Analyzing treatment aggressiveness and identifying high‐risk patients in diabetic foot ulcer return to care

Rates of diabetes and its associated comorbidities have been increasing in the United States, with diabetic foot ulcer treatment representing a large cost to the patient and healthcare system. These ulcers often result in multiple hospital admissions. This study examined readmissions following inpatient care for a diabetic foot ulcer and identified modifiable factors associated with all‐cause 30‐day readmissions to the inpatient or emergency department (ED) setting. We hypothesized that patients undergoing aggressive treatment would have lower 30‐day readmission rates. We identified patient discharge records containing International Classification of Disease ninth revision codes for both diabetes mellitus and distal foot ulcer in the State Inpatient and Emergency Department databases from the Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project in Florida and New York, 2011–2012. All‐cause 30‐day return to care visits (ED or inpatient) were analyzed. Patient demographics and treatment characteristics were evaluated using univariate and multivariable regression models. The cohort included 25,911 discharges, having a mean age of 63 and an average of 3.8 comorbidities. The overall rate of return to care was 30%, and 21% of subjects underwent a toe or midfoot amputation during their index stay. The most common diagnosis codes upon readmission were diabetes mellitus (19%) and infection (13%). Patients with a toe or midfoot amputation procedure were less likely to be readmitted within 30 days (odds ratio: 0.78; 95% confidence interval: 0.73, 0.84). Presence of comorbidities, black and Hispanic ethnicities, and Medicare and Medicaid payer status were also associated with higher odds of readmission following initial hospitalization (p < 0.05). The study suggests that there are many factors that affect readmission rates for diabetic foot ulcer patients. Understanding patients at high‐risk for readmission can improve counseling and treatment strategies for this fragile patient population.     

Perception and Awareness of Bariatric Surgery in Canada: a National Survey of General Surgeons

Background

The objective of this study was to assess Canadian general surgeons’ knowledge of bariatric surgery and perceived availability of resources to manage bariatric surgery patients.

Methods

A self-administered questionnaire was developed using a focus group of general surgeons. The questionnaire was distributed at two large general surgery conferences in September and November 2012. The survey was also disseminated via membership association electronic newsletters in November and December 2012.

Results

One hundred sixty-seven questionnaires were completed (104 practicing surgeons, 63 general surgery trainees). Twenty respondents were bariatric surgeons. Among 84 non-bariatric surgeons, 68.3 % referred a patient in the last year for bariatric surgery, 79 % agreed that bariatric surgery resulted in sustained weight loss, and 81.7 % would consider referring a family member. Knowledge gaps were identified in estimates of mortality and morbidity associated with bariatric procedures. The majority of surgeons surveyed have encountered patients with complications from bariatric surgery in the last year. Over 50 % of surgeons who do not perform bariatric procedures reported not feeling confident to manage complications, 35.4 % reported having adequate resources and equipment to manage morbidly obese patients, and few are able to transfer patients to a bariatric center. Of the respondents, 73.3 % reported residency training provided inadequate exposure to bariatric surgery, and 85.3 % felt that additional continuing medical education resources would be useful.

Conclusions

There appears to be support for bariatric surgery among Canadian general surgeons participating in this survey. Knowledge gaps identified indicate the need for more education and resources to support general surgeons managing bariatric surgical patients.

     

Aberrant gene methylation implicated in the progression of monoclonal gammopathy of undetermined significance to multiple myeloma

Malignant transformation is a multistep process that may involve dysregulation of oncogenes and tumour suppressor genes, and monoclonal gammopathy of undetermined significance (MGUS) is believed to be a precursor of multiple myeloma. To investigate whether aberrant promoter methylation might be involved in the evolution of MGUS to multiple myeloma, we examined the p16, protein tyrosine phosphatase, non-receptor type 6 (SHP1), death-associated protein (DAP) kinase, E-cadherin and oestrogen receptor genes, most being tumour suppressor genes, by methylation-specific polymerase chain reaction. In 32 cases of multiple myeloma and 19 cases of MGUS, significantly more frequent methylation of p16 (p = 0.001), SHP1 (p< or =0.001) and E-cadherin (p< or =0.001) genes was found in multiple myeloma than in MGUS. Methylation of DAP kinase and oestrogen receptor genes was comparable in multiple myeloma and MGUS. In conclusion, methylation of p16, SHP1 and E-cadherin genes might be involved in the progression of MGUS to multiple myeloma.     

Identification of neutralizing linear epitopes from the VP1 capsid protein of Enterovirus 71 using synthetic peptides

Enterovirus 71 (EV71) is the main causative agent of Hand, foot and mouth disease (HFMD) and has been associated with severe neurological diseases resulting in high mortalities. Currently, there is no vaccine available and treatment is limited to palliative care. In this study, antisera were raised in mice against 95 overlapping synthetic peptides spanning the VP1 capsid protein of EV71. Two peptides, SP55 and SP70, containing amino acid 163-177 and 208-222 of VP1, respectively, are capable of eliciting neutralizing antibodies against EV71 in the in vitro microneutralization assay. SP70 was identified to be particularly potent in eliciting a neutralizing antibody titer comparable to that obtained with a whole virion-immune serum. Immunization of mice with either SP55 or SP70 triggered an EV71-specific IgG response as high as that obtained with the whole virion as immunogen. The IgG sub-typing revealed that the neutralizing antibodies elicited by both synthetic peptides are likely belonging to the IgG1 sub-type. Alignment with databases showed that the amino acid residues of SP70 are highly conserved amongst the VP1 sequences of EV71 strains from various sub-genogroups. Altogether, these data indicate that SP70 represents a promising candidate for an effective synthetic peptide-based vaccine against EV71.     

TDP-43 in familial and sporadic frontotemporal lobar degeneration with ubiquitin inclusions

TAR DNA-binding protein 43 (TDP-43) is a major pathological protein of sporadic and familial frontotemporal lobar degeneration with ubiquitin-positive, tau-negative inclusions (FTLD-U) with or without motor neuron disease (MND). Thus, TDP-43 defines a novel class of neurodegenerative diseases called TDP-43 proteinopathies. We performed ubiquitin and TDP-43 immunohistochemistry on 193 cases of familial and sporadic FTLD with or without MND. On selected cases, immunoelectron microscopy and biochemistry were performed. Clinically defined frontotemporal dementias (FTDs) included four groups: 1) familial FTD with mutations in progranulin (n = 36), valosin-containing protein (n = 5), charged multivesicular body protein 2B (n = 4), and linked to chromosome 9p (n = 7); 2) familial cases of FTD with unknown gene association (n = 29); 3) sporadic FTD (n = 72); and 4) familial and sporadic FTD with MND (n = 40). Our studies confirm that the spectrum of TDP-43 proteinopathies includes most cases of sporadic and familial FTLD-U with and without MND and expand this disease spectrum to include reported families with FTD linked to chromosome 9p but not FTD with charged multivesicular body protein 2B mutations. Thus, despite significant clinical, genetic, and neuropathological heterogeneity of FTLD-U, TDP-43 is a common pathological substrate underlying a large subset of these disorders, thereby implicating TDP-43 in novel and unifying mechanisms of FTLD pathogenesis.     

Comparison of sonographic appearance of normal and postradiotherapy parotid glands: a preliminary study

This study was undertaken to evaluate and compare the grey-scale and Doppler sonographic features of postradiotherapy (RT) and normal parotid glands. A total of 10 patients with previous head and neck RT and with different degrees of xerostomia were included. Another 10 healthy subjects, who are age and gender-matched with the 10 patients, were also recruited. Grey-scale and Doppler ultrasound examinations of parotid glands were performed on both the patients and healthy subjects. The parotid glands were assessed for their size, echogenicity, echotexture, conspicuity of intraparotid ducts, blood flow velocity and vascular resistance. Results showed that post-RT parotid glands tended to be smaller than normal parotid glands with a significant difference in the transverse dimension (p < 0.05). Normal parotid glands appeared homogeneous, hyperechoic relative to the adjacent muscles and had marginally seen intraparotid ducts. Post-RT parotid glands were heterogeneous, isoechoic (50%) or hypoechoic (50%) relative to the adjacent muscles, and the intraparotid ducts were either marginally (50%) or obviously (50%) seen on ultrasound. The PSV, RI and PI of normal parotid glands were significantly higher than that of post-RT parotid glands (p < 0.05). However, the difference in EDV between normal and post-RT parotid glands was not significant (p > 0.05). In conclusion, ultrasound is useful in assessing parotid glands. To avoid image misinterpretation, post-RT changes in the sonographic appearance of parotid glands should be considered in examining patients with previous head and neck RT.     

Validation of the eleven-point pain scale in the measurement of migraine headache pain

The four-point pain scale (none, mild, moderate, severe) and the 11-point pain scale (0 = no pain, 10 = pain as bad as it could be) have been used in migraine studies to assess treatment efficacy. The primary objective of this study was to investigate the validity and responsiveness of the 11-point pain scale using the four-point pain scale as a benchmark. Using data from 95 migraine patients recruited from headache clinics, this study found that 11-point pain scale scores were highly correlated with four-point pain scores. The correlations between the pain scales were significantly higher than the correlations with quality of life measures such as functional ability and emotional feelings. The 11-point pain scale was 55% more sensitive than the four-point pain scale in detecting clinically important differences. The strong linear relationship between the two pain scales allowed researchers to transform four-point pain scores to 11-point pain scores using regression weights.     

Male Breast Cancer: A Population-Based Comparison with Female Breast Cancer in Hong Kong,Southern China: 1997–2006

Background

Male breast cancer (MBC) is uncommon. As a result, there is limited availability of studies and reviews and even fewer reports from Asia. This is the largest population-based study to compare Chinese MBC patients with female patients during a 10-year period in Hong Kong, Southern China.

Methods

A retrospective review of medical records of 132 male and 8,118 female breast cancer patients between year 1997 and 2006 in Hong Kong was performed. Each MBC patient was matched with three female breast cancer patients for further analysis. Different characteristics, overall, breast-cancer specific, and disease-free survivals (DFS) were compared.

Results

Mean age at diagnosis of male and female patients was 64.5 and 52.7 years respectively. Male patients showed lower histological grade, overall stage, smaller tumor size, and more positive sensitivity in hormone receptors. They were more likely to die of causes other than breast cancer. Matched analysis found that the 5-year overall survival (OS), breast-cancer–specific mortality, and DFS for male and female patients were 78.7, 90.5, 90.5, and 77.9, 86.4, and 81.4 % respectively. Male patients had poorer OS at early overall stage but better breast-cancer—specific mortality rates at any age (p < 0.01). Male patients had a significant risk of dying due to any cause in the presence of distant relapse and had less risk of dying when tumor was ER-positive and HER2-positive.

Conclusions

Chinese male breast cancer patients tend to have poorer OS but better breast-cancer—specific survival compared with their female counterparts.     

Hospital Costs Associated With Laparoscopic and Open Inguinal Herniorrhaphy

Purpose:

The purpose of this study was to compare the total hospital costs associated with elective laparoscopic and open inguinal herniorrhaphy.

Methods:

A prospectively maintained database was used to identify patients who underwent elective inguinal herniorrhaphy from April 2009 to March 2011. A retrospective review of electronic patient records was performed along with a standardized case-costing analysis using data from the Ontario Case Costing Initiative. The main outcomes were operating room (OR) and total hospital costs.

Results:

Two hundred eleven patients underwent elective unilateral inguinal herniorrhaphy (117 open and 94 laparoscopic), and 33 patients underwent elective bilateral inguinal herniorrhaphy (9 open and 24 laparoscopic). OR and total hospital costs for open unilateral inguinal hernia repair were significantly lower than for the laparoscopic approach (median total cost, $3207.15 vs $3723.66; P < .001). OR and total hospital costs for repair of elective bilateral inguinal hernias were similar between the open and laparoscopic approaches (median total cost, $4574.02 vs $4662.89; P = .827).

Conclusions:

In the setting of a Canadian academic hospital, when considering the repair of an elective unilateral inguinal hernia, the OR and total hospital costs of open surgery were significantly lower than for the laparoscopic techniques. There was no statistical difference between OR and total hospital costs when comparing open surgery and laparoscopic techniques for the repair of bilateral inguinal hernias. Given the perioperative benefits of laparoscopy, further studies incorporating hernia-specific outcomes are necessary to determine the cost-effectiveness of each approach and to define the optimal treatment strategy.