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Shaikh DH, Patel H, Munshi R, Sun H, Mehershahi S, Baiomi A, Alemam A, Pirzada U, Nawaz I, Naher K, Hanumanthu S, Nayudu S. Patients with Clostridium difficile infection and prior appendectomy may be prone to worse outcomes. World J Gastrointest Surg 2021; 13:1436-1447. [PMID: 34950432 PMCID: PMC8649559 DOI: 10.4240/wjgs.v13.i11.1436] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Revised: 08/29/2021] [Accepted: 09/17/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Clostridium difficile infection (CDI) occurs due to a dysbiosis in the colon. The appendix is considered a ‘safe house’ for gut microbiota and may help repopulate gut flora of patients with CDI.
AIM To study the impact of prior appendectomy on the severity and outcomes of CDI.
METHODS We retrospectively reviewed data of 1580 patients with CDI, admitted to our hospital between 2008 to 2018. Patients were grouped based on the presence or absence of the appendix. The primary aim was to (1) assess all-cause mortality and (2) the severity of CDI. Severity was defined as per the Infectious Diseases Society of America criteria. Logistic regression, and propensity score analysis using inverse probability of treatment weights (IPTW) was performed.
RESULTS Of the 1580 patients, 12.5% had a history of appendectomy. There was no statistical difference in mortality between patients with a prior appendectomy or without (13.7% vs 14%, P = 0.877). However, a history of appendectomy affected the severity of CDI [odds ratio (OR) = 1.32, 95% confidence interval: 1.01-1.75]. On IPTW, this association remained significant (OR = 1.59, P < 0.05). On multivariable analysis of secondary outcomes, prior appendectomy was also associated with toxic megacolon (OR = 5.37, P < 0.05) and colectomy (OR = 2.77, P < 0.05).
CONCLUSION Prior appendectomy may affect the severity of CDI, development of toxic megacolon and the eventual need for colectomy. Since treatment of CDI is governed by its severity, stronger antibiotic regimens or earlier use of fecal microbiota transplant may be a viable option for patients with prior appendectomy.
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Affiliation(s)
- Danial Haris Shaikh
- Division of Gastroenterology, Department of Medicine, BronxCare Health System, Bronx, NY 10457, United States
| | - Harish Patel
- Division of Gastroenterology, Department of Medicine, BronxCare Health System, Bronx, NY 10457, United States
| | - Rezwan Munshi
- Department of Medicine, Nassau University Medical Center, New York, NY 11554, United States
| | - Haozhe Sun
- Division of Gastroenterology, Department of Medicine, BronxCare Health System, Bronx, NY 10457, United States
| | - Shehriyar Mehershahi
- Division of Gastroenterology, Department of Medicine, BronxCare Health System, Bronx, NY 10457, United States
| | - Ahmed Baiomi
- Division of Gastroenterology, Department of Medicine, BronxCare Health System, Bronx, NY 10457, United States
| | - Ahmed Alemam
- Division of Gastroenterology, Department of Medicine, BronxCare Health System, Bronx, NY 10457, United States
| | - Usman Pirzada
- Department of Medicine, BronxCare Health System, Bronx, NY 10457, United States
| | - Iqra Nawaz
- Department of Medicine, BronxCare Health System, Bronx, NY 10457, United States
| | - Kamrun Naher
- Department of Medicine, BronxCare Health System, Bronx, NY 10457, United States
| | - Siddarth Hanumanthu
- Division of Gastroenterology, Department of Medicine, BronxCare Health System, Bronx, NY 10457, United States
| | - Suresh Nayudu
- Division of Gastroenterology, Department of Medicine, BronxCare Health System, Bronx, NY 10457, United States
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Makker J, Shaikh D, Patel H, Hanumanthu S, Sun H, Zaidi B, Ravi M, Balar B. Characteristics of Patients with Post-Colonoscopy Unplanned Hospital Visit: A Retrospective Single-Center Observational Study. Clin Exp Gastroenterol 2021; 14:19-25. [PMID: 33500647 PMCID: PMC7826066 DOI: 10.2147/ceg.s285573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 12/13/2020] [Indexed: 11/23/2022] Open
Abstract
Background Colonoscopy, although a low-risk procedure, is not without associated adverse events. The rates of major adverse events such as perforation and bleeding after a colonoscopy are well reported. The rates of minor incidents following a colonoscopy, however, are less well examined. Recently the Centers for Medicare and Medicaid Services (CMS) started public reporting on the quality of outpatient endoscopy facilities by using a measure of risk-standardized rates of unplanned hospital visits within 7 days of colonoscopy. Aim We intended to record and present the characteristics of our patient population who had an unplanned hospital visit within 7 days after undergoing colonoscopy in an outpatient setting. Methods This is a retrospective single-center observational study. During the study period of July 2018 to December 2019, we reviewed charts of all patients who returned to the emergency room within a week of undergoing an outpatient colonoscopy. Patient demographics, clinical data and details of colonoscopy were collected and analyzed. Results Of the 5344 outpatient colonoscopies performed, our post-colonoscopy emergency room visit rate was 1.05% (n=56). The mean age of the participants was 58 years and 55% were male; 32% of our patients reported gastrointestinal symptoms such as abdominal pain or gastrointestinal bleeding. Patients with gastrointestinal symptoms had a higher rate of polypectomies performed (36.4% vs 11.8%, P = 0.04) and reported higher illicit drug use (31.9% vs 5.9%, P = 0.02) compared with those with non-gastrointestinal complaints. After colonoscopy, 41% of the patients reported reasons for emergency room visits that were entirely unrelated to the procedure. Conclusion Our study highlights that unplanned visits within 7 days of colonoscopy are not necessarily related to the procedure, and those that are, tend to be due to unavoidable patient factors. Hence the CMS measure may not be an accurate determinant of the quality of procedure or facility care delivered.
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Affiliation(s)
- Jasbir Makker
- Department of Medicine, BronxCare Health System, Affiliated with Icahn School of Medicine at Mount Sinai, Bronx, NY 10457, USA.,Division of Gastroenterology, BronxCare Health System, Affiliated with Icahn School of Medicine at Mount Sinai, Bronx, NY 10457, USA
| | - Danial Shaikh
- Department of Medicine, BronxCare Health System, Affiliated with Icahn School of Medicine at Mount Sinai, Bronx, NY 10457, USA.,Division of Gastroenterology, BronxCare Health System, Affiliated with Icahn School of Medicine at Mount Sinai, Bronx, NY 10457, USA
| | - Harish Patel
- Department of Medicine, BronxCare Health System, Affiliated with Icahn School of Medicine at Mount Sinai, Bronx, NY 10457, USA.,Division of Gastroenterology, BronxCare Health System, Affiliated with Icahn School of Medicine at Mount Sinai, Bronx, NY 10457, USA
| | - Siddarth Hanumanthu
- Department of Medicine, BronxCare Health System, Affiliated with Icahn School of Medicine at Mount Sinai, Bronx, NY 10457, USA.,Division of Gastroenterology, BronxCare Health System, Affiliated with Icahn School of Medicine at Mount Sinai, Bronx, NY 10457, USA
| | - Haozhe Sun
- Department of Medicine, BronxCare Health System, Affiliated with Icahn School of Medicine at Mount Sinai, Bronx, NY 10457, USA
| | - Bushra Zaidi
- Department of Medicine, BronxCare Health System, Affiliated with Icahn School of Medicine at Mount Sinai, Bronx, NY 10457, USA
| | - Madhavi Ravi
- Department of Medicine, BronxCare Health System, Affiliated with Icahn School of Medicine at Mount Sinai, Bronx, NY 10457, USA.,Division of Gastroenterology, BronxCare Health System, Affiliated with Icahn School of Medicine at Mount Sinai, Bronx, NY 10457, USA
| | - Bhavna Balar
- Department of Medicine, BronxCare Health System, Affiliated with Icahn School of Medicine at Mount Sinai, Bronx, NY 10457, USA.,Division of Gastroenterology, BronxCare Health System, Affiliated with Icahn School of Medicine at Mount Sinai, Bronx, NY 10457, USA
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Abstract
AIM To analyse the location and extent of tissue damage induced after argon laser epilation. METHODS Laser burns were applied to the lid margins of four patients before excision for entropion ("live tissue") and the lid margin of one patient was lasered after an excision for ectropion ("dead tissue"). The laser burns were directed towards the lash follicle and between 10 and 50 burns were applied with an argon blue-green laser set at power 0.9-1.0 W, at 0.1-0.2 second duration and a 100 micro m spot size. The tissues were processed for conventional histology. Serial sections were obtained and used for area measurements and three dimensional reconstructions of the burns to determine the volume and location of tissue destruction. RESULTS The laser created a cone-shaped region of tissue ablation with surrounding coagulative necroses. Maximum burn depth was 1.2 mm in dead tissue and 0.8 mm in live tissue. Maximum necrosis depth was 1.4 mm in dead tissue and 0.9 mm in live tissue. Follicle depth ranged from 0.8 mm to 1.9 mm. Some of the burns had been misdirected in the dermis leaving target hair follicles intact, despite being of adequate depth. CONCLUSIONS The argon laser has some potential for ablation of lash follicles, but accurate placement of the burn is essential and energy levels greater than those currently recommended should be applied. The treatment is ineffective in patients unable to remain immobile.
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Affiliation(s)
- S Hanumanthu
- Department of Ophthalmology, Royal Alexandra Hospital, Paisley, UK
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Abstract
Heart failure is one of the most common reasons for admission to acute care hospitals. A proportion of these admissions are probably low risk and could be managed in subacute care facilities, resulting in substantial cost savings. To investigate the proportion of low-risk hospital admissions for heart failure, all admissions for heart failure to Vanderbilt University Medical Center between July 1993 and June 1995 were identified (n = 743). One hundred twenty of these admissions were randomly selected, reviewed, and classified into a high-risk versus low-risk group on admission based on the severity of heart failure and the presence of life-threatening complications. Of the 120 admissions, 57 (48%) were classified as high risk based on the presence of moderate to severe heart failure for the first time or recurrent heart failure with a major complicating factor. Sixteen admissions (28%) were associated with adverse outcomes, including myocardial infarction in 5 (9%), intubation in 6 (11%), and death in 4 (7%). Sixty-three admissions (52%) were classified as low risk based on the presence of new-onset mild heart failure or mild to moderate recurrent heart failure with no complicating factors. Most of these admissions were for dyspnea without any life-threatening complication; 57 (91%) had no evidence of interstitial or alveolar pulmonary edema, and arterial oxygen saturation averaged 95 +/- 3%. Only 3 of these low risk admissions (5%) were associated with an adverse cardiovascular event. None of the patients died. These data suggest that over half of the patients admitted for heart failure to an acute care facility are low risk and probably could be managed in a subacute care setting, resulting in large cost savings.
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Affiliation(s)
- J Butler
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, TN 37232-0883, USA
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Abstract
BACKGROUND Most patients with heart failure are currently managed by physicians with little specific expertise in heart failure. This management system has been associated with evidence of suboptimal care, such as high rates of hospital readmission and underuse of ACE inhibitors. The current study was undertaken to determine whether hospitalization rates and functional outcomes are improved when patients are managed by physicians with special expertise in heart failure working in a dedicated heart failure program. METHODS AND RESULTS All patients with heart failure referred to the Vanderbilt Heart Failure and Heart Transplantation Program between July 1994 and June 1995 were identified. Annual hospitalization rates, medications, and peak exercise capacity before and after referral were compared in patients followed for >30 days. A total of 187 patients were referred during the index time period, of whom 134 (72%) were followed for >30 days. During the year before referral, 94% of the patients were hospitalized (210 cardiovascular hospitalizations) versus 44% of the patients during the year after referral (104 hospitalizations) (53% reduction) (P<.01). Hospitalizations for heart failure decreased from 164 to 60 for all patients regardless of follow-up duration and decreased from 97 to 30 (69% reduction) for patients followed at least 1 year after referral. Eighty-eight of the patients were able to exercise at the time of referral. Peak exercise VO2 in this group increased from 12.8+/-4.7 to 15.7+/-4.8 mL x min(-1) x kg(-1) (P<.01) by 6 months after referral. Loop diuretic doses were on averaged doubled during the first 6 months after referral. CONCLUSIONS These findings suggest that patients with heart failure have fewer hospitalizations for heart failure and are significantly more functional when managed by heart failure specialists working in a dedicated heart failure program rather than by physicians with limited expertise in heart failure.
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Affiliation(s)
- S Hanumanthu
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tenn 37232-6300, USA
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