The role of Ifosfamide-doxorubicin chemotherapy in histology-specific, high grade, locally advanced soft tissue sarcoma, a 14-year experience

PURPOSE

To compare long-term outcomes of high-grade, primary soft-tissue-sarcoma (STS), using Ifosfamide-Doxorubicin vs local therapy alone, in histology-specific sarcomas.

METHODS

Retrospective analysis was performed on 127 patients from 2005 to 2018, with high-grade STS of extremity or trunk, >5 cm, that were either Synovial-Cell, Dedifferentiated-Liposarcoma (DDL), Myxofibrosarcoma, Round-Cell-Liposarcoma (RCLS), Undifferentiated-Pleomorphic-Sarcoma (UPS), or Undifferentiated-Sarcoma-not-otherwise-specified (US-NOS), with central pathology review. Ifosfamide-Doxorubicin was generally given neoadjuvant over 5 cycles, followed by radiation and wide excision, with chemotherapy given in 38 patients, while 89 received local therapy alone. Multi-variable-analysis (MVA) of prognostic factors was performed, and local-recurrence-free-survival (LRFS), distant-metastases-free-survival (DMFS), disease-specific-survival (DSS), and overall-survival (OS) were estimated using Kaplan-Meier, and adjusted using propensity-score matching.

RESULTS

Median follow-up was 4.5 years. Younger age (p < 0.0001) and Synovial histology (p = 0.0002) were more likely to undergo chemotherapy. Ifosfamide-Doxorubicin improved 5-year DMFS (p = 0.02), DSS (p = 0.01), and OS (p = 0.01), by univariate comparisons, as well as sub-analysis of non-synovial histology, but significance was lost after propensity-score matching for DMFS (p = 0.10), DSS (p = 0.09), and OS (p = 0.07). Size >10 cm, trunk location, and lack of chemotherapy significantly lowered DMFS, DSS, and OS on MVA, while DDL had more favorable survival; although size, trunk location, and DDL histology were not significantly different between treatment groups. Ifosfamide-Doxorubicin independently improved DMFS (p = 0.001), DSS (p = 0.01), and OS (p = 0.001) on MVA.

CONCLUSION

Ifosfamide-Doxorubicin may be more beneficial in younger patients with >5 cm, high-grade, STS of the trunk or extremity in Synovial-Cell, DDL, Myxofibrosarcoma, RCLS, UPS, and US-NOS.

The Efficacy of Silver-Ion Implanted Catheters in Reducing Peritoneal Dialysis-Related Infections

♦ Background

Dialysis-related infections are the commonest cause of catheter loss and transfer to hemodialysis. Surface modifications of the catheter that reduce infections are of major importance.

♦ Objective

The efficacy of silver-ion treated catheters in reducing dialysis-related infections was tested.

♦ Methods

The study design was a prospective, randomized controlled trial. Patients were implanted with either a silver-treated study catheter or a control catheter. Prospective collection of data included infectious complications and catheter survival.

♦ Results

The subject groups were comprised of 67 silver-treated catheters and 72 control catheters. Demographic characteristics of the study and control groups were equal. Exit-site infection rates for the study group and control group (0.52 and 0.45 episodes/patient-year of dialysis respectively) were not different by Poisson regression analysis ( p > 0.4). Peritonitis rates were identical for the two groups (0.37 episodes/patient-year) and were not different by Poisson analysis ( p > 0.9). Antibiotic-free intervals between infections for the study and control groups were not significantly different for exit-site infections ( p = 0.58), peritonitis ( p = 0.44), or both infections combined ( p = 0.47). Actuarial analyses showed no differences between the groups in the probability of remaining free of exit-site infection ( p> 0.2) or peritonitis ( p > 0.7). Similarly, catheter survival was not significantly different between the groups ( p > 0.6).

♦ Conclusion

Surface modification of catheters with ion beam implantation of silver produced no clinical effect with respect to reducing dialysis-related infections.

Prospective Comparison of Downward and Lateral Peritoneal Dialysis Catheter Tunnel-Tract and Exit-Site Directions

Objective

Guidelines for optimal peritoneal dialysis access support both downward and lateral exit-site directions. Numerous clinical reports support the superiority of downward exit sites but none substantiate lateral configurations.

Methods

This prospective study compared infectious and mechanical complications between 85 catheters with a preformed arcuate bend to produce a downward exit site and 93 catheters with a straight intercuff segment configured to create a lateral exit site.

Results

Kaplan–Meier survivals were not different for time to first exit-site infection ( p = 0.62), tunnel infection ( p = 0.89), or peritonitis ( p = 0.38) for downward and lateral exit-site directions. Poisson regression showed no differences in rates (episodes/patient-year) of exit-site infection (0.26 vs 0.27, p = 0.86), tunnel infection (0.02 vs 0.03, p = 0.79), peritonitis (0.42 vs 0.43, p = 0.87), or catheter loss (0.06 vs 0.09, p = 0.29) for downward and lateral exit sites. Kaplan–Meier analyses of antibiotic-free intervals for exit-site ( p = 0.94) and peritonitis infections ( p = 0.72) were not different for the two groups. There was one case of catheter tip displacement with flow dysfunction in each group. There were no pericatheter hernias or spontaneous cuff extrusions. Catheter survival between groups was not different ( p = 0.20).

Conclusions

Catheter types employing downward and lateral tunnel-tract and exit-site configurations produce equivalent outcomes for infectious and mechanical complications.

Complications of Radial Column Plating of the Distal Radius

Background: Distal radius fractures treated with open reduction and internal fixation are commonly stabilized with a volar locking plate; however, more complex fracture patterns may require supplemental fixation with fragment-specific implants. The objective of this study was to evaluate the outcomes of distal radius fractures treated with radial column plates. Methods: A consecutive series of 61 patients who sustained distal radius fractures underwent radial column plating alone or in conjunction with other implants between August 2006 and January 2014. Thirty-one patients returned for follow-up or returned a mailed questionnaire at an average of 4.1 years. The outcomes measures included Visual Analog Scale (VAS); Disabilities of the Arm, Shoulder and Hand (DASH); and Patient-Rated Wrist Evaluation (PRWE) scores. Results: Sixty-one patients with a mean age of 55 years (range, 20-87) met inclusion criteria and were available for follow-up or chart review at an average of 5.2 years (range, 1.6-9.0 years). Seventeen of 61 (28%) underwent radial column plate removal. Twenty patients returned for final follow-up examination, and 11 completed questionnaires via mail. Subjective scores included a mean postoperative VAS of 0.72, DASH score of 17.2, and PRWE score of 15.7. Hardware sensitivity and wrist stiffness were the most common complications at final follow-up. Conclusions: Radial column plating of the distal radius is a safe treatment modality and a valuable adjunct in the setting of complex distal radius fractures, but patients should be counseled that there is a 28% chance that hardware removal may be required. Our retrospective review found evidence of few complications and objective scores consistent with return to normal function.

Ten year treatment complication outcomes of radical prostatectomy versus external beam radiation therapy versus brachytherapy for 1,503 patients with intermediate risk prostate cancer

e16599

Background: To compare 10 year treatment complication outcomes of radical prostatectomy(RP) vs external beam radiation therapy(EBRT) vs brachytherapy(BT) for patients with intermediate risk prostate cancer(IRPC). Methods: A retrospective analysis was performed on 1,503 IRPC patients who underwent treatment from 2004 to 2007, using univariate comparisons. 819 underwent RP, 574 underwent EBRT, and 110 underwent BT using iodine-125. Urinary and rectal complications for RP were graded as severe if patients required ≥ 3 pads/diapers per day, required chronic use of condom catheter or penile clamp, daily self-catheterization, placement of sling or artificial urinary sphincter, or developed rectal fistula/incontinence. Complications for EBRT and BT were graded as severe if they were classified as grade 3 or 4 on the Radiation Therapy Oncology Group grading system for late effects. For erectile dysfunction, the prevalence of patients requiring injections, pumps or penile implants were calculated after a minimum of 1 year of follow up. Results: Median follow up was 10.0 years for RP, 9.6 for EBRT, and 9.8 for BT. Neoadjuvant androgen deprivation therapy was given in 0.6% for RP patients vs 58.9% of EBRT vs 12.7% of BT, p < 0.0001. Median age for RP vs EBRT vs BT was 62.1, 70.8, 65.3, p < 0.0001. The 10-year prevalence of severe urinary complications for RP vs EBRT vs BT was 10.1%, 12.5%, 4.6%, p = 0.04. The percentage of patients having a pre-treatment American Urological Association(AUA) urinary score for RP vs EBRT vs BT was 7.3%, 11.5%, 97.3%, p < 0.0001. The 10-year prevalence of severe rectal complications for RP vs EBRT vs BT was 0.5%, 1.6%, 0.0%, p = 0.06. The 10-year prevalence of erectile dysfunction devices for RP vs EBRT vs BT was 24.3%, 6.6%, 8.2%, p < 0.0001. Conclusions: After 10 years of follow-up, BT had the lowest rate of severe urinary complications, which may due to using the AUA score to avoid implanting those who had significant baseline obstructive voiding symptoms. EBRT had a higher rate of severe rectal complications. RP had the highest probability of undergoing treatment using erectile dysfunction devices, despite having younger patients.

Ten year treatment complication outcomes of radical prostatectomy versus external beam radiation therapy versus brachytherapy for 1,503 patients with intermediate risk prostate cancer

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Background: To compare 10 year treatment complication outcomes of radical prostatectomy(RP) vs external beam radiation therapy(EBRT) vs brachytherapy(BT) for patients with intermediate risk prostate cancer(IRPC). Methods: A retrospective analysis was performed on 1,503 IRPC patients who underwent treatment from 2004 to 2007, using univariate comparisons. 819 underwent RP, 574 underwent EBRT, and 110 underwent BT using iodine-125. Urinary and rectal complications for RP were graded as severe if patients required ≥ 3 pads/diapers per day, required chronic use of condom catheter or penile clamp, daily self-catheterization, placement of sling or artificial urinary sphincter, or developed rectal fistula/incontinence. Complications for EBRT and BT were graded as severe if they were classified as grade 3 or 4 on the Radiation Therapy Oncology Group grading system for late effects. For erectile dysfunction, the prevalence of patients requiring injections, pumps or penile implants were calculated after a minimum of 1 year of follow up. Results: Median follow up was 10.0 years for RP, 9.6 for EBRT, and 9.8 for BT. Neoadjuvant androgen deprivation therapy was given in 0.6% for RP patients vs 58.9% of EBRT vs 12.7% of BT, p < 0.0001. Median age for RP vs EBRT vs BT was 62.1, 70.8, 65.3, p < 0.0001. The 10-year prevalence of severe urinary complications for RP vs EBRT vs BT was 10.1%, 12.5%, 4.6%, p = 0.04. The percentage of patients having a pre-treatment American Urological Association(AUA) urinary score for RP vs EBRT vs BT was 7.3%, 11.5%, 97.3%, p < 0.0001. The 10-year prevalence of severe rectal complications for RP vs EBRT vs BT was 0.5%, 1.6%, 0.0%, p = 0.06. The 10-year prevalence of erectile dysfunction devices for RP vs EBRT vs BT was 24.3%, 6.6%, 8.2%, p < 0.0001. Conclusions: After 10 years of follow-up, BT had the lowest rate of severe urinary complications, which may due to using the AUA score to avoid implanting those who had significant baseline obstructive voiding symptoms. EBRT had a higher rate of severe rectal complications. RP had the highest probability of undergoing treatment using erectile dysfunction devices, despite having younger patients.

Abstract TMP56: Are Depressed Stroke Survivors Less Likely to Be Adherent to Secondary Prevention Therapies?

Introduction: Depression is common after ischemic stroke (IS). Stroke survivors who are depressed are at greater risk for suboptimal recovery, recurrent vascular events, poor quality of life, and mortality. However, how depression leads to poor IS outcomes is unclear and few studies have shown an association between depression after stroke and healthcare use. Objective: To evaluate the impact of depression on medication adherence after stroke.

Methods: We analyzed the multicenter database comprising information drawn from electronic medical records and pharmacy records (Healthconnect, POINT). All ischemic stroke patients presenting to one of 11 medical centers within a health maintenance organization in California between January 1, 2007 and June 30, 2015 with at least 2 medication fills for a stroke prevention medication and six months of information were evaluated. Adherence was calculated for antihypertensive, hypoglycemic, and lipid lowering medications, but not for antiplatelet or anticoagulant medications as the latter may be obtained over the counter, or with variable daily dosing, which would bias adherence calculations. Adherence was calculated by using the continuous medication gap (CMG) methodology, which determines the cumulative period that no medication was available to the patient. The number of days for which the patient did not have the medication was divided by the number of days in the study window for that patient.

Results: There were 9933 patients with ischemic stroke during the study period. Of these, 2019 had a diagnosis of depression made after the index stroke. Among the non-clinically depressed patients the CMG adherence was 0.22 (Standard Deviation +/- 0.29), while among clinically depressed patients it was 0.28 (SD +/-0.32, p<0.0001).

Conclusions: Ischemic stroke survivors diagnosed with depression after an index stroke are overall 26% less likely to be adherent to key secondary prevention drugs than their non-depressant counterparts. Poor medication adherence among depressed stroke patients may be an important contributor to their relatively poorer clinical outcomes.

Carnoy's solution fixation with compression significantly increases the number of lymph nodes yielded from colorectal cancer specimens

BACKGROUND AND OBJECTIVES

Carnoy's fixation and compression represents a novel technique to enhance lymph node evaluation and accuracy of staging after colorectal cancer resection.

METHODS

This study was performed in all adults undergoing colorectal cancer operations by Kaiser Permanente surgeons at two separate facilities. Patients were assigned to either location based upon surgeon and patient availability. One group of patients had their lymph nodes examined with current standard manual technique (MT). The other group had their specimens fixed with Carnoy's solution and then compressed (CT) to assess for lymph nodes.

RESULTS

A total of 157 patients were enrolled. Seventy-eight patient specimens underwent MT and 79 patient specimens underwent the new compression technique (CT). CT resulted in a significant increase in total lymph node yield per specimen (37.6 ± 18.5 nodes with CT vs 18.9 ± 8.8 nodes with MT; P < 0.0001). CT also resulted in sufficient lymph node sampling (>12 nodes) in all 79 patients in the group compared with 13 of 78 patients (17%) with an insufficient lymph node evaluation in the MT group ( P = 0.0002).

CONCLUSION

This study demonstrated that Carnoy's fixation with compression can significantly increase lymph node yields in colorectal cancer specimens and allow for a higher rate of adequate lymph node sampling.

Mail order pharmacy use and adherence to secondary prevention drugs among stroke patients

BACKGROUND AND PURPOSE

Mail order pharmacies (MOP) are increasingly being used to deliver medications for chronic disease management. Their use is linked to similar or even greater medication adherence than local pharmacy (LP) use. We are unaware of any studies that have evaluated the association of mail order pharmacy use with drug adherence among stroke patients.

METHODS

We conducted cross-sectional analyses of patients discharged with ischemic stroke from 24 hospitals in a managed care network, who received a new anticoagulant, antiplatelet, anti-glycemic, antihypertensive, and/or lipid-lowering medication between January 1, 2007 and June 30, 2015. We defined good adherence as medication availability ≥80% of the time, and compared adherence between mail-order users (≥66% of refills by mail) and local pharmacy users (all refills in person). Relationship between delivery method and adherence was evaluated using multivariate regression models.

RESULTS

A total of 44,658 eligible patients refilled an index medication. Of these, 13,295 in the LP and 6801 in MOP groups met inclusion criteria. Patients in the MOP group were more likely to be white, and less likely to have hypertension, diabetes, and smoke tobacco. Continuous Medication Gap (CMG) adherence was 0.28 in the LP group and 0.11 in the MOP group (p < 0.001). At 90-days there were 893 hospital readmissions for the LP group and 375 for the MOP group for a rate of 0.07 vs 0.06 (p < 0.001). In the multivariable analysis, adherence was associated with MOP use, (OR 0.12, 95% CI 0.11-0.14) and decreased readmission at 90 days (OR 0.62, 95% CI 0.55-0.71).

CONCLUSIONS

Stroke patients who use MOP vs. LP are more likely to have good medication adherence. Future studies should examine the impact of mail-order pharmacy use on vascular risk marker control and events after stroke.

Ten year treatment outcomes of radical prostatectomy vs external beam radiation therapy vs. brachytherapy for 1,503 patients with intermediate risk prostate cancer

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Background: To compare 10-year treatment outcomes of RP (radical prostatectomy) vs EBRT (external beam radiation therapy) vs BT (brachytherapy) for patients with IRPC (intermediate risk prostate cancer). Methods: A retrospective analysis using propensity score matching was performed on 1,503 IRPC patients who underwent treatment from 2004 to 2007. 819 underwent RP, 574 underwent EBRT to a median dose of 75.3 Gray, and 110 underwent BT using iodine-125. Biochemical failure was defined by the AUA (American Urological Association) definition of PSA (prostate specific antigen) failure for RP patients, and the ASTRO-Phoenix definition (American Society of Therapeutic Radiology and Oncology) for the EBRT and BT patients. Results: Median follow up was 10 years for RP, 9.6 for EBRT, and 9.8 for BT (range 1-13.4 years). With RP 76.3% had Gleason score 7 vs 72.8% for EBRT vs 57.3% for BT, p = 0.0001. Median initial PSA was 7.4 for RP, 9.4 for EBRT, and 8.3 for BT, p < 0.0001. Neoadjuvant androgen deprivation therapy was given in 58.9% of EBRT patients vs 12.7% of BT vs 0.6% for RP, p < 0.0001. Only 14% of BT received supplemental external radiation. The 10-year FFBF (freedom from biochemical failure) was 82.0% for BT vs 58.0% for RP vs 58.8% for EBRT, p < 0.0001. Subset analysis of unfavorable IRPC patients showed a 10 year FFBF of 81.6% for BT vs 55.8% for RP vs 51.0% for EBRT, p < 0.0001. The 10-year freedom from salvage therapy was 89.5% for BT vs 64.0% for RP vs 73.4% for EBRT, p < 0.0001. There were no significant differences in distant metastases-free survival, prostate cancer-specific survival, or overall survival after adjusting for age. Multivariate analysis between pairwise groups with BT balanced by stabilized inverse probability of treatment weights showed that BT remained an independent predictor for improved FFBF, p = 0.049 for BT vs EBRT, and p < 0.0001 for BT vs RP. Conclusions: Brachytherapy using iodine-125 is a reasonable treatment option for IRPC patients. Although BT showed improved FFBF after propensity score matching, this did not impact overall survival.

Abstract TMP101: Mail Order Pharmacy Use is Associated With Greater Adherence to Secondary Preventive Medications and Lower Hospital Readmission Among Stroke Patients

Background: Mail order pharmacies (MOP) are increasingly being used to deliver medications for chronic disease management. Their use is linked to similar or greater medication adherence than local pharmacy (LP) use. Medication adherence is associated with improved outcomes, including reduced cardiovascular events, health care costs, and mortality. We are unaware of any studies that have evaluated the association of MOP use with medication adherence among stroke patients.

Objective: To investigate whether stroke patients who use MOPs were more likely to have good medication adherence than those who used LPs and whether adherence was associated with 90 day hospital re-admission after stroke.

Methods: We conducted cross-sectional analyses of patients discharged with ischemic stroke from 24 hospitals who received a new anticoagulant, antiplatelet, antiglycemic, antihypertensive, and/or lipid-lowering medication between 01/JAN/2007 and 30/JUL/2016. We compared adherence between MOP users (at least 66% of refills by mail) and LP users (all refills in person). Adherence was calculated by using the Continuous Medication Gap (CMG) methodology, which determines the cumulative period that no medication was available to the patient. The number of days for which the patient did not have the medication is divided by the number of days in the study window for that patient. A CMG adherence score of 0 meant that the patient had no overall gaps in their medications (perfect adherence), a negative number meant that the patient had more medication than days, and a positive number meant that the patient did not have enough medication for the days they should be taking their medication (poor adherence).

Results: A total of 44,658 eligible patients refilled an index medication. Of these, 13,676 in the LP and 6,907 in MOP group met inclusion criteria. CMG adherence was 0.28 in the LP group and 0.11 in the MOP group ( p < 0.001). At 90-days there were 893 hospital readmissions for the LP group and 375 for the MOP group for a rate of 0.073 vs. 0.058 (p < 0.001).

Conclusions: Stroke patients who obtain medication by mail are more likely to have good adherence, and less likely to be readmitted than those who obtain medications from their local pharmacies.

Outcomes of Elbow Arthroscopic Osteocapsular Arthroplasty

PURPOSE

To evaluate the results of elbow arthroscopic osteocapsular arthroplasty (AOA) and determine which factors influence the outcome in a large group of patients with primary osteoarthritis.

METHODS

A consecutive series of 46 patients with elbow osteoarthritis underwent AOA by a single surgeon (N.G.H.) between December 2005 and January 2013. Thirty-one patients returned for a comprehensive physical examination an average of 3.4 years later. The outcomes measures included visual analog scale (VAS), Mayo Elbow Performance Scores (MEPS), Disabilities of the Arm, Shoulder, and Hand (DASH), and American Shoulder and Elbow Society (ASES) scores. Preoperative and postoperative continuous variables were compared and a multivariable regression analysis was performed.

RESULTS

Thirty-one patients with a mean age of 48 years (range, 19-77 years) returned for final follow-up, including 27 men and 4 women. Statistically significant improvement was observed in extension deficit (24° before surgery to 12° after surgery), flexion (126° before surgery to 135° after surgery), visual analog scale (6.4 before surgery to 1.6 after surgery), and Mayo Elbow Performance Scores (57 [poor] before surgery to 88 [good] after surgery). Subjective scores included a mean postoperative Disabilities of the Arm, Shoulder, and Hand score of 13 and an American Shoulder and Elbow Society pain score of 40. No complications were noted at final follow-up.

CONCLUSIONS

Elbow AOA is a safe, efficacious treatment for patients with mild to moderate osteoarthritis. Our retrospective review found significant improvement in elbow motion, pain and clinical outcomes.

Identification and evaluation of risk factors in patients with continuously uncontrolled hypertension

An aggressive strategy to manage hypertension in a large integrated healthcare organization achieved blood pressure control in 82% of hypertensive patients, as compared with 52% nationwide. It is unknown why the remaining 18% is uncontrolled. The objective of this study was to identify characteristics associated with patients whose blood pressure remains continuously uncontrolled. This nested case-control study included 1583 continuously uncontrolled cases and 7901 matched controls. Univariate analysis revealed patients who visited their primary care provider frequently (odds ratio, 0.42; 95% confidence interval, 0.39-0.46) were adherent to antihypertensive medications (odds ratio, 0.12; 95% confidence interval, 0.10-0.14), and dispensed more medications (odds ratio, 0.86; 95% confidence interval, 0.85-0.87) were less likely to be continuously uncontrolled. Patient characteristics that were associated with continuously uncontrolled hypertension were the Patient Health Questionnaire-9 score and higher body mass index. Since patients with controlled hypertension visited their provider more often, patients with continuously uncontrolled hypertension may benefit from more interaction with their healthcare system.

Arthroscopic surgery for global versus focal pincer femoroacetabular impingement: are the outcomes different?

To determine outcomes from arthroscopic surgery for global pincer femoroacetabular impingement (FAI), a large multicenter prospective study investigating arthroscopic surgical outcomes was performed with minimum 2-year follow-up. Global (center-edge angle 40+ degrees) and Focal (center-edge angle 25–39 degrees) cohorts were based on pre-operative radiographs. Pre-operative and intra-operative findings, surgical procedures, post-operative nonarthritic hip score (NAHS) and satisfaction (5-point Likert scale), complications and conversion arthroplasties were compared. A nested case–control study was also performed. The Global cohort consisted of 15 patients (18 hips) of mean age 37.2 years. Pre-operative NAHS was 51.5 and 74.1 at 24+ months post-surgery. The change in NAHS was significant (P = 0.01). Mean satisfaction was 4.2. There was one total hip arthroplasty (THA) conversion (5.6%), no revision surgeries or complications. The Focal cohort consisted of 125 patients (129 hips) of mean age 39.8 years. Pre-operative NAHS was 54.8 and 77.8 at 24+ months post-surgery. The change in NAHS was significant (P < 0.0001). Mean satisfaction was 4.2. There were eight THA conversions (6.2%), three complications (2.3%) and two revision surgeries (1.5%). Cohort comparisons revealed no statistically significant difference in NAHS (P = 0.30), satisfaction (P = 0.92) or THA conversion rate (P = 0.91). The nested case–control study found mean post-operative change in NAHS was +22.2 and +20.4, respectively, at 24+ months (P = 0.76). Arthroscopic treatment of global pincer FAI is a safe and effective procedure. With outcomes comparable to those observed in the arthroscopic treatment of lesser focal deformities, arthroscopic surgery provides a less invasive option for the treatment of global pincer FAI.

A large cohort study evaluating risk factors associated with uncontrolled hypertension

Hypertension is the most common primary diagnosis in the United States. Risks for long-term consequences such as myocardial infarction, heart failure, stroke, and kidney disease continue to significantly increase as long as hypertension remains uncontrolled. This retrospective cohort study of 661,075 patients identified with uncontrolled hypertension, defined as systolic blood pressure (SBP) ≥ 140 mm Hg and/or diastolic blood pressure (DBP) ≥ 90 mm Hg, from a large integrated healthcare organization was conducted to examine multiple patient characteristics to determine their association with uncontrolled hypertension. Multivariate analysis revealed that compared with Caucasians, African Americans (odds ratio [OR], 1.18; 95% confidence interval [CI], 1.16-1.20) were significantly associated with uncontrolled hypertension, as were unpartnered populations (OR, 1.15; 95% CI, 1.14-1.17), number of antihypertensive medications prescribed (OR, 1.37; 95% CI, 1.33-1.41), and adherence to most antihypertensive medications. A secondary analysis found an association between uncontrolled blood pressure and Patient Health Questionnaire-9 (PHQ-9) score (OR, 1.21; 95% CI, 1.16-1.26). Our findings suggest that the presence of these identified risk factors recommends a commitment to a more aggressive hypertension management program to prevent cardiovascular disease caused by uncontrolled hypertension.

Embedded Catheters: Minimizing Excessive Embedment Time and Futile Placement while Maintaining Procedure Benefits

BACKGROUND

Embedding peritoneal catheters far in advance of anticipated need may successfully commit patients to their modality choice and reduce central venous catheter use but can be complicated by excessive embedment periods and futile catheter placement.

OBJECTIVE

Embedded catheter outcomes were studied to identify factors that minimize inordinate embedment time and futile placement while maintaining procedure benefits.

METHODS

Clinical and laboratory data were examined in 107 patients with embedded catheters that were either externalized, remained embedded, or were futilely placed.

RESULTS

Externalization of 84 catheters was performed after a median embedment period of 9.4 months. Flow dysfunction occurred in 14.3% of externalized catheters. Overall function rate was 98.8% after laparoscopic revision. One patient changed their mind about modality choice. Except for 1 patient hospitalized acutely in a facility unfamiliar with embedded catheters, none remaining on a peritoneal dialysis pathway initiated dialysis with a central venous catheter. Including catheters with extremely long embedment periods, the incidence of futile placement was 13.1%. Multiple regression analysis identified estimated glomerular filtration rate (eGFR) and serum albumin as the 2 variables best associated with catheter embedment duration (r(2) = 0.44, p < 0.0001). Diabetic nephropathy was statistically more likely to be associated with lower serum albumin values (p < 0.0001); however, no association was noted between diabetic status and embedment duration (p = 0.62).

CONCLUSIONS

Timing of the embedment procedure should include appraisal of both eGFR and serum albumin. Appropriate consideration of these values together may help minimize excessive embedment periods and decrease futile placements while preserving procedure benefits.

Arthroscopic hip labral reconstruction with a gracilis autograft versus labral refixation: 2-year minimum outcomes

BACKGROUND

There is high interest but very little evidence to support labral reconstruction of the hip. Purpose/

HYPOTHESIS

The purpose of this study was to determine the clinical effectiveness of arthroscopic hip labral reconstruction using gracilis autograft in the multistep surgeries for femoroacetabular impingement (FAI). The hypothesis was that patients undergoing arthroscopic hip labral reconstruction with gracilis autograft would have improvement in symptoms and function attributable to this procedure.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A comparative retrospective review at a large medical facility was performed of patients who underwent labral reconstruction with a gracilis autograft (RECON group) and those who underwent labral refixation (REFIX group) between October 2008 and November 2009. Inclusion criteria were adult patients having undergone arthroscopic surgery for symptomatic cam-pincer FAI without advanced radiographic osteoarthritis, who had both acetabular and femoral osteoplasties with a minimum 2-year follow-up. Patient satisfaction and preoperative and postoperative nonarthritic hip scores (NAHS) were obtained. Predictive modeling, linear regression, and a nested case-control study were performed.

RESULTS

A total of 54 patients met the inclusion criteria. The RECON group (n = 8; mean age, 34.6 years; range, 18-58 years) with an average 30-month follow-up (range, 24-37 months) and 100% participation reported a high level of patient satisfaction (7 high, 1 moderate). The mean NAHS improved by 50.5 points (P = .008) in the RECON group and 22.5 points (P < .0001) in the REFIX group; however, the preoperative NAHS was lower (P < .05) in the RECON group than in the REFIX group. Only the surgery group (RECON vs REFIX) and the preoperative NAHS were significantly associated with the NAHS at follow-up. The predictive model and linear regression revealed a 15.0- and 14.6-point increase, respectively, in the postoperative NAHS in the RECON group compared with the REFIX group. There were no major complications, revision surgeries, or conversion arthroplasties after labral reconstruction.

CONCLUSION

Arthroscopic hip labral reconstruction with gracilis tendon autograft is a safe and effective procedure. Patients undergoing labral reconstruction may not necessarily have outcomes inferior to those of patients undergoing labral refixation despite more severe initial labral insufficiency.

Triage of patients with acute diverticulitis: are some inpatients candidates for outpatient treatment?

AIM

Current recommendations regarding the triage of patients with acute diverticulitis for inpatient or outpatient treatment are vague. We hypothesized that a significant number of patients treated as an inpatient could be managed as an outpatient.

METHOD

A retrospective cohort study was carried out of 639 patients admitted for a first episode of diverticulitis. The diagnosis of acute diverticulitis was confirmed by computed tomography (CT). The endpoints included length of stay, need for surgery, percutaneous drainage and mortality. Patients were considered to have had a minimal hospitalization, defined as survival to discharge without needing a procedure, hospitalization of ≤ 3 days and no readmission for diverticulitis within 30 days after discharge.

RESULTS

Of 639 patients, 368 (57.6%) had a minimal hospitalization. Female gender and CT scan findings of free air/fluid were negatively associated with the likelihood of minimal hospitalization. The presence of an abscess < 3 cm and stranding on CT did not predict the need for a higher level of care. Despite the statistical significance of several patient-level predictors, the model did not identify patients likely to need only minimal hospitalization.

CONCLUSION

Most patients admitted with acute diverticulitis are discharged after minimal hospitalization. Free air/liquid in a patient admitted for acute diverticulitis indicates a more severe clinical course.

Incidence of atypical nontraumatic diaphyseal fractures of the femur

Bisphosphonates reduce the rate of osteoporotic fractures in clinical trials and community practice. "Atypical" nontraumatic fractures of the diaphyseal (subtrochanteric or shaft) part of the femur have been observed in patients taking bisphosphonates. We calculated the incidence of these fractures within a defined population and examined the incidence rates according to duration of bisphosphonate use. We identified all femur fractures from January 1, 2007 until December 31, 2011 in 1,835,116 patients older than 45 years who were enrolled in the Healthy Bones Program at Kaiser Southern California, an integrated health care provider. Potential atypical fractures were identified by diagnostic or procedure codes and adjudicated by examination of radiographs. Bisphosphonate exposure was derived from internal pharmacy records. The results showed that 142 patients had atypical fractures; of these, 128 had bisphosphonate exposure. There was no significant correlation between duration of use (5.5 ± 3.4 years) and age (69.3 ± 8.6 years) or bone density (T-score -2.1 ± 1.0). There were 188,814 patients who had used bisphosphonates. The age-adjusted incidence rates for an atypical fracture were 1.78/100,000/year (95% confidence interval [CI], 1.5-2.0) with exposure from 0.1 to 1.9 years, and increased to 113.1/100,000/year (95% CI, 69.3-156.8) with exposure from 8 to 9.9 years. We conclude that the incidence of atypical fractures of the femur increases with longer duration of bisphosphonate use. The rate is much lower than the expected rate of devastating hip fractures in elderly osteoporotic patients. Patients at risk for osteoporotic fractures should not be discouraged from initiating bisphosphonates, because clinical trials have documented that these medicines can substantially reduce the incidence of typical hip fractures. The increased risk of atypical fractures should be taken into consideration when continuing bisphosphonates beyond 5 years.

Injuries in professional modern dancers: incidence, risk factors, and management

Modern (or contemporary) dance has become increasingly popular, yet little has been reported with respect to modern dance injuries and their consequences. The purpose of this study is to define the incidence, risk factors, and management of musculoskeletal injuries in professional modern dancers. A total of 184 dancers in the United States completed an anonymous 17-page questionnaire on their injuries, including extensive details regarding the two most severe injuries that had occurred in the prior 12 months. According to their self-reports, a total of 82% of the dancers had suffered between one and seven injuries. The foot and ankle (40%) was the most common site of injury, followed by the lower back (17%) and the knee (16%). The rate of injuries was 0.59 per 1,000 hours of class and rehearsal. Injured male dancers returned to full dancing after a median of 21 days, while females returned after a median of 18 days. Most dancers missed no performances due to injury. Of the medical consultations sought by dancers for their injuries, 47% were made to physicians, 41% to physical therapists, and 34% to chiropractors. The majority of dancers adhered to the advice given them by consultants (87% of males and 78% of females for the most severe injury). While the majority of injuries were considered work-related (61% of the most severe injury and 69% of the second most severe), few were covered by Workers' Compensation insurance (12% and 5% respectively). These professional modern dancers suffer from a rate of injury similar to other groups of professional dancers. Most dancers return to a partial level of dancing several weeks before attempting full-capacity dancing.

Comparative analysis of two-piece extended peritoneal dialysis catheters with remote exit-site locations and conventional abdominal catheters

BACKGROUND

An alternative peritoneal catheter exit-site location is sometimes needed in patients with obesity, floppy skin folds, intestinal stomas, urinary and fecal incontinence, and chronic yeast intertrigo. Two-piece extended catheters permit remote exit-site locations away from problematic abdominal conditions.

OBJECTIVE

The effect on clinical outcomes by remotely locating catheter exit sites to the upper abdomen or chest was compared to conventional lower abdominal sites.

METHODS

In a nonrandomized design, peritoneal access was established with 158 extended catheters and 270 conventional catheters based upon body habitus and special clinical needs. Prospective data collection included patient demographics, infectious and mechanical complications, and catheter survival.

RESULTS

Kaplan-Meier survival time until first exit-site infection was longer for extended catheters (p = 0.03). Poisson regression showed no difference in exit site, subcutaneous tunnel, and peritonitis infection rates; however, the proportion of catheters lost during peritonitis episodes was significantly greater for extended catheters (p = 0.007) and appeared to be due primarily to coagulase-negative staphylococcus organisms. Poisson regression showed interactions of body mass index (BMI) and diabetic status in determining catheter loss from peritonitis for both catheter types (p = 0.02). Extended catheter patients had higher BMI and diabetes prevalence (p < 0.0001). Overall extended catheter survival at 1, 2, and 3 years (92%, 80%, 71%) trended lower than conventional devices (93%, 87%, 80%; p = 0.0505).

CONCLUSIONS

Extended catheters enable peritoneal access for patients in whom conventional catheter placement would be difficult or impossible. Certain patient and extended-catheter characteristics may contribute to loss from peritonitis.

Outpatient treatment of acute diverticulitis: rates and predictors of failure

PURPOSE

Many patients with acute diverticulitis can be managed as outpatients, but the success rate of this approach has not been thoroughly studied. We analyzed a large cohort of patients treated on an outpatient basis for an initial episode of acute diverticulitis to test our hypothesis that outpatient treatment of acute diverticulitis is highly effective.

METHODS

We analyzed patients within the Kaiser Permanente Southern California system (from 2006 to 2007) who were diagnosed with an initial episode of diverticulitis during an emergency room visit and subsequently discharged home. Each patient underwent a computed tomography (CT) scan for diagnosis or for confirmation of a diagnosis, and each radiologic report was evaluated regarding the presence of free fluid, phlegmon, perforation, and abscess. Treatment failure was defined as a return to the emergency room or an admission for diverticulitis within 60 days of the initial evaluation.

RESULTS

Our study included 693 patients, of whom 54% were women, the average age was 58.5 years, and 6% failed treatment. In multivariate analysis, women (odds ratio, 3.08 [95% CI, 1.31-7.28]) and patients with free fluid on CT scan (odds ratio, 3.19 [95% CI, 1.45-7.05]) were at significantly higher risk for treatment failure. Age, white blood cell count, Charlson score, and duration of antibiotics were not significant predictive factors.

CONCLUSIONS

In a retrospective analysis, among a cohort of patients who were referred for outpatient treatment, we found that such treatment was effective for the vast majority (94%) of patients. Women and those with free fluid on CT scan appear to be at higher risk for treatment failure.

Effect of Prior Abdominal Surgery, Peritonitis, and Adhesions on Catheter Function and Long-Term Outcome on Peritoneal Dialysis

Adhesions from previous surgery and peritonitis can lead to peritoneal dialysis catheter insertion failure, visceral injury, and poor dialysis function. Employing a laparoscopic approach, the effect of adhesiolysis on mechanical catheter complications and long-term catheter survival was prospectively examined in 436 catheter placement procedures having a 57.8 per cent prevalence rate of previous surgery. Adhesiolysis was required in 31.8 per cent of cases with prior surgery and in 3.3 per cent of procedures without previous operations. The incidence of adhesiolysis was directly related to the number of prior surgeries ( P < 0.0001). The incidence of catheter insertion failure from extensive adhesions was 1.8 per cent. Survival probability free from catheter obstruction was lower in patients requiring adhesiolysis compared with subjects with prior surgery not requiring adhesiolysis ( P = 0.01). Laparoscopic rescue procedures limited catheter losses from flow obstruction to only 0.7 per cent. As a result, long-term catheter survival was not different among patients regardless of prior surgery and/or adhesion status ( P = 0.2). Scars on the abdomen and prior peritonitis do not predict the extent of adhesions and should not be used to judge eligibility for peritoneal dialysis. Presently, laparoscopy is the only practical way to provide optimal peritoneal access in patients with a history of surgery and peritonitis.

Knee replacement: epidemiology, outcomes, and trends in Southern California: 17,080 replacements from 1995 through 2004

BACKGROUND AND PURPOSE

There are limited population-based data on utilization, outcomes, and trends in total knee arthroplasty (TKA). The purpose of this study was to examine TKA utilization and short-term outcomes in a pre-paid health maintenance organization (HMO), and to determine whether rates and revision burden changed over time. We also studied whether this population is representative of the general population in California and in the United States.

METHODS

Using hospital utilization and membership databases from 1995 through 2004, we calculated incidence rates (IRs) of primary and revision TKA for every 10,000 health plan members. The demographics of the HMO population were compared to published census data from California and the United States.

RESULTS

The age and sex distributions of the study population were similar to those of the general population in California and the United States. 15,943 primary TKAs and 1,137 revision TKAs were performed during the 10-year period. Patients below the age of 65 accounted for one-third of all primary replacements and one-third of all revision replacements. IRs of primary TKAs increased from 6.3 per 10,000 in 1995 to 11.0 per 10,000 in 2004, at a rate of 5% per year (p<0.001). IRs of revision TKAs increased from 0.41 per 10,000 in 1995 to 0.74 per 10,000 in 2004 (p=0.4). Revision burden remained stable over the 10-year observation period. Surgical complications were higher in revision TKA than in primary TKA (10% vs. 7.7%; p=0.007). 90 day complication rates for primary and revision TKA including death were 0.3% and 0.6% (p=0.1) and for pulmonary embolism 0.5% and 0.4% (p=0.6). 90 day re-admission rates for primary and revision TKA including infection were 0.5% and 4.2% (p<0.001), for myocardial infarction 0.1% each, and for pneumonia 0.2% and 0.4% (p=0.08).

INTERPRETATION

The incidence of primary and revision TKA increased between 1995 and 2005. The rates of postoperative complications were low. Comparisons of the study population and the underlying general populations of interest indicate that this population can be used to predict the incidences and outcomes of TKA in the general population of California and of the United States as a whole.

Sodium bicarbonate vs sodium chloride for the prevention of contrast medium-induced nephropathy in patients undergoing coronary angiography: a randomized trial

CONTEXT

Sodium bicarbonate has been suggested as a possible strategy for prevention of contrast medium-induced nephropathy, a common cause of renal failure associated with prolonged hospitalization, increased health care costs, and substantial morbidity and mortality.

OBJECTIVE

To determine if sodium bicarbonate is superior to sodium chloride for preventing contrast medium-induced nephropathy in patients with moderate to severe chronic kidney dysfunction who are undergoing coronary angiography.

DESIGN, SETTING, AND PATIENTS

Randomized, controlled, single-blind study conducted between January 2, 2006, and January 31, 2007, and enrolling 353 patients with stable renal disease who were undergoing coronary angiography at a single US center. Included patients were 18 years or older and had an estimated glomerular filtration rate of 60 mL/min per 1.73 m(2) or less and 1 or more of diabetes mellitus, history of congestive heart failure, hypertension, or age older than 75 years.

INTERVENTIONS

Patients were randomized to receive either sodium chloride (n = 178) or sodium bicarbonate (n = 175) administered at the same rate (3 mL/kg for 1 hour before coronary angiography, decreased to 1.5 mL/kg per hour during the procedure and for 4 hours after the completion of the procedure).

MAIN OUTCOME MEASURE

The primary end point was a 25% or greater decrease in the estimated glomerular filtration rate on days 1 through 4 after contrast exposure.

RESULTS

Median patient age was 71 (interquartile range, 65-76) years, and 45% had diabetes mellitus. The groups were well matched for baseline characteristics. The primary end point was met in 13.3% of the sodium bicarbonate group and 14.6% of the sodium chloride group (relative risk, 0.94; 95% confidence interval, 0.55-1.60; P = .82). In patients randomized to receive sodium bicarbonate vs sodium chloride, the rates of death, dialysis, myocardial infarction, and cerebrovascular events did not differ significantly at 30 days (1.7% vs 1.7%, 0.6% vs 1.1%, 0.6% vs 0%, and 0% vs 2.2%, respectively) or at 30 days to 6 months (0.6% vs 2.3%, 0.6% vs 1.1%, 0.6% vs 2.3%, and 0.6% vs 1.7%, respectively) (P > .10 for all).

CONCLUSION

The results of this study do not suggest that hydration with sodium bicarbonate is superior to hydration with sodium chloride for the prevention of contrast medium-induced nephropathy in patients with moderate to severe chronic kidney disease who are undergoing coronary angiography.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00312117.

Hospitalization rates in daily home hemodialysis versus peritoneal dialysis patients in the United States

BACKGROUND

Daily hemodialysis (DHD) is associated with improvements in hypertension, left ventricular hypertrophy, mineral metabolism, nutrition, and quality of life, but efficacy is uncertain because of potential selection bias. To reduce the influence of selection bias, we sought to compare hospital admissions for our population of DHD patients with peritoneal dialysis (PD) patients who initiated training during the same period. We also compared our hospital data with the US Renal Data Service database.

STUDY DESIGN

Prospective nonrandomized cohort study.

SETTING & PARTICIPANTS

22 (16 male) DHD and 64 (33 male) PD patients who initiated training between March 2003 and September 2007 at our center and remained in our program for at least 6 months.

PREDICTORS

Dialysis modality (DHD or PD).

OUTCOMES

Number of hospital admissions and length of stay.

RESULTS

Median age at initiation of training was 52 years (range, 33 to 76 years) for DHD patients versus 54 years (range, 21 to 82 years) for PD patients (P = 0.5), and median vintage was 23 months (range, 0 to 145 months) for DHD patients versus 0 month (range, 0 to 244 months) for PD patients (P < 0.001). Fifty percent of DHD and 56% of PD patients had a diagnosis of diabetes mellitus (P = 0.8). We observed 27 DHD and 82 PD admissions (0.68 and 0.76 admissions/patient-year, respectively) during the study period (P = 0.5). We also observed 130 DHD and 605 PD hospital days (3.3 and 5.6 days/patient-year, respectively; P < 0.001).

LIMITATIONS

Patients were not randomly assigned between the study group and control group; study group was small.

CONCLUSIONS

Our study suggests that despite similar patient demographics, patients treated with DHD spend fewer days in the hospital than PD patients in the United States. Although selection bias could partially explain our lower hospitalization rate, other factors, including improvements in blood pressure control, nutrition, and fewer fluctuations in dry weight, probably contributed to the stability of our patients.

Performance of the GeneXpert enterovirus assay for detection of enteroviral RNA in cerebrospinal fluid

BACKGROUND

The GeneXpert Dx System allows for automated extraction, processing, amplification and real-time detection of target nucleic acids.

OBJECTIVES

To evaluate the performance of the Cepheid Xpert enterovirus (EV) assay for detection of EV RNA compared to a nucleic acid sequence based amplification (NASBA) assay and a user-developed TaqMan RT-PCR assay.

STUDY DESIGN

Assays were evaluated using a 12-member proficiency panel and up to 138 CSF specimens. Samples in which EV RNA was detected by two or more assays were considered true positives.

RESULTS

The GeneXpert, NASBA, and TaqMan assays correctly identified 10, 8, and 7 of 12 proficiency panel members, respectively. For detection of EV RNA in CSF, the sensitivities of the GeneXpert, NASBA, and TaqMan were 100%, 87.5%, and 96%, respectively. There were no false positives. Two samples tested by GeneXpert and NASBA yielded indeterminate or invalid results and could not be resolved.

CONCLUSIONS

The Xpert EV assay is a sensitive and specific method for detection of EV RNA in CSF specimens. The ease of use, random access capability, and minimal hands-on time with the automated GeneXpert system affords laboratories with little molecular diagnostics expertise an opportunity to complete a clinically useful testing within 2.5 h.

A profile of the demographics and training characteristics of professional modern dancers

Modern dancers are a unique group of artists, performing a diverse repertoire in dance companies of various sizes. In this study, 184 professional modern dancers in the United States (males N=49, females N=135), including members of large and small companies as well as freelance dancers, were surveyed regarding their demographics and training characteristics. The mean age of the dancers was 30.1 +/- 7.3 years, and they had danced professionally for 8.9 +/- 7.2 years. The average Body Mass Index (BMI) was 23.6 +/- 2.4 for males and 20.5 +/- 1.7 for females. Females had started taking dance class earlier (age 6.5 +/- 4.2 years) as compared to males (age 15.6 +/- 6.2 years). Females were more likely to have begun their training in ballet, while males more often began with modern classes (55% and 51% respectively, p < 0.0001). The professional modern dancers surveyed spent 8.3 +/- 6.0 hours in class and 17.2 +/- 12.6 hours in rehearsal each week. Eighty percent took modern technique class and 67% reported that they took ballet technique class. The dancers who specified what modern technique they studied (N=84) reported between two and four different techniques. The dancers also participated in a multitude of additional exercise regimens for a total of 8.2 +/- 6.6 hours per week, with the most common types being Pilates, yoga, and upper body weightlifting. The dancers wore many different types of footwear, depending on the style of dance being performed. For modern dance alone, dancers wore 12 different types of footwear. Reflecting the diversity of the dancers and companies surveyed, females reported performing for 23.3 +/- 14.0 weeks (range: 2-52 weeks) per year; males reported performing 20.4 +/- 13.9 weeks (range: 1-40) per year. Only 18% of the dancers did not have any health insurance, with 54% having some type of insurance provided by their employer. However, 23% of the dancers purchased their own insurance, and 22% had insurance provided by their families. Only 16% of dancers reported that they had Workers' Compensation coverage, despite the fact that they were all professionals, including many employed by major modern dance companies across the United States. It is concluded that understanding the training profile of the professional modern dancer should assist healthcare providers in supplying appropriate medical care for these performers.

Inappropriate gold standard bias in cervical cancer screening studies

As acetic acid-aided visual inspection (VIA) and colposcopic-directed biopsy miss small >/=cervical intraepithelial neoplasia (CIN) 2, inflation of sensitivity of VIA may occur when colposcopic-directed biopsy is the gold standard for >/=CIN 2. To determine whether such inflation occurs, we reviewed 375 women with >/=CIN 2 from the Shanxi Province Cervical Cancer Screening Study II. These women had positive self or physician-collected tests for high-risk human papillomavirus or abnormal cervical cytology and had VIA followed by colposcopy with directed biopsy and endocervical curettage (ECC). If a cervical quadrant had no lesion, a random biopsy at the squamocolumnar junction within that quadrant was obtained. Sensitivity of colposcopic-directed biopsy was higher for >/=CIN 2 involving 3-4 cervical quadrants (81.3%) than for >/=CIN 2 involving 0-2 quadrants (49.0%, p < 0.001). Sensitivities of VIA, cytology of >/=ASC-US, >/=LSIL, and >/=HSIL were higher for >/=CIN 2 involving 3-4 quadrants than for >/=CIN 2 involving 0-2 quadrants. When a colposcopic-directed biopsy gold standard was compared with that of a 5-biopsy standard (which included >/=CIN 2 from colposcopic-directed biopsy, random biopsy, or ECC), the sensitivity for >/=CIN 2 of VIA was inflated by 20.0% (65.9% vs. 45.9%, p < 0.001). Sensitivities of other screening tests were not affected. Similar inflation of sensitivity of VIA was found with an endpoint of >/=CIN 3 (70.4% vs. 52.0%, p = 0.0013). Inflation of sensitivity of VIA depended upon agreement between colposcopic-directed biopsy and the screening tests as measured by kappa. Studies of VIA that used colposcopic-directed biopsy as the gold standard require reevaluation.

A prospective randomized study of anterior cruciate ligament reconstruction: a comparison of patellar tendon and quadruple-strand semitendinosus/gracilis tendons fixed with bioabsorbable interference screws

BACKGROUND

Debate exists regarding the optimal graft for anterior cruciate ligament reconstruction. Few studies have compared the differences in outcome after reconstruction using similar fixation methods.

HYPOTHESIS

Similar outcomes will be seen after anterior cruciate ligament reconstruction with bone-patellar tendon-bone or quadruple-strand semitendinosus/gracilis tendons fixed with bioabsorbable interference screws.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

Ninety-nine patients were prospectively randomized to bone-patellar tendon-bone (46 patients) or quadruple-strand semitendinosus/gracilis (53 patients) reconstruction groups. The bone-patellar tendon-bone group had slightly lower preinjury Tegner scores (6.7 vs 7.1, P = .03); otherwise, the groups were similar. All surgeries were performed by a single surgeon using an endoscopic technique with bioabsorbable interference screw fixation. Patients were evaluated at 3, 6, 12, and 24 months.

RESULTS

Forty-six bone-patellar tendon-bone and 50 quadruple-strand semitendinosus/gracilis patients were available at 24 months (97%). No differences in International Knee Documentation Committee grade, Lysholm score, Tegner activity level, range of motion, single-legged hop test, KT-1000 arthrometer manual maximum difference, Short Form-36, or patient knee rating were found. The bone-patellar tendon-bone group had better flexion strength in the operated leg than in the nonoperated leg (102% vs 90%, P = .0001), fewer patients complaining of difficulty jumping (3% vs 17%, P = .03), and a greater number of patients returning to preinjury Tegner level (51% vs 26%, P = .01). The quadruple-strand semitendinosus/gracilis group had better extension strength in the operated leg than in the nonoperated leg (92% vs 85%, P = .04), fewer patients with sensory deficits (14% vs 83%, P = .0001), and fewer patients with difficulty kneeling (6% vs 20%, P = .04). Both groups showed significant improvement in KT-1000 arthrometer manual maximum difference, Lysholm score, Tegner activity level, International Knee Documentation Committee grade, and patient knee rating score.

CONCLUSIONS

Good outcomes were seen in both the bone-patellar tendon-bone and quadruple-strand semitendinosus/gracilis groups. Subtle differences were noted between the groups, which may help guide optimal graft choice.

Urodynamic evaluation of urethral competency in women with posterior vaginal support defects

OBJECTIVES

To determine whether posterior vaginal wall support defects mask stress incontinence and the effects of these defects on common urodynamic tests used to evaluate urethral competency.

METHODS

We performed a prospective analysis of urodynamic evaluation with and without posterior vaginal stabilization in 54 women with Stage 2 or greater posterior vaginal prolapse and 54 women with Stage 0 and 1 posterior vaginal prolapse.

RESULTS

Posterior vaginal stabilization resulted in statistically significant reductions in the Valsalva leak point pressure, maximal urethral closure pressure, and pressure transmission ratios in the case group and inconsistent changes in the control group. Posterior vaginal stabilization unmasked stress incontinence in 12 (54%) of 22 case patients but none of the control patients. Previous incontinence surgery (odds ratio 57.4, 95% confidence interval 5.8 to 568, P = 0.001) was the strongest predictor for occult stress incontinence in patients with Stage 2 or greater rectocele. Also, notable, but less significant, associations were found between hysterectomy (odds ratio 6.7, 95% confidence interval 1.5 to 29, P = 0.01) and severity of rectocele (odds ratio 1.9, 95% confidence interval 1.1 to 3.3, P = 0.02) with occult incontinence.

CONCLUSIONS

The results of our study have shown that stress incontinence can be masked in women with Stage 2 or greater posterior vaginal support defects.

Prospective comparison of downward and lateral peritoneal dialysis catheter tunnel-tract and exit-site directions

OBJECTIVE

Guidelines for optimal peritoneal dialysis access support both downward and lateral exit-site directions. Numerous clinical reports support the superiority of downward exit sites but none substantiate lateral configurations.

METHODS

This prospective study compared infectious and mechanical complications between 85 catheters with a preformed arcuate bend to produce a downward exit site and 93 catheters with a straight intercuff segment configured to create a lateral exit site.

RESULTS

Kaplan-Meier survivals were not different for time to first exit-site infection (p = 0.62), tunnel infection (p = 0.89), or peritonitis (p = 0.38) for downward and lateral exit-site directions. Poisson regression showed no differences in rates (episodes/patient-year) of exit-site infection (0.26 vs 0.27, p = 0.86), tunnel infection (0.02 vs 0.03, p = 0.79), peritonitis (0.42 vs 0.43, p = 0.87), or catheter loss (0.06 vs 0.09, p = 0.29) for downward and lateral exit sites. Kaplan-Meier analyses of antibiotic-free intervals for exit-site (p = 0.94) and peritonitis infections (p = 0.72) were not different for the two groups. There was one case of catheter tip displacement with flow dysfunction in each group. There were no pericatheter hernias or spontaneous cuff extrusions. Catheter survival between groups was not different (p = 0.20).

CONCLUSIONS

Catheter types employing downward and lateral tunnel-tract and exit-site configurations produce equivalent outcomes for infectious and mechanical complications.

Subsequent risk and presentation of cervical intraepithelial neoplasia (CIN) 3 or cancer after a colposcopic diagnosis of CIN 1 or less

OBJECTIVE

The purpose of this study was to determine the risk and presentation of cervical intraepithelial neoplasia (CIN) 3 or cancer after colposcopic diagnosis of CIN 1 or less.

STUDY DESIGN

After colposcopy for an abnormal cytology, women with CIN 1 or less had annual cytology evaluations and high-risk human papillomavirus (HPV) tests (Hybrid Capture II). Colposcopy was repeated if the cytology result was ASC-H, or worse, ASC-US/high-risk HPV test positive, or every 2 years if the cytology was normal/high-risk HPV test positive. Differences in rates of CIN 3 or cancer were compared by log rank Kaplan-Meier survival analysis.

RESULTS

With median follow-up periods of 26.3 months, 47 of 2490 women (1.9%) with CIN 1 or less subsequently had CIN 3 or cancer. Subsequent CIN 3 or cancer was more likely if the high-risk HPV test was initially positive (45/1960 women [2.3%]) compared with negative (2/530 women [0.4%]; P = .0002) and if women were older (age > or = 30 years, 28/1021 women [2.7%]; age 20-29 years, 17/1017 women [1.7%]; age < 20 years, 2/452 women [0.4%]; P = .045). When CIN 3 or cancer was diagnosed, 45 of 46 women (97.8%) had positive high-risk HPV test and 42/46 women (91.3%) had an abnormal cervical cytology. The yield of CIN 3 or cancer per colposcopy for women (4/205 women [2.0%]) who had normal cervical cytology/positive high-risk HPV tests was lower than for women (41/541 women [7.6%]) who had abnormal cervical cytology/positive high-risk HPV tests (chi-square test, 8.3; P < .005), and it did not increase with increasing length of follow-up.

CONCLUSION

Annual cytology and high-risk HPV tests with colposcopy for high-risk HPV test positive/abnormal cytology and at least every 2 years for high-risk HPV test positive/normal cytology is advised after a colposcopic diagnosis of CIN 1 or less.

The Case For Case Reports

The management of patients with cancer teaches us the worth of logical thought, the advantage of flexibility of thinking and the thrill of occasionally doubting the experts. Asking questions and learning from the answers teaches us how to think. On the other hand, searching for the single best treatment, when no single treatment works for all patients, leads to a sort of intellectual tyranny that has numerous names: the gold standard, the community standard, best practice, and evidence-based medicine (EBM), with the implication that to take an alternative management route is substandard and unethical.

Arthroscopic release and latissimus dorsi transfer for shoulder internal rotation contractures and glenohumeral deformity secondary to brachial plexus birth palsy

BACKGROUND

Internal rotation contractures due to external rotation weakness secondary to brachial plexus birth palsy frequently lead to glenohumeral deformity and impaired shoulder function. Our surgical approach to treat these contractures relies on arthroscopic release for young children (less than three years old) and combines arthroscopic release with latissimus dorsi transfer for older children. We report the results for the first thirty-three children followed for a minimum of two years after such treatment.

METHODS

Nineteen children with a mean age of 1.5 years (all younger than three years of age) underwent arthroscopic contracture release as the only primary procedure, and fourteen children with a mean age of 6.7 were also treated with a latissimus dorsi transfer. Passive external rotation with the arm at the side and passive and active elevation were measured for all patients preoperatively. Passive and active external rotation, internal rotation, and elevation were measured for all patients postoperatively. Magnetic resonance imaging was performed preoperatively and postoperatively to evaluate the status of the glenohumeral joint.

RESULTS

Preoperative passive external rotation averaged -2 degrees for the children who underwent arthroscopic contracture release only and -24 degrees for those who also were treated with a latissimus dorsi transfer. Arthroscopic release achieved a marked increase in passive external rotation and a centered position of the glenohumeral joint at the time of surgery in all but the oldest child in the series, who had severe deformity. The contracture recurred in four of the younger children who had an isolated release, and this was treated with a repeat arthroscopic release and a secondary latissimus dorsi transfer. None of the children who had a primary latissimus dorsi transfer had recurrence of the contracture. At the time of follow-up, the mean passive external rotation was increased by 67 degrees (p < 0.005) in the fifteen children with a successful arthroscopic release, 81 degrees (p < 0.005) in those treated with a primary latissimus dorsi transfer, and 78 degrees in the four patients who were treated with a late latissimus dorsi transfer because the isolated arthroscopic release failed. The mean active elevation increased 12 degrees , 3 degrees , and 10 degrees , respectively, in the three groups. Internal rotation was not measured consistently preoperatively, but when it had been it was found to have decreased substantially postoperatively. Magnetic resonance imaging performed prior to the surgery showed a pseudoglenoid deformity in eighteen of the children. At two years, magnetic resonance images were available for fifteen of those children, and twelve of the images showed marked remodeling of the deformity.

CONCLUSIONS

In children who are younger than three years of age, arthroscopic release effectively restores nearly normal passive external rotation and a centered glenohumeral joint at the time of surgery. In most of these children, external rotation strength is sufficient to maintain this range of motion and to improve glenoid development when preoperative deformity was present. The addition of a latissimus dorsi transfer in older children predictably results in similar improvements. Gains in active elevation are minimal. All children have a loss of internal rotation, which is moderate in most of them but is severe in some.

Optimal Peritoneal Dialysis Catheter Type and Exit Site Location: An Anthropometric Analysis

An anthropometric analysis of 200 adult patients was performed to provide better guidance in catheter selection and placement. Height, weight, various abdominal wall measurements, and gender effects were analyzed. Suitability of Tenckhoff catheters with straight and preformed bends in the intercuff segment was evaluated regarding ability to produce deep pelvic position of the catheter tip and ideal exit site location. Conflicts with belt line and with skin creases and folds were recorded. Results showed that abdominal wall measurements varied widely by height and weight. Swan neck catheters with a downwardly directed external limb and exit site were significantly better suited for females (62% versus 27%, p < 0.0001). Tenckhoff catheters with straight intercuff segments with a laterally directed tunnel tract and exit site were significantly better matched to males (78% versus 30%, p < 0.0001). Neither catheter was suitable in 25% of subjects, emphasizing the need for an extended catheter system capable of remotely locating the exit site to the upper abdomen or chest without compromising pelvic position of the catheter tip. Appropriate preoperative evaluation with selection of the best suited catheter should replace the substandard practice of using a pet catheter to fit all patients and rigidly placing the insertion incision at a set location irrespective of body habitus.

Hospitalization for acute diverticulitis does not mandate routine elective colectomy

BACKGROUND

Previous studies suggest that elective colectomy is often required after an episode of acute diverticulitis.

HYPOTHESIS

Acute diverticulitis initially treated nonoperatively does not require elective colectomy.

DESIGN

Retrospective cohort study.

SETTING

Twelve Kaiser Permanente hospitals in Southern California.

PATIENTS

Three thousand one hundred sixty-five patients with acute diverticulitis.

INTERVENTIONS

Colectomy or nonoperative treatment with or without percutaneous abscess drainage.

MAIN OUTCOME MEASURES

Recurrent diverticulitis.

RESULTS

Emergency colectomy was performed in 614 patients (19.4%). Nonoperative treatment was initially used in 2551 patients (80.6%). Of these, 185 patients (7.3%) had an elective colectomy and the remaining 2366 patients (92.7%) did not. Factors associated with undergoing elective colectomy compared with nonoperative treatment were younger age of the patient, fewer comorbidities, and percutaneous abscess drainage. Mean follow-up was 8.9 years, with a maximum of 12 years. After nonoperative treatment, 314 patients (13.3%) recurred-222 patients had a single recurrence and 92 patients had a rerecurrence. After adjusting for other variables, older age (hazard ratio, >/=50 years vs <50 years = 0.68; 95% confidence interval, 0.53-0.87) was associated with a lower recurrence, whereas higher comorbidity was associated with higher recurrence. Gender and percutaneous abscess drainage had no influence on recurrence. All 92 rerecurrences were treated nonoperatively. The risk of a rerecurrence (29.3%) was significantly higher than a first recurrence (P<.001). Age, gender, Charlson comorbidity index, and percutaneous abscess drainage did not predict rerecurrence.

CONCLUSIONS

Very few patients with acute diverticulitis treated nonoperatively have recurrence. Younger age was associated with recurrence. A first recurrence was the only factor that predicted rerecurrences. The low recurrence rate argues against routine elective colectomy after successful nonoperative management of acute diverticulitis.

Surgical salvage of peritoneal dialysis catheters from chronic exit-site and tunnel infections

BACKGROUND

Chronic exit-site and tunnel infections of the peritoneal dialysis catheter are significant causes of catheter loss. Surgical salvage procedures that can effectively resolve the infection and preserve dialysis are of major importance.

METHODS

Thirteen patients with chronic exit-site and tunnel infections underwent surgical salvage consisting of unroofing the tunnel tract and shaving of the superficial catheter cuff. A control group of 138 patients implanted during the same time span as the study group was used for infection rate and survival comparisons.

RESULTS

The salvage procedure cured the infection in all patients. No dialysate leaks occurred. Peritoneal dialysis was not interrupted. Surgical salvage provided successful long-term peritoneal dialysis that was equivalent to the cohort dialysis population.

CONCLUSION

Surgical salvage by unroofing/cuff shaving is an effective long-term solution for chronic exit-site and tunnel infection.

Epidemiology of prolapse and incontinence questionnaire: validation of a new epidemiologic survey

The epidemiology of prolapse and incontinence questionnaire (EPIQ) was developed to screen for female pelvic floor disorders (PFD). Content and face validity, reliability, internal consistency and criterion validity of the EPIQ to detect the presence of pelvic organ prolapse (POP), stress urinary incontinence (SUI), overactive bladder (OAB) and anal incontinence (AI) is presented. Cronbach's alpha; Spearman's, kappa, intraclass correlations, factor analysis and Chi-Squared tests were used for analysis. Questions related to PFD proved internally consistent (alpha = 0.91) and reproducible (correlations >0.70) for all but three items on the EPIQ. Positive and negative predictive values of the EPIQ to detect PFD were: POP = 76% and 97%, SUI = 88% and 87%, OAB = 77% and 90% and AI = 61% and 91% respectively. EPIQ is a psychometrically validated screening instrument that may identify women at high risk of having pelvic floor disorders in large undiagnosed populations.

The use of Visual Analog Scale in urogynecologic research: a psychometric evaluation

OBJECTIVE

The purpose of this study was to assess the validity of Visual Analog Scales in urogynecologic research.

STUDY DESIGN

In phase I, 35 women completed short forms of the urogenital distress inventory, incontinence impact questionnaire, and Beck depression inventory fast screen using the Likert-type scale and Visual Analog Scale formats. Reliability was estimated with Spearman's correlations and Cronbach's alpha; construct validity was assessed with the use of factor analyses. In phase II, 101 women were recruited for the test-retest reliability assessment of the Visual Analog Scale formats of the urogenital distress inventory and incontinence impact questionnaire short forms. Reproducibility was analyzed with intraclass correlations.

RESULTS

In phase I, correlations between the Likert-type scale and the Visual Analog Scale were good: urogenital distress inventory (0.748), incontinence impact questionnaire (0.787), and Beck depression inventory fast screen (0.852; P <.05). In phase II, intraclass correlations were 0.898 and 0.938 for the urogenital distress inventory and incontinence impact questionnaire scores, respectively ( P <.001).

CONCLUSION

The Visual Analog Scale is a simple, reliable, and reproducible method for the assessment of quality of life in urogynecologic research.

Restenosis in Intervened Coronaries with Hyperhomocysteinemia (RICH)

BACKGROUND

Controversy exists regarding the contribution made by elevated serum homocysteine evels in raising the risk of restenosis after percutaneous coronary interventions. The objective of this study was to determine whether elevated homocysteine evels increase the risk of restenosis.

METHODS

Two hundred and two consecutive patients undergoing percutaneous coronary intervention with stents on previously nonintervened native coronary arteries were eligible for enrollment in the study. Before the percutaneous coronary intervention, a fasting serum homocysteine evel was drawn. Patients were followed-up by their primary cardiologists for recurrence of symptoms. Those patients who had a recurrence of anginal symptoms consistent with clinical restenosis were referred for a repeat angiogram. All other patients were followed-up medically. The homocysteine evels of the patients who had repeat angiography for recurrent symptoms were compared to those who were followed-up medically.

RESULTS

Age, stent ength, stent diameter, and homocysteine evels were all associated with an increased risk of restenosis in the univariate analysis. In the multiple ogistic regression model, the only variable that remained significant in relation to an increased risk of restenosis was homocysteine. There was a significant difference in the mean homocysteine evels between the restenosis group (13.7 micromol/L) and those without restenosis (9.6 micromol/L; P <.0001). A homocysteine evel > or =11.1 micromol/L was identified as the best threshold for an increased risk of restenosis with a sensitivity of 75.0% and specificity of 76.9% (OR 6.5, CI 2.3-18.6; P =.0004).

CONCLUSION

This study demonstrates that elevated homocysteine evels strongly correlate with an increased risk of restenosis.