Referral Bias Research Articles

Geographical pattern of carcinoma gallbladder in Bihar and its association with river Ganges and arsenic levels: Retrospective individual consecutive patient data from Regional Cancer Centre.

Background:Indo-Gangetic basin is known to have higher incidence of gallbladder cancer. Proximity to River Ganga and high heavy metal in soil exposure have been postulated as risk factors.Aim:This study aims to evaluate the geographical pattern of gallbladder cancer from consecutive patient database enrolled in hospital-based cancer registry (HBCR).Objectives:To evaluate demographic profile and districtwise/zonewise dispersion of gallbladder cancer cases registered in HBCR from year 2014 to 2016. To evaluate association of carcinoma gallbladder (CaGB) due to proximity of Ganges, districts of high soil arsenic levels and referral bias.Materials and Methods:Demographic profile and district-based location of individual consecutive gallbladder cancer patient registered in Regional Cancer Centre from the year 2014 till 2016 were analyzed. Population data from 2011 census and arsenic soil content data from central groundwater body were obtained. Frequency distribution, cross tabulation, and odds ratio were used to analyze risk of CaGB across population subsets in Bihar.Results:A total of 1291 consecutive patients of CaGB were registered from 2014 to 2016. Median age at diagnosis was 55 years (range 18–95 years). Male to female ratio was 0.6. Patna (16%) followed by Vaishali (5.8%), Sitamarhi (5%), Madhubani (4.7%), Gaya (4%), and Samastipur (4%) had highest cases. Districts along main central River Ganga (n = 12) and those exposed to high arsenic soil content (n = 15) had higher odds ratio for CaGB, 1.72 (95% confidence interval [CI]: 1.54–1.91, P = 0.001), and 1.45 (95% CI: 1.30–1.62, P = 0.001), respectively. Districts within 100 km radius of our institute had higher gallbladder cancer cases, odds ratio 1.81 (95% CI: 1.62–2.03, P = 0.001), suggesting significant referral bias predominantly contributed by cases registered under Patna and Vaishali districts.Conclusion:CaGB is major public health problem in Bihar. Exposure to high soil arsenic levels and proximity to River Ganga are strongly associated with gallbladder cancer. Systematic population-based longitudinal studies are needed to explore above hypothesis.

Spectrum of Pituitary disorders: A retrospective study from Basrah, Iraq.

Background: Pituitary disorders spectrum includes a wide variety of diseases.This study aimed at a comprehensive description of such disorders for patients from Faiha Specialized Diabetes, Endocrine and Metabolism Center (FDEMC) in Basrah (Southern Iraq). Methods:Retrospective data analysis of FDEMC for the period from January 2012 through June 2017. We included all patients with pituitary disorders who have MRI pituitary. Results:The pituitary disorders were more common among women. Those with macroadenoma were older than those with microadenoma with nearly equal gender prevalence of macroadenoma. Pituitary adenoma constituted the bulk of pituitary disorders in this registry (67.2%). Growth hormone secreting adenoma were the commonest adenoma seen in 41.0% followed by clinically non-functioning pituitary adenoma(NFPA)in 31.4% and prolactinoma in 26.9%. About 64.8% of pituitary adenoma was macroadenoma. Macroadenoma was seen in 73.4 % of growth hormone secreting adenoma, 61.2% in NFPA and 62.0% of prolactinoma (of them six were giant prolactinoma) Conclusion: Pituitary adenoma constituted the bulk of pituitary disorders in Basrah, growth hormone secreting adenoma is the commonest adenoma followed by NFPA and prolactinoma due to referral bias. A change in practice of pituitary adenoma treatment is needed.

GP.02 A population-based study of “no evident disease activity” (NEDA) in multiple sclerosis

Background: NEDA is a composite measure that may ultimately influence clinical decisions concerning switches of disease modifying therapy (DMT) for relapsing remitting multiple sclerosis (RRMS) patients. Cohort studies from MS clinics suggest NEDA is not sustained over time in most patients despite DMT but may be limited by referral bias. We investigated NEDA in a population-based RRMS cohort. Methods: We identified all incident cases of RRMS in Olmsted County from 01/01/2000-12/31/2011. Retrospective chart review was conducted to determine persistence of NEDA -following RRMS diagnosis. NEDA failure was defined as new MRI activity, relapse, or expanded disability status scale (EDSS) -worsening. Results: There were 93 incident cases of RRMS with 82 individuals having sufficient follow-up to determine persistence of NEDA. Prior to NEDA failure 44 were not on DMT, 37 were on first-tier, injectable DMT, and 1 received mitoxantrone. NEDA was maintained by 63% at 1 year, 38% at 2 years, 19% at 5 years, and 12% at 10 years. Disability measured by EDSS was no different at 10 years in patients maintaining NEDA versus those that failed NEDA at one year (p=0.3). Conclusions: Maintenance of NEDA beyond 2 years is infrequent among a population-based cohort of newly diagnosed RRMS patients and similar to prior clinic-based cohorts.

Ado-trastuzumab emtansine (T-DM1) induced pulmonary toxicity: A retrospective analysis of a single institution experience.

e13004 Background: T-DM1 is an antibody drug conjugate with proven efficacy in metastatic breast cancer for progressive disease refractory to trastuzumab. FDA prescribing information cites a pneumonitis incidence of 0.8% (7/884 cases) based on clinical trial experience. We sought to identify the incidence of this toxicity at our institution. Furthermore, we attempted to identify potential risk factors for drug induced pneumonitis and examine the clinical course leading to resolution of pulmonary symptoms. Methods: We performed a retrospective analysis of EMR data inclusive of all women and men, age 18 and older, treated with T-DM1 at out institution from 1/1/2013-11/1/2017 for breast cancer. Records were reviewed for clinical symptoms and or radiographic evidence concerning for pneumonitis. We identified variables of interest with regard to potential risk factors for toxicity. Results: Upon review, 50 patients were included, 6 (12%) of whom had radiographic and/or clinical symptoms concerning for T-DM1 induced pneumonitis. Grade 3 pneumonitis was observed in 3/6 patients. All 6 patients had metastatic or unresectable breast cancer. Out of the 6 patients, 5 (83%) had suspected pulmonary metastases, 1 (17%) had a history of underlying lung disease, and 5 (83%) had a history of prior taxane therapy. Pulmonary metastases (p=0.38), median number of treatment cycles (p=0.29), prior taxane (p=1), underlying lung disease (p=1), and hormone receptor positivity (p=0.66) did not meet statistical significance for an association with pneumonitis. Time (days) on T-DM1 did not predict for pneumonitis (p=0.32). Steroids were given in 4/6 of the cases, with a time to complete resolution of 29.6 days (range 3-81 days). Conclusions: Pneumonitis is a recognized toxicity of T-DM1. While our sample size is small, the number of events was higher than described in the literature, which may be an artifact of referral bias. Future studies with a larger sample population may detect potential risk factors for toxicity. Reassuringly, patients who received steroids with cessation of T-DM1 achieved improvement of pneumonitis and resolution of symptoms.

Ultrasound requested by general practitioners or for symptoms unrelated to the thyroid gland may explain higher prevalence of thyroid nodules in females

BackgroundA higher prevalence of thyroid nodules/carcinoma in females is well-known from the literature. The reasons for this difference are not fully explained. We intended to assess gender variation in the referral for ultrasound-guided fine needle aspiration (FNA) of thyroid nodules, to study reasons for gender referral differences, and to assess differences in nodules characteristics between genders. MethodsIncluded were 272 consecutive patients, with 290 nodules submitted to FNA. Patients were questioned on the reason why ultrasound (US) examination was required. Electronic medical records were reviewed. Nodules' ultrasound/cytological characteristics were assessed. Variables studied: referral cause; referral pattern (hospital-specialist versus general-practitioner); number of nodules; age, thyroid function; nodule size, TIRADS classification, resistive index, Doppler pattern, Bethesda categorisation. Variables were compared between males and females referred for FNA. Significant variables were assessed with logistic regression. ResultsOf the 272 patients, 215(79%) were women with a female:male referral ratio for FNA of 3.8:1. Non-parametric statistically significant differences (p < 0.05) were found between genders in: thyroid function, nodule size, referral pattern and referral cause. Nodule size and thyroid function tests became non-significant in logistic regression. Cause and referral pattern remained significantly associated with gender. Referral by a general-practitioner was associated with a 2.6-fold increase in odds of referring a female. Causes unrelated to the thyroid were associated with a 3.2-fold increase in odds of female reference. ConclusionsA referral bias might be responsible for the higher rate of thyroid nodules in female patients, both due to referral by general practitioners and due to causes indirectly related to the thyroid gland.

Spectrum of Pituitary disorders: A retrospective study from Basrah, Iraq

Background: Pituitary disorders spectrum includes a wide variety of diseases.This study aimed at a comprehensive description of such disorders for patients from Faiha Specialized Diabetes, Endocrine and Metabolism Center (FDEMC) in Basrah (Southern Iraq). Methods: Retrospective data analysis of FDEMC for the period from January 2012 through June 2017. We included all patients with pituitary disorders who have MRI pituitary. Results: The pituitary disorders were more common among women. Those with macroadenoma were older than those with microadenoma with nearly equal gender prevalence of macroadenoma. Pituitary adenoma constituted the bulk of pituitary disorders in this registry (67.2%). Growth hormone secreting adenoma were the commonest adenoma seen in 41.0% followed by clinically non-functioning pituitary adenoma(NFPA)in 31.4% and prolactinoma in 26.9%. About 64.8% of pituitary adenoma was macroadenoma. Macroadenoma was seen in 73.4 % of growth hormone secreting adenoma, 61.2% in NFPA and 62.0% of prolactinoma (of them six were giant prolactinoma) Conclusion: Pituitary adenoma constituted the bulk of pituitary disorders in Basrah, growth hormone secreting adenoma is the commonest adenoma followed by NFPA and prolactinoma due to referral bias. A change in practice of pituitary adenoma treatment is needed.

Characteristics and Outcomes Reported by Patients With Primary Sclerosing Cholangitis Through an Online Registry

Primary sclerosing cholangitis (PSC) is a fibrostenosing disease of the bile ducts associated with inflammatory bowel disease (IBD), for which the only treatment is liver transplantation. PSC progression has been defined in cohorts from referral centers or single-nation population databases. However, observations made from these cohorts have limited applicability owing to referral bias and demographic confounders. We analyzed data from the worldwide PSC Partners Patient Registry, an international online database established in 2014 to obtain information from individuals with PSC or their caretakers and compare symptoms, disease progression, and treatments of PSC in the United States and other countries. We analyzed demographic and clinical characteristics, symptoms, and clinical outcomes of patients with PSC using the PSC Partners Patient Registry. Participants completed an online standardized questionnaire and electronic case report, providing information on age, age at symptom onset, age at PSC diagnosis, methods of diagnosis, concurrent diagnoses, family history, and medication use. Of 873 registrants, 811 (92.9%) had completed questionnaires and 528 (65.1%) had their PSC diagnosis confirmed; we found no significant demographic or clinical differences between patients with vs without a confirmed diagnosis. In contrast to other studies, we found a higher proportion of individuals with PSC to be female (52.5%). However, the mean age at PSC diagnosis (32.4 ± 14.7 y) and the proportion of individuals with PSC and IBD (67.1%) were similar to those from prior reports. Most cases in the database were from the United States (74.9%). More than half of the participants reported having pruritus, abdominal pain, fatigue, or sleep disturbances; rates were not significantly different among participants within vs outside the United States. There was no significant difference in treatment with ursodeoxycholic acid between participants within vs outside the United States (50.0% and 57.8%; P= .07). The median time of transplant-free survival was 21 years; transplant-free survival was associated with female sex and Crohn's disease. Our findings from an analysis of data from the PSC Partners Patient Registry confirm those from previous studies, although we found a higher proportion of individuals with PSC to be female. In addition to allowing efficient collection of patient-reported outcomes, the patient-driven registry allows for inclusion of previously under-represented cases of PSC.

Referral bias in ALS epidemiological studies.

BackgroundDespite concerns about the representativeness of patients from ALS tertiary centers as compared to the ALS general population, the extent of referral bias in clinical studies remains largely unknown. Using data from EURALS consortium we aimed to assess nature, extent and impact of referral bias.MethodsFour European ALS population-based registries located in Ireland, Piedmont, Puglia, Italy, and Limousin, France, covering 50 million person-years, participated. Demographic and clinic characteristics of ALS patients diagnosed in tertiary referral centers were contrasted with the whole ALS populations enrolled in registries in the same geographical areas.ResultsPatients referred to ALS centers were younger (with difference ranging from 1.1 years to 2.4 years), less likely to present a bulbar onset, with a higher proportion of familial antecedents and a longer survival (ranging from 11% to 15%) when compared to the entire ALS population in the same geographic area.ConclusionsA trend for referral bias is present in cohorts drawn from ALS referral centers. The magnitude of the possible referral bias in a particular tertiary center can be estimated through a comparison with ALS patients drawn from registry in the same geographic area. Studies based on clinical cohorts should be cautiously interpreted. The presence of a registry in the same area may improve the complete ascertainment in the referral center.

Spectrum of Sellar and Parasellar Region Lesions: A retrospective study from Basrah, Iraq.

Background:Sellar and parasellar region lesions spectrum includes a wide variety of diseases. This study aimed at providing a comprehensive overview of such lesions in patients from Faiha Specialized Diabetes, Endocrine and Metabolism Center (FDEMC) in Basrah (Southern Iraq). Methods: Retrospective data analysis from FDEMC for the period January 2012 through June 2017. We included all patients with sellar and parasellar region lesions who received a MRI scan on their pituitary region Results: The total enrolled patients were 232 (84 men and 148 women),with age range 15-75 years.Pituitary disease and adenoma were more common among women. Those with macroadenoma were older than those with microadenoma, with nearly equal gender prevalence of macroadenoma. Pituitary adenoma constituted the bulk of pituitary disease in this setting (67.2%). Growth hormone secreting adenoma were the most common adenoma seen in 41.0%, followed by clinically non-functioning pituitary adenoma (NFPA) in 31.4% and prolactinoma in 26.9%. About 64.8% of pituitary adenoma was macroadenoma. Macroadenoma was seen in 73.4% of growth hormone secreting adenoma (acromegaly), 61.2% in NFPA and 62.0% of prolactinom a(of them six were giant prolactinoma). Conclusion: Pituitary adenoma constituted the bulk of sellar and parasellar region lesions, growth hormone secreting adenoma is the the most common adenoma followed by NFPA and prolactinoma due to referral bias. A change in practice of adenoma treatment is needed.

Abstract 202: Outcomes of Region-Wide Cardiac Rehabilitation

Background: Cardiac rehabilitation (CR) is recommended for patients with cardiovascular disease, however the impact of a region-wide, centrally managed CR model with local non-medical community-based delivery of CR is unknown in a universal health care system setting. Objectives: To determine the impact of a regional 6-month, once per week supervised exercise session CR model on mortality and re-hospitalization compared to a matched control within a regional health care system. Methods: The regional CR service comprised: a standardized regional referral strategy for patients with established cardiac disease including stable heart failure, local (within a 30-minute drive time from place of residence) CR service delivery by trained CR professionals. Patient data that was prospectively entered into a regional CR database for patients referred to CR from 2012 through 2014, was linked to government mandated administrative databases and all-cause mortality and hospitalization rates were compared between patients who were referred to CR vs. a matched cohort who were not. Matching included age, sex, year of referral, socioeconomic status, and cardiac condition at hospital discharge. Mortality and re-hospitalization were assessed at 1-yr post index cardiac event excluding the initial 6-month period to account for immortal time bias. Results: Fewer patients who completed CR compared to matched controls died (14/1,318 or 1.1% vs. 31/1,318 or 2.4%, p=0.011), or were readmitted to hospital (128 or 9.7% vs. 190 or 14.4%, p&lt;0.001). Fewer patients who started but did not complete CR (CR non-completers) died compared to matched controls (10/639 or 1.6% vs. 21/639 or 3.3%, p=0.045), however there was no difference in hospital readmission rates between CR non-completers compared to matched controls (18.0% vs. 14.9%, p=0.13). More patients who were referred to CR but did not enroll in CR, died compared to matched controls (241/3,933 or 6.1% vs. 196/3,933 or 5.0%, p=0.027), or were readmitted to hospital (932 or 23.7% vs. 643 or 16.3%, p&lt;0.001). Conclusions: In a universal health-care system, patients who completed a regionally coordinated, locally delivered, standardized CR program close to home, experienced lower mortality or re-hospitalization rates compared to matched patients not referred to CR. This association was not likely due to a referral bias as patients who were referred to CR but did not enroll in CR faired worse, not better, compared to matched non-CR referred patients. Health care system decision makers (e.g. provincial governments in Canada) should strongly consider funding regional CR strategies.

The effect of selection and referral biases for the treatment of localised prostate cancer with surgery or radiation

BackgroundConsultation with radiation oncologists, in addition to urologists, is advocated for patients diagnosed with prostate cancer. Treatment patterns for patients receiving consultation from radiation oncologists in addition to urologists have not previously been described.MethodsWe conducted a matched cohort study of men with newly diagnosed non-metastatic prostate cancer in Ontario, Canada. Patients who underwent consultation with a radiation oncologist prior to treatment were matched 1:1 with patients managed by a urologist alone based on tumour and patient characteristics. We examined rates of active treatment (surgery or radiotherapy) within one year following diagnosis.ResultsAmong 5708 matched pairs (11,416 patients), those who received radiation oncology consultation were more likely to undergo active treatments whether they had intermediate or high-risk disease (88.6% vs. 65.9%, p < 0.0001; adjusted odds ratio 4.0, 95% CI: 3.6–4.4) or low-risk disease (56.1% vs. 13.3%, p < 0.0001; adjusted odds ratio 8.4, 95% CI: 6.7–10.6). This effect persisted after considering age, comorbidity, tumour volume and year of diagnosis.ConclusionsPatients newly diagnosed with prostate cancer who receive radiation oncology consultation are associated with a higher rate of active treatment, compared to patients managed by urologists only. Selection and referral biases, and unmeasured confounding such as patient preference must be considered as important factors attributing this association.

An Integrative Synthesis of Literature on Disproportionality in Special Education

Research studies have historically indicated that students from racially and ethnically diverse backgrounds are overidentified for special education, suggesting bias in referral, assessment, and placement practices. Other studies, however, have suggested that students from racially and ethnically diverse backgrounds are not overrepresented in special education or may be underidentified for services. There is a perceptual interpretive element in defining the problem of disproportionality, as the use of different data sets and analyses impact how both the problem and results are interpreted. The purpose of this manuscript was to examine the ways in which current studies analyze disproportionality through statistical methods, and to compare those analyses based on the conceptualization of covariates. An integrative systematic review of the literature builds on previous works that examine the issue of disproportionality.

Esophageal cancer male to female incidence ratios in Africa: A systematic review and meta-analysis of geographic, time and age trends

Esophageal squamous cell carcinoma (ESCC) remains the predominant histological subtype of esophageal cancer (EC) in many transitioning countries, with an enigmatic and geographically distinct etiology, and consistently elevated incidence rates in many Eastern and Southern African countries. To gain epidemiological insights into ESCC patterns across the continent, we conducted a systematic review and meta-analysis of male-to-female (M:F) sex ratios of EC age-standardised (world) incidence rates in Africa according to geography, time and age at diagnosis. Data from 197 populations in 36 countries were included in the analysis, based on data from cancer registries included in IARC’s Cancer Incidence in Five Continents, Cancer in Africa and Cancer in Sub-Saharan Africa reports, alongside a systematic search of peer-reviewed literature. A consistent male excess in incidence rates overall (1.7; 95% CI: 1.4, 2.0), and in the high-risk Eastern (1.6; 95% CI: 1.4, 1.8) and Southern (1.8; 95% CI: 1.5, 2.0) African regions was observed. Within the latter two regions, there was a male excess evident in 30–39 year olds that was not observed in low-risk regions. Despite possible referral biases affecting the interpretability of the M:F ratios in place and time, the high degree of heterogeneity in ESCC incidence implies a large fraction of the disease is preventable, and directs research enquiries to elucidate early-age exposures among young men in Africa.

Gender-related Difference in Clinical Outcome of the Patient with Atrial Fibrillation after Radiofrequency Catheter Ablation.

Background and ObjectivesPrevious studies provided controversial result about gender differences in the clinical outcome after radiofrequency catheter ablation (RFCA) for atrial fibrillation (AF). We assessed pure difference after adjustment of referral bias.MethodsThe clinical outcomes including freedom from AF/atrial tachycardia (AT) recurrence after RFCA were compared between women and men in 1:1 confounding factor matching with age, AF type, periods since diagnosis (±12 months), and procedure era (±12 months). Subgroup analysis was performed in categories defined by AF type and age of 55 (mean menopausal age of Asian women).ResultsTotal 1,875 patients with AF underwent 2,307 RFCA between January 1998 and May 2014 in a single center. Total 367 women (19.6%, 59±10 years) who had undergone first ablation were included. Women had larger left atrial diameter index (26±4 vs. 23±4 mm/m2; p<0.001) and higher peri-procedural complications (9.2% vs. 4.9%; p=0.030) compared to men. The freedom from AF/AT recurrence after RFCA was not different between both groups (71% vs. 76%; log-rank p=0.131, mean follow-up of 55 months). Women with non-paroxysmal AF (PAF) had significantly worse outcome (54% vs. 69%; p=0.014), especially in subgroup with age ≤55 (48% vs. 71%; p=0.010). In multivariate analysis, female gender was an independent predictor of recurrence in subgroup with non-PAF and age ≤55 (hazard ratio [HR], 2.539; 95% confidence interval [CI], 1.112–5.801; p=0.027).ConclusionsThe clinical outcome after RFCA was not different between both genders regardless of referral bias. However, the gender difference became evident in patients under 55 years with non-PAF.

The Case Volume Issue in Head and Neck Oncology

In the past few years, several evidences reported better outcomes, in terms of reduced toxicities and longer survival, for head and neck cancer (HNC) patients when "regionalized," namely if they are managed at "high-volume" cancer referral centers (CRC). The benefit of case volume has been demonstrated in HNC patients primarily treated with surgery and in those receiving curative radiotherapy and chemotherapy. Many factors could explain these positive results: organization, facilities, processes of care, quality assurance programs, professional expertise, technology, and patient referral bias. In other words, the "high volume" could be linked both to all hospital-related volume and to the expertise of each involved professional figure (e.g., surgeon, radiation oncologist, medical oncologist, etc.). In this context, it is still debatable whether there is a need to understand which one of these factors is more able to influence the final outcomes of HNC patients. Considering the complexity and heterogeneity of HNC, all of these aspects are likely to impact and plot each other. However, there is no consensus regarding the criteria and the cut-off used to define as "high" the case volume. Moreover, some limitations or biases of the regionalization process have to be highlighted: (1) personal and financial discomfort of patients, their caregivers, and families; (2) a frequent referral of the healthiest or youngest patients to CRC could change the survival outcomes; (3) potential higher difficulties for colleagues working outside of CRC in the emergency. Nevertheless, the case volume represents one of the factors impacting on the quality of the treatment itself, in terms of reduced toxicity and better treatment outcome. Therefore, it should be considered as a stratifying factor in randomized controlled trials for HNC patients.

Cutaneous dermatomyositis disease course followed over time using the Cutaneous Dermatomyositis Disease Area and Severity Index

Limitedstudies describe the longitudinal course of cutaneous dermatomyositis (DM). To characterize disease course in treated cutaneous DM by using the Cutaneous Dermatomyositis Disease Area and Severity Index (CDASI), a validated outcome instrument. A retrospective cohort included patients with DM who had their CDASI activity subscore recorded for at least 2years. Disease progression was classified as improved, worsened, or stable, and disease course was classified as monophasic, polyphasic, or chronic. Subjects were divided into groups with disease of mild (n=16) and moderate-to-severe (n=24) baseline severity. A total of 40 patients with DM met inclusion criteria. The majority demonstrated improvement in disease activity (n=21 [52.5%]) rather than worsening (n=7 [17.5%]) and stable (n=12 [30.0%]) disease. Most patients with mild disease remained stable (n=10 [62.5%]), whereas most with moderate-to-severe disease improved (n=19 [79.2%]). A polyphasic course (n=33 [82.5%]) predominated over monophasic (n=5 [12.5%]) and chronic (n=2 [5%]) courses. The average number of flares per year per number of years of follow-up was independent of baseline disease activity. The retrospective design, potential referral bias, and cutoff values in classification criteria are limitations. Baseline CDASI activity score is associated with particular patterns of disease course and progression in cutaneous DM.

Ulcerative Colitis: Are We Neglecting Its Progressive Character

Introduction: Ulcerative colitis (UC) is a chronic disease but its progressive character, with structural damage, is insufficiently studied. Objectives: To analyze a group of patients without referral bias, regarding its clinical course, the morphological damage, and functional status. Methods: We evaluated UC patients diagnosed between January 1, 2000 and December 31, 2004, living in the direct referral area of the hospital and determined the medication use, colectomy rate, structural damage (“lead pipe,” stenosis, pseudopolyps, fibrous bridges), and anorectal function (prospective evaluation with the Cleveland Clinic Incontinence Score [CCIS] and the Fecal Incontinence Quality of Life Scale). Results: We identified 104 patients, 47% female, with a mean age at diagnosis of 38 ± 17 years, 24% with proctitis, 57% with left colitis, and 19% with pancolitis. In 3 patients, it was not possible to obtain follow-up data. Of the studied patients, 56% needed corticosteroid therapy, 38% immunosuppressants, and 16% anti-tumor necrosis factors (anti-TNFs). After a mean follow-up of 13 ± 2 years, we found structural damage in 25 patients (24%): 5% with proctocolectomy, 15% with “lead pipe,” 16% with pseudopolyps, and 3% with stenosis and fibrous bridges. Reference to functional anorectal disorders was identified in 49%, mostly previous and self-limited episodes of incontinence, but including persistent incontinence in 10% (CCIS 8 ± 4.8). There was an increased incidence of structural damage and anorectal dysfunction in patients who needed corticosteroid therapy (p = 0.001), immunosuppressants (p < 0.001), and anti-TNFs (p = 0.002) and an association of structural damage with anorectal dysfunction (p < 0.001). There was no association between age and anorectal dysfunction, including incontinence episodes. Conclusions: UC is a disease with structural and functional consequences in a significant subset of patients. This should be incorporated when defining the therapeutic strategy.

Diagnostic Yield of Random Colon Biopsies for Microscopic Colitis: A Community-Based Assessment

Introduction: Microscopic colitis(MC) is a diagnosis frequently considered in patients undergoing colonoscopy for diarrhea. Recent studies identified variables to predict likelihood of finding MC on colonoscopy, including: 1) weight loss 2) BMI 3) nocturnal stools 4) autoimmune disease and 5) medications introduced three months prior to diarrhea onset. These studies were performed at academic medical centers and thus could be influenced by referral bias. No community-based studies have evaluated these predictive variables for diagnostic yield of MC in the general population. Methods: A national pathology database was queried for colon biopsies conducted at a community-based ambulatory surgery center from January through December 2014. Diagnostic codes utilized included diarrhea, change in bowel habits, nonspecific colitis. Specimens with MC diagnosis, either collagenous colitis (CC) or lymphocytic colitis (LC), were recorded as cases. Biopsies with normal colon histology served as controls. A retrospective chart review was performed on all samples using the predictor variables listed above, excluding nocturnal stools. Results: We identified 413 colonoscopies with biopsies obtained at random locations in normal appearing colon mucosa. There were 38 cases (17CC, 21LC), 375 controls with a diagnostic yield for MC of 10.1%. Univariable analyses identified age and weight loss as positive predictors of MC. BMI was a negative predictor(Table 1). Medications or autoimmune disease were not significant on univariable analysis. Multivariable analysis revealed BMI was no longer a significant negative predictor, while age, modeled as a continuous variable, remained a significant positive predictor (Table 2). Weight loss was not included in multivariable analysis due to missing data upon chart review. However, a subgroup regression analysis of patients with non-missing weight loss data suggested age and BMI as predictors of MC.Table: Table. Univariable Logistic Regression ModelsTable: Table. Multivariable Logistic Regression ModelsConclusion: To our knowledge, this is the first community-based study evaluating the diagnostic yield of MC on random colon biopsies in patients with diarrheal presentations. The yield of MC is low (10%), raising questions on the utility of obtaining biopsies without considering predictive variables. In our study, multivariable regression analysis did not clearly establish predictive factors for MC. However independently, an older patient, a patient with weight loss, or a patient with low BMI who presents with diarrhea could heighten suspicions for MC and justify colonoscopy with biopsy.

Downstream resource utilization following SPECT: Impact of age and gender

BackgroundPrevious studies have identified a downstream referral age and gender bias for invasive coronary anatomy evaluation after single-photon emission computed tomography myocardial perfusion imaging (SPECT MPI). The present study evaluates if such bias still persists despite advancements in SPECT MPI and angiography. We hypothesized that women and patients ≥80 years old are less likely to undergo invasive coronary angiography after adjusting for clinical and scan variables. MethodsPatients (n = 3824) who referred to a nuclear cardiology laboratory at a tertiary medical center were retrospectively identified. Regression analysis tested age (<55; 55-69; 70-79; ≥80 years) and gender as predictors of diagnostic angiogram at 90 days post-SPECT after adjustment for known CAD, CAD risk equivalent, SSS, SDS, and LVEF. ResultsYounger patients were more likely to undergo an angiogram as compared to octogenarians (77% more likely if <55 years old, 69% if 55-69 years old, and 52% if 70-79 years old). No effect was found for gender. ConclusionsOlder patients were less likely to be referred for angiogram as compared to their younger counterparts. Further study is needed to determine which factors guide this decision-making process in older adults and the influence of these factors on the referral bias.

Pulmonary Hypertension Due to Left Heart Disease.

Pulmonary hypertension (PH) due to left heart disease (PH-LHD) is a significant predictor of outcome for patients with any type of heart failure (HF), and represents a subset of PH affecting a large number of patients. Because the condition is no standalone inherent pulmonary vascular disorder but the consequence of heart disease, its understanding is dependent on a thorough insight in current HF epidemiology, pathophysiology, diagnosis, and treatments. Although the age-specific incidence of HF is decreasing, this trend is less dramatic for HF with preserved ejection fraction than for HF with reduced ejection fraction. Both the current 2015 ESC/ERS guidelines for the diagnosis and treatment of PH, and the 2016 ESC guidelines for the diagnosis and treatment of acute and chronic HF have adopted new insights in the current understanding of PH-LHD (PH group 2), but no consensus has been reached. Due to multimorbidity, advanced age, referral biases, and a large proportion of noncardiovascular deaths in this population, proper hemodynamic and clinical characterization of patients with and without significant pulmonary vascular disease is important. Definitions largely depend on fluid status which should be assessed prior to any hemodynamic assessment. Benefit from pulmonary arterial hypertension–targeted treatments appears unlikely from today's perspective, but there is an immense unmet need for any treatments of this condition, and proper trials still have to be done.