families of hepatitis B-related HCC patients, and whether HCC shares a familial predisposition with liver cirrhosis among HBsAg carriers. METHODS: A total of 671 first-degree relatives of HBsAg-positive HCC cases were recruited using abdominal ultrasonography and tests for HBsAg and serum aminotransferases. They were from 165 simplex families defined as having only one HCC case and 72 multiplex families with more than one case. In analyses of family history of HCC and cirrhosis, the data set consisted of 4,471 unrelated asymptomatic HBsAg carriers recruited in a prospective study. RESULTS: There was no significant difference in the HBsAg-positive rate among relatives between multiplex (55.7%) and simplex (48.1%) families. Sonographic evidence of liver cirrhosis was present in 14.4% of HBsAg-positive relatives from multiplex families but in only 7.8% of HBsAg-positive relatives from simplex families (multiplex versus simplex families: adjusted odds ratio [OR] = 2.29; 95% CI: 1.10-4.77). Among unrelated asymptomatic HBsAg carriers, the adjusted OR of liver cirrhosis associated with a first-degree family history of HCC was 2.80 (95% CI: 1.68-4.66). This association was stronger in HBsAg carriers <50 years. No association was seen between family history of HCC and hepatitis activity based on elevated levels of aminotransferases. CONCLUSIONS: Familial aggregation of HCC in HBsAg carriers is associated with familial clustering of liver cirrhosis.