Retrospective Case-matched Study Research Articles

Texture Analysis of Preoperative CT Images for Prediction of Postoperative Hepatic Insufficiency: A Preliminary Study

Texture analysis is a promising method of analyzing imaging data to potentially enhance diagnostic capability. This approach involves automated measurement of pixel intensity variation that may offer further insight into disease progression than do standard imaging techniques alone. We postulated that postoperative liver insufficiency, a major source of morbidity and mortality, correlates with preoperative heterogeneous parenchymal enhancement that can be quantified with texture analysis of cross-sectional imaging. A retrospective case-matched study (waiver of informed consent and HIPAA authorization, approved by the Institutional Review Board) was performed comparing patients who underwent major hepatic resection and developed liver insufficiency (n= 12) with a matched group of patients with no postoperative liver insufficiency (n= 24) by procedure, remnant volume, and year of procedure. Texture analysis (with gray-level co-occurrence matrices) was used to quantify the heterogeneity of liver parenchyma on preoperative CT scans. Statistical significance was evaluated using Wilcoxon's signed rank and Pearson's chi-square tests. No statistically significant differences were found between study groups for preoperative patient demographics and clinical characteristics, with the exception of sex (p < 0.05). Two texture features differed significantly between the groups: correlation (linear dependency of gray levels on neighboring pixels) and entropy (randomness of brightness variation) (p < 0.05). In this preliminary study, the texture of liver parenchyma on preoperative CT was significantly more varied, less symmetric, and less homogeneous in patients with postoperative liver insufficiency. Therefore, texture analysis has the potential to provide an additional means of preoperative risk stratification.

Improved outcomes with peritoneal dialysis catheter placement after cardiopulmonary bypass in infants

Acute kidney injury (AKI) is common in infants after cardiopulmonary bypass and is associated with poor outcomes. Peritoneal dialysis improves outcomes in adults with AKI after bypass, but pediatric data are limited. This retrospective case-matched study was conducted to determine if the practice of peritoneal dialysis catheter (PDC) placement during congenital heart surgery is associated with improved clinical outcomes in infants at high risk for AKI. Forty-two infants undergoing congenital heart surgery with planned PDC placement (PDC+) were age-matched to infants undergoing similar surgery without PDC placement (PDC-). Demographic, baseline and outcome data were compared. Our primary outcome was negative fluid balance on postoperative days 1 to 3. Secondary outcomes included time to negative fluid balance, time to extubation, frequency of electrolyte corrective medications, inotrope scores, and other clinical outcomes. Baseline data did not differ between groups. The PDC+ group had a higher percentage of negative fluid balance on postoperative days 1 and 2 (57% vs 33%, P=.04; 85% vs 61%, P=.01). The PDC+ group had shorter time to negative fluid balance (16 vs 32 hours, P<.0001), earlier extubation (80 vs 104 hours, P=.02), improved inotrope scores (P=.04), and fewer electrolyte imbalances requiring correction (P=.03). PDC-related complications were rare. PDC use is safe and associated with earlier negative fluid balance and improved clinical outcomes in infants at high risk for AKI. Routine PDC use should be considered for infants undergoing cardiopulmonary bypass. Further prospective studies are essential to prove causative effects of PDC placement in this population.

Early Classic Hemofiltration Exhibits No Benefits in Severe Acute Pancreatitis With Early Organ Failure: A Retrospective Case-Matched Study

Continuous venovenous hemofiltration (CVVH) is an important organ supportive technique. This study aimed to evaluate the impact of early classic CVVH on the outcomes of severe acute pancreatitis (SAP) patients with early organ failure (EOF). Between 2008 and 2012, a total of 44 SAP patients with EOF were admitted to our department. The 44 patients were classified into two groups according to whether they received early classic CVVH (2 L/h, initiated within 24 h after admission): 25 patients received early CVVH (ECVVH group), and 19 patients did not receive early CVVH (control group). The two groups were matched for age and Acute Physiology and Chronic Health Evaluation II scores. The severity of organ dysfunctions was evaluated by Sequential Organ Failure Assessment (SOFA) scores. Each group included 19 patients. The baseline characters between the two groups were balanced. The SOFA scores in the ECVVH group increased compared with those in the control group. The time to weaning from mechanical ventilation was significantly longer in the ECVVH group (log-rank test: χ(2) = 4.007, P = 0.045). Renal support was also significantly prolonged in the ECVVH group (the number of patients receiving CVVH 72 h after admission: 10 vs. 3, respectively, P = 0.038). Nine patients died in the ECVVH group versus six patients in the control group (P = 0.508). In conclusion, our study failed to prove that early classic CVVH had any benefits on the outcomes of SAP patients with EOF. Unexpectedly, early classic CVVH worsened organ functional capacity. However, it is possible that CVVH using advanced techniques may be beneficial in SAP patients with EOF.

Efficacy of a functionally-based neurorehabilitation programme: A retrospective case-matched study of rehabilitation outcomes following traumatic brain injury

Objective: To investigate the efficacy of a functionally-based neurorehabilitation programme.Design: Retrospective, case-matched cohort design.Setting: An inpatient acquired brain injury (ABI) service at a post-acute rehabilitation facility. In 2001, a functionally-based rehabilitation model was introduced that streams patients into neurocognitive (NC) and neurophysical (NP) treatment groups based on predominant functional deficits.Methods: Sixty-nine patients with TBI admitted to the ABI service before implementation of the functionally-based programme comprised a historical control group. These patients were individually case-matched to 69 participants admitted after the functionally-based programme began. Rehabilitation outcomes were compared between matched patients treated before and after implementation of the programme.Outcome measures: Rehabilitation length of stay (RLOS), Functional Independence Measure (FIM) and Disability Rating Scale (DRS) at rehabilitation discharge and FIM efficiency.Results: At discharge, the NP-stream had a significantly higher FIM motor efficiency compared to the historical control (0.41 vs. 0.29; p = 0.01). The NC-stream had significantly less disability, as measured by the DRS, compared to its control (3.63 vs. 5.05; p = 0.01).Conclusions: This study presents preliminary evidence that a rehabilitation programme that targets functional needs rather than diagnosis may be useful in improving function after traumatic brain injury.

Evaluation of Weight-Based Dosing of Unfractionated Heparin in Obese Children

To determine whether pediatric patients with obesity receiving weight-based dosages of unfractionated heparin (UFH) exhibit an enhanced response when dosed by actual body weight compared with nonobese patients as assessed primarily by the frequency of supratherapeutic anticoagulation. Secondary measures included UFH doses associated with therapeutic anticoagulation. This single-institution retrospective case-matched study included children with and without obesity, matched on a 1:1 basis, who received a weight-based continuous infusion of UFH. Therapeutic monitoring values were defined for activated partial thromboplastin time (aPTT) level (70-101 seconds) and anti-activated factor X (Xa) level (0.35-0.7 U/mL). The study included 50 children. The percentage of patients with supratherapeutic anticoagulation at any point in the study, as measured by either aPTT or anti-Xa level, was similar in the obese and nonobese groups (76% vs 72%; P = 1.0). However, compared with patients without obesity, those with obesity received a lower mean starting dose (17.4 vs 20.2 U/kg/hour; P = .013) and a lower mean maintenance dose (19.1 vs 24.3 U/kg/hour; P = .033) to achieve stable therapeutic monitoring test values. There was no difference in mean initial post-UFH aPTT between the 2 groups, but the mean initial anti-Xa level was higher in the obese group (0.45 vs 0.29 U/mL; P = .045). Compared with children without obesity, those with obesity who received actual body weight-based continuous UFH infusions did not exhibit a higher frequency of supratherapeutic anticoagulation, but did require lower dosages to achieve comparable anticoagulation. Our results highlight recognized discrepancies between aPTT and anti-Xa monitoring assays.

Comparison of Anti-Xa Levels in Obese and Non-Obese Pediatric Patients Receiving Treatment Doses of Enoxaparin

To determine if using actual body weight to dose enoxaparin in obese pediatric patients results in higher anti-Xa levels compared with non-obese pediatric patients. This was a retrospective case-matched study of obese and non-obese pediatric patients receiving treatment doses of enoxaparin in a tertiary care children's hospital. Patients were included if they were initiated on treatment doses of enoxaparin, had appropriate anti-Xa levels drawn, and were between 2 and 18 years of age. Patients with renal insufficiency, hyperbilirubinemia, goal anti-Xa level <0.5 or >1 unit/mL, or receiving mechanical circulatory support were excluded. Obese patients who met study criteria were matched on a 1:1 basis with non-obese patients. All baseline characteristics were similar except for body mass index percentile (98.2 ± 2 vs 48.7 ± 15, P < .01). Obese patients had higher initial anti-Xa levels (0.67 ± 0.27 vs 0.53 ± 0.24 unit/mL, P = .028). Over time, obese patients required a lower mean dose to achieve therapeutic anti-Xa levels than non-obese patients (0.81 ± 0.19 vs 1.1 ± 0.4 mg/kg, P = .005). The mean initial anti-Xa level was higher in obese pediatric patients compared with non-obese pediatric patients, but a dosage adjustment was not required. Obese patients may need closer monitoring over time to avoid supratherapeutic levels and possible bleeding events.

Clinical Effects of Statin Use on Gastric Cancer Prevention

To the Editor: By analyzing the National Health Insurance data on the use of statins and risk factors of gastric cancer in 337 gastric cancer patients and 1,348 propensity-matched controls, Dr Chiu et al. ( 1 ) revealed that statin use was associated with a 32 % reduction in risk (an odds ratio of 0.68) of gastric cancer in Taiwan. However, it is not possible to translate the clinical eff ects of statin use observed in this study into the general population. Th e incidence of gastric cancer in Taiwan is estimated to be around 0.015 % ( 2 ), which is far 24,000,000 of the population in Taiwan. In the Methods section of the article, Dr Chiu et al. mention that under the conditions of detecting an odds ratio of 0.5 with 80 % power at the 5 % signifi cance level, a controlto-case of 4 is planned. I think that the odds ratio is overestimated, because any study has not shown such a strong eff ect of statins against gastric cancer. Additionally, it would be reasonable to increase the ratio of control-to-case to reduce the risk of selection bias. Th e large population-based study with a long-term follow-up period may be more feasible than the case – control study for evaluating the eff ects of statins on cancer prevention. Although it would be more diffi cult to adjust for risk factors such as H. pylori infection and atrophic gastritis in the prospective study than in the retrospective case-matched study, risk adjustment may not be necessarily required in populations at low risk for gastric cancer.

Hand-assisted laparoscopy leads to efficient colorectal cancer surgery

BackgroundLaparoscopic-assisted (LA) colorectal resections have improved short-term outcomes compared with open resections. Lack of tactile feedback, though, has led to lengthy operations and high conversion rates with attendant adverse effects on patients. Hand-assisted laparoscopy (HAL), in contrast, provides tactile feedback while still being minimally invasive. We hypothesize that HAL compared with LA for colorectal cancer resections will be associated with lower conversion rates and decreased operative times, without compromising the advantages of laparoscopy. Materials and methodsWe performed a retrospective case-matched study of patients undergoing LA or HAL colorectal cancer resections from 2002 to 2010, using a prospectively maintained colorectal cancer database at a Veterans Affairs Medical Center. Short-term outcomes analyzed (using the Wilcoxon signed rank and McNemar’s tests) included operative and perioperative variables and surrogate markers of adequacy of oncologic care. ResultsForty-seven LA patients were matched 1:1 by age and resection with 47 HAL patients. Patients in the HAL group had significantly lower blood loss (100 versus 150 cc, P = 0.04), operative times (206 versus 252 min, P = 0.002), and conversion rates (6% versus 38%, P < 0.0005). They also spent fewer days in the intensive care unit (0 versus 1, P = 0.004) and had quicker return of flatus (3 versus 4 d, P = 0.03). HAL resulted in more lymph nodes resected (21 versus 15, P = 0.03) and a more adequate lymph node harvest (98% versus 77%, P = 0.01). ConclusionsHAL is associated with improved operative efficiency, conversion rates, and lymphadenectomy as compared with LA colorectal cancer resections. HAL should be considered in the management of colorectal cancer patients.

Case-Matched Outcomes in Bariatric Surgery for Treatment of Type 2 Diabetes in the Morbidly Obese Patient

To compare the relative efficacy of medical management, the duodenal switch (DS), and the laparoscopic adjustable gastric band (LAGB) to the Roux-en-Y gastric bypass (RYGB) for treatment of type 2 diabetes mellitus (T2DM). The RYGB resolves T2DM in a high proportion of patients and is considered the standard operation for T2DM resolution in morbidly obese patients. However, no data exist comparing the efficacy of medical management and other bariatric operations to the RYGB for treatment of T2DM in comparable patient populations. We performed a retrospective case-matched study of morbidly obese patients with T2DM who had undergone medical management (nonsurgical controls [NSC]; N = 29), LAGB (N = 30), or DS (N = 27) and were compared with matched T2DM patients who had undergone RYGB. Matching was performed with respect to age, sex, body mass index, and hemoglobin A1C (HbA1C). Outcomes assessed were changes in body mass index, HbA1C, and diabetes medication scores at 1 year. The Roux-en-Y gastric bypass produced greater weight loss, HbA1C normalization, and medication score reduction compared to both NSC and LAGB-matched cohorts. Duodenal switch produced greater reductions in HbA1C and medication score than RYGB, despite no greater weight loss at 1 year. Surgical complications were rarely life threatening. This study provides an important perspective about the comparative efficacy of LAGB, DS, and NSC to the RYGB for treatment of T2DM among obese patients. After 1 year of follow-up, RYGB is superior to NSC and LAGB with respect to weight loss and improvement in diabetes whereas DS is superior to RYGB in reducing HbA1C and medication score.

Case-matched comparison with standard versus reduced intensity conditioning regimen in chronic myeloid leukemia patients

This retrospective case-matched study evaluated the efficacy of reduced intensity conditioning (RIC) regimen on early and late allogeneic transplant outcome in chronic myeloid leukemia (CML) patients. Twenty-eight patients conditioned with RIC regimen were matched to 56 patients who received a myeloablative conditioning (MAC) regimen. The main criteria for case matching among our CML allotransplant cohort were the Gratwohl scoring system. The median score was 2 (1-4) in each group. The pretransplant disease status was first chronic phase (CP1, n = 20), CP2 (n = 2), and advanced phase (n = 6) in RIC, and CP1 (n = 46), CP2 (n = 3), and advanced phase (n = 7) in MAC. The duration of neutropenia and thrombocytopenia was shorter in RIC than MAC. The grade and duration of mucositis were less in RIC. The need for total parenteral nutrition (21% vs. 77%, p < 0.0001) and febrile neutropenic episodes (50% vs. 95%, p < 0.0001) were observed less frequently in RIC compared with MAC-given patients. Acute or chronic graft versus host diseases (GvHD) were not affected by the intensity of conditioning regimen. The incidence of transplant-related mortality was higher in MAC (7% vs. 14%, p = 0.01). Although more relapse/progression was observed in the RIC group, the probability of 5- and 10-year leukemia-free- and overall survival were similar regardless of conditioning regimen intensity (p > 0.05). In early first CP, the pair of female donor-male recipient and the development of chronic GvHD prolonged both leukemia-free survival and overall survival in multivariate analysis. According to our single-center matched-pair analysis, the use of RIC regimens in patients with low-risk CML results with toxicities less, responses later, and relapses more frequent than the MAC regimens.

Should we reoperate for recurrent high-grade astrocytoma?

Despite optimal treatment of post-operative radiotherapy and chemotherapy for newly diagnosed high-grade astrocytoma, nearly all patients eventually recur. However, the efficacy of reoperation for recurrent astrocytoma is still debatable as to different surgical indications. To investigate the therapeutic effect of reoperation on patients with recurrent high-grade astrocytoma more objectively, a retrospective case-matched study was carried out. The clinical data of 63 cases of recurrent high-grade astrocytoma treated between January 2006 and December 2008 were studied. A total of 21 cases received reoperation immediately after tumor recurrence, while 42 cases without reoperation were matched by gender, age, Karnofsky Performance Scale (KPS) score, histopathology, recurrent interval after the first operation, extent of initial surgery, adjuvant treatment and characteristics of recurrent tumor. The study showed that the median survival time was 7 months in the reoperation group, while in non-reoperation group, it was 4 months. There was significant difference on univariate analysis (P < 0.001). Moreover, the median duration time of progression-free survival (PFS) after tumor recurrence was significantly (P < 0.001) longer in the reoperation group (5 months) than that in the non-reoperation group (2.5 months). The prognostic factors of recurrent high-grade astrocytoma included reoperation, KPS score and tumor location. It was indicated that reoperation could prolong the survival time and improve the quality of survival in patients of recurrent high-grade astrocytoma.

Direct Peritoneal Resuscitation Accelerates Primary Abdominal Wall Closure after Damage Control Surgery

Damage control surgery is a staged approach to the trauma patient in extremis that improves survival, but leads to open abdominal wounds that are difficult to manage. We evaluated whether directed peritoneal resuscitation (DPR) when used as a resuscitation strategy in severely injured trauma patients with hemorrhagic shock requiring damage control surgery would affect the amount of and timing of resuscitation and/or show benefits in time to abdominal closure and reduction of intra-abdominal complications. A retrospective case-matched study of patients undergoing damage control surgery for hemorrhagic shock secondary to trauma between January 2005 and December 2008 was performed. Twenty patients undergoing standardized wound closure and adjunctive DPR were identified and matched to 40 controls by Injury Severity Score, age, gender, and mechanism of injury. A single early death was excluded because of inability to control ongoing hemorrhage. There were no differences in age, gender, or mechanism of injury between the groups. Injury Severity Score (35.07 +/- 17.1 versus DPR 34.95 +/- 16.95; p = 0.82) and packed red blood cell administration in 24 hours (23.8 +/- 14.35 U versus DPR 26.9 +/- 14.1 U; p = 0.43) were similar between the groups. Presenting pH was similar between the study group and the DPR group (7.24 +/- 0.13 d versus DPR 7.26 +/- 0.11; p = 0.8). Time to definitive abdominal closure was significantly less in the DPR group compared with controls (DPR: 4.35 +/- 1.6 d versus 7.05 +/- 3.31; p < 0.003). DPR also allowed for a higher rate of primary fascial closure, lower intra-abdominal complication rate, and lower rate of ventral hernia formation at 6 months. Adjunctive DPR afforded a definitive wound closure advantage compared with Wittmann patch closure techniques (DPR 4.35 +/- 1.6 versus Wittmann patch 6.375 +/- 1.3; p = 0.004). The addition of adjunctive DPR to the damage control strategy shortens the interval to definitive fascial closure without affecting overall resuscitation volumes. As a result, this mitigates intra-abdominal complications associated with open abdomen and damage control surgery and affords better patient outcomes.

GM-CSF in Stem Cell Transplant (SCT) Recipients: Impact of Graft-Versus Host Disease on Invasive Fungal Infections (IFIs)

Background: GM-CSF is thought to be beneficial in SCT patients with IFI. The impact of GM-CSF in SCT recipients with GVHD and IFI was evaluatedMethods: A retrospective case-matched (GM-CSF [n = 12] vs. no GM-CSF [n = 27]) study was undertaken to compare outcomes if IFIs diagnosed >100 days following transplantation during 2000–2006. A response was defined as complete or partial response (CR/PR) and considered 3 months after IFI diagnosis or earlier in patients with earlier response. All value are given as median ± s.d. The systemic antifungal therapy in > 60% of patients included echinocandin and anti-mold triazole, or polyene agent.Results: Please refer to the table below. Patients who received GM-CSF were younger (age 36 ± 17 vs. 51 ± 13 years); neutropenic (<500 cells/uL) at onset of infection (50% vs. 11%; P = 0.014); had lower monocyte counts (10 ± 236 vs. 220 ± 575 cells/uL; P = 0.021) and frequently required intensive care unit stay (50% vs 15%; P = 0.043). A 50% response was observed in the GM-CSF treated SCT recipients with GVHD and IFIs, whereas, 41% response occurred in the group who received no concurrent Gm-CSF (P = 0.6). Similarly, IFI-associated deaths were less frequently observed in GM-CSF treated patients (41%) compared with 55% seen in patients who had not received GM-CSF (P = 0.7). There was a slight increase in survival among SCT recipients treated with GM-CSF (48 ± 21 days vs. 34 ± 19 days in no GM-CSF group P = 0.05)Conclusions: Late fungal infections in SCT recipients with GVHD, when treated with GM-CSF-based therapy had comparable outcomes despite having significantly more neutropenia, severe monocytopenia and ICU stay.CharacteristicsGM-CSF N = 12 (5%No GM-CSF N = 27 (%)p-valueUnderlying Disease-Leukemia Relapsed/refractory Cancer10 (83) 5 (42)18 (67) 6 (22)0.12 0.26Proven and probable IFI9 (75)21 (78)1GVHD (extensive)5 (42)14 (52)0.57High Dose Steroids7 (58)18 (67)0.72Disseminated IFI3 (25)4 (15)0.65Breakthrough IFI10 (83)25 (93)0.57APACHI II Score at time of IFI diagnosis11+/−4 (range 5–18)12+/−3 (range 5–19)0.47

Mortality Associated With Nephropathy After Radiographic Contrast Exposure

To define outcomes from contrast-induced nephropathy (CIN) after both intra-arterial and intravenous administration of contrast medium. We performed a retrospective case-matched cohort study at Mayo Clinic's site in Rochester, MN, from April 1, 2004, to March 31, 2006. All contrast procedures were evaluated for inclusion. Contrast-induced nephropathy was defined as creatinine elevation of 25% or more after contrast exposure or of more than 0.5 mg/dL within 7 days of contrast exposure. Cases of CIN were matched 1:3 with controls by age, sex, pre-procedure creatinine elevation, diabetes mellitus, and type of imaging procedure. A total of 809 patients who developed CIN were matched to 2427 patients who did not develop CIN after contrast exposure. In multivariate analyses, CIN was significantly associated with 30-day mortality (odds ratio, 3.37; 95% confidence interval [CI], 2.58-4.41; P<.001) and overall mortality (hazard ratio, 1.57; 95% CI, 1.32-1.86; P<.001) after adjustment for heart failure, hypertension, medications, total hydration, iodine load, prior contrast exposure, and all matched variables during the study period. Intravenous contrast administration was a risk factor for 30-day mortality (odds ratio, 2.91; 95% CI, 1.17-7.23; P=.02) and overall mortality (hazard ratio, 3.02; 95% CI, 1.89-4.82; P<.001) compared with intra-arterial administration of contrast after adjustment for heart failure, hypertension, medications, total hydration, iodine load, prior contrast exposure, and all matched variables during the study period. Contrast-induced nephropathy after administration of contrast medium is associated with increased mortality. This risk is higher in patients in whom contrast medium is administered intravenously than in those in whom it is administered intra-arterially.

Inhaled aminoglycosides in cancer patients with ventilator-associated Gram-negative bacterial pneumonia: safety and feasibility in the era of escalating drug resistance

We sought to evaluate the safety and feasibility of inhaled aminoglycosides or colistin in cancer patients with ventilator-associated pneumonia (VAP) due to Gram-negative bacteria (GNB). A retrospective case-matched study was obtained after obtaining IRB approval in patients at the intensive care unit at our NCI-designated comprehensive cancer center between 1999 and 2005. Sixteen patients with GNB-VAP who received inhaled aminoglycosides or colistin were compared with 16 patients who had received these antibiotics intravenously alone. Eligible patients were required to have received at least six doses of inhaled therapy, or 3 or more days of intravenous therapy. Clinical Pulmonary Infection Scores were used to assess pneumonia severity. Standard ATS criteria were used to define VAP. Patients treated with inhaled antibiotics were less likely to have received corticosteroids (13% vs 50%; P < 0.02) and had a higher median baseline creatinine level (0.85 vs 0.6 mg/dL; P < 0.02) than patients treated intravenously. Pseudomonas aeruginosa (69%) was the most common cause of VAP. There were no serious adverse events associated with inhaled antibiotics. Patients who received these antibiotics intravenously developed renal dysfunction (31%); none of the patients treated with inhaled antibiotics developed nephrotoxicity (P < or = 0.04). Patients treated with inhaled antibiotics were more likely to have complete resolution of clinical (81% vs 31% in the intravenous antibiotic group; P < 0.01) and microbiologic infection (77% vs 8% in the intravenous antibiotic group: P < 0.0006). In a multivariate analysis adjusted for corticosteroid use, inhaled antibiotic therapy was predictive of complete clinical resolution (odds ratio [OR], 6.3; 95% confidence interval [CI], 1.1, 37.6; P < 0.04) and eradication of causative organisms (OR 36.7; 95% CI, 3.3, 412.2; P < 0.003). In critically ill cancer patients with Gram-negative VAP, inhaled aminoglycosides were tolerated without serious toxicity and may lead to improved outcome.

Does Functional Vision Behave Differently in Low-Vision Patients with Diabetic Retinopathy?—A Case-Matched Study

A retrospective case-matched study designed to compare patients with diabetic retinopathy (DR) and other ocular diseases, managed in a low-vision clinic, in four different types of functional vision. Reading, mobility, visual motor, and visual information processing were measured in the patients (n = 114) and compared with those in patients with other ocular diseases (n = 114) matched in sex, visual acuity (VA), general health status, and age, using the Activity Inventory as a Rasch-scaled measurement tool. Binocular distance visual acuity was categorized as normal (20/12.5-20/25), near normal (20/32-20/63), moderate (20/80-20/160), severe (20/200-20/400), profound (20/500-20/1000), and total blindness (20/1250 to no light perception). Both Wilcoxon matched pairs signed rank test and the sign test of matched pairs were used to compare estimated functional vision measures between DR cases and controls. Cases ranged in age from 19 to 90 years (mean age, 67.5), and 59% were women. The mean visual acuity (logMar scale) was 0.7. Based on the Wilcoxon signed rank test analyses and after adjusting the probability for multiple comparisons, there was no statistically significant difference (P > 0.05) between patients with DR and control subjects in any of four functional visions. Furthermore, diabetic retinopathy patients did not differ (P > 0.05) from their matched counterparts in goal-level vision-related functional ability and total visual ability. Visual impairment in patients with DR appears to be a generic and non-disease-specific outcome that can be explained mainly by the end impact of the disease in the patients' daily lives and not by the unique disease process that results in the visual impairment.

Clinical Utility and Economic Impact of Introducing a Bowel Management System

The primary objective of this study was to compare rates of urinary tract and soft tissue infections in critically ill burn patients before and following introduction of a Bowel Management System (BMS). We also analyzed the economic impact of the BMS as compared to reactive management of fecal soiling via cleansing and dressing changes. A retrospective case-matched before-after study was completed. Critically ill burn patients using a BMS were matched with similar patients managed before introduction of the device based on gender, total body surface area burned, burn location, ventilation days, and hospital length of stay. Reductions in hospital-acquired urinary tract infections and skin and soft tissue infections were observed after introduction of the BMS. Despite its initial cost, it proved more cost effective than a reactive bowel management strategy based on cleansing and dressing changes when fecal soiling occurs. Proactive use of a bowel management device appears to reduce some infectious sequelae in a complicated burn care population and proved cost-effective for our facility.

Should ileoanal pouch surgery be staged for patients with mucosal ulcerative colitis on immunosuppressives?

Much debate has revolved around whether patients with mucosal ulcerative colitis (MUC) receiving immunosuppression should be weaned off immunosuppressives before undergoing ileal pouch surgery. Therefore, the aim of this study was to assess the affect of immunosuppressive drugs on postoperative complications after ileoanal pouch surgery. A retrospective medical record review of patients with MUC who underwent ileal pouch surgery while taking immunosuppressive drugs such as azathioprine, 6-mercaptopurine (6-MP), methotrexate, and cyclosporin A was performed. Postoperative complications in the study group were compared to three matched groups: patients with MUC who had ileoanal pouch surgery while taking systemic steroids, patients with MUC not receiving any immunosuppressive drugs, and patients with familial adenomatous polyposis. Twenty-two patients with MUC who underwent ileoanal pouch surgery while taking immunosuppressive drugs were identified from a prospectively entered database of patients who had this surgery between 1988 and 2005. All but two patients underwent temporary fecal diversion. Fifteen patients were taking 6-MP or azathioprine; six were on cyclosporine A, and one both on azathioprine and cyclosporine A. Fifteen patients were also taking steroids at the time of ileoanal pouch surgery. Early (within 30 days of surgery) and late complications occurred in 36 and 50% of the study group patients, respectively, but did not significantly differ from a matched group of patients with MUC who did not take immunosuppressive drugs. Patients with familial adenomatous polyposis had a significantly lower long-term complication rate. This retrospective case-matched study suggests that the use of immunosuppressive drugs and cyclosporine A may not be associated with an increased rate of complications after ileoanal pouch surgery.

The combination of cyclophosphomide, thalidomide and dexamethasone is an effective alternative to cyclophosphamide – vincristine – doxorubicin – methylprednisolone as induction chemotherapy prior to autologous transplantation for multiple myeloma: a case-matched analysis

A retrospective case-matched study was conducted to compare the oral regimen CTD (cyclophosphamide – thalidomide – dexamethasone) and infusional CVAMP (cyclophosphamide – vincristine – doxorubicin – methylprednisolone) as induction therapy followed by autologous peripheral blood stem-cell transplantation (PBSCT) for newly diagnosed multiple myeloma patients. The response rate after three cycles of treatment was statistically higher with CTD (n = 27) compared to CVAMP (n = 27) (89% vs. 56%, P = 0.016). Toxicity studies showed more neutropenia (grade 3/4) (4% vs. 60%, P = 0.0002) with CVAMP and more thrombotic episodes with CTD (11% vs. 4%). CTD may emerge as the superior induction regimen prior to PBSCT, in terms of high efficacy and better tolerability.

Use of Percutaneous Endoscopic Gastrostomy Feeding Tubes and Functional Recovery in Stroke Rehabilitation: A Case-Matched Controlled Study

Iizuka M, Reding M. Use of percutaneous endoscopic gastrostomy feeding tubes and functional recovery in stroke rehabilitation: a case-matched controlled study. Objective To compare the morbidity, mortality, and functional recovery of patients who require percutaneous endoscopic gastrostomy (PEG) placement for the management of dysphagia after stroke. Design Retrospective case-matched controlled study. Setting Acute stroke rehabilitation inpatient unit. Participants Patients (N=193) who were admitted for stroke rehabilitation with a PEG tube in place from January 1, 1993, to December 31, 2002, were matched with 193 case controls without PEG. Patients and controls were within 90 days of stroke onset, and were matched for age, sex, type of stroke, FIM instrument score, duration from onset to stroke unit admission, and year of admission. Interventions Not applicable. Main outcome measures Length of rehabilitation hospital stay, improvement in FIM scores, FIM efficiency score, need for transfer back to acute care hospital, diagnosis for which transfer was required, final discharge destination, and survival status. Results Significant differences were found between the 2 groups, PEG versus control, respectively, in the following variables: FIM efficiency (.42±.57 vs .56±.55, P=.016); need for transfer back to acute hospital (58/193 vs 23/193, P=.001); and survival status dead/alive (14/179 vs 3/190, P=.006). Nonsignificant differences were as follows: length of rehabilitation hospital stay (46.9±24.8d vs 43.3±19.7d, P=.11), improvement in total FIM score from admission to discharge (16.9±17.9 vs 21.0±15.5, P=.72), and final discharge destination home/institutional care (96/83 vs 101/89, P=.93). Pneumonia was the most frequent reason for transfer to acute care for patients with PEG. Conclusions Patients who meet criteria for admission to a stroke rehabilitation unit and who have a PEG in place are at increased risk for medical complications and death. Those who survive, however, show similar functional recovery and rate of home discharge as case-matched controls.