Retrospective Case-cohort Study Research Articles

Point-of-care viscoelastic testing improves the outcome of pregnancies complicated by severe postpartum hemorrhage

Study Objective. To compare the clinical outcomes of patients with severe postpartum hemorrhage (PPH) managed with and without the use of Point-of-Care Viscoelastic Testing (PCVT) to direct blood product replacement. Design. A retrospective cohort study of consecutive cases of severe PPH managed at a single tertiary care center between January 1, 2011 and July 31, 2015. Cases included patients managed using PCVT. Controls were patients managed using a standardized massive hemorrhage transfusion protocol, either because PCVT was not yet available or because no PCVT credentialed providers were on site. Setting. Delivery room, postoperative recovery area, intensive care unit. Patients. There were 6,708 cesarean deliveries and 13,641 vaginal births during the study period. Eighty six patients (0.4% of all deliveries) developed severe PPH. Severe PPH occurred in 1% (68/6,708) of cesarean and 0.1% (18/13,641) of vaginal deliveries. Twenty-eight of these 86 patients (32.6%) were managed with PCVT and 58 (67.4%) without PCVT. Interventions. Patients with severe PPH were managed according to a standardized massive transfusion protocol or a PCVT-based protocol to direct blood product replacement. Measurements. PCVT testing was performed using a ROTEM delta device. Results. Patients in the PCVT cohort received significantly fewer transfusions of packed red blood cells, fresh frozen plasma, and platelet concentrates. They also had a significantly lower estimated blood loss, and a significantly lower incidence of cesarean hysterectomy and postoperative ICU admission as compared with patients not managed using PCVT. The length of postpartum hospitalization was also significantly shorter in the PCVT cohort. Among patients who gave birth within 24 hours of admission, the direct cost of hospitalization was 40% lower for patients in the PCVT cohort. Conclusions. PCVT-based goal-directed blood product replacement management was associated with substantial benefits over a standardized massive transfusion protocol both in terms of patient outcomes and cost of care.

Adherence to Clinical Practice Guidelines (CPG) management of dengue infection in adults (revised 2nd edition).

The Malaysian Dengue Clinical Practice Guidelines (CPG) have been developed to provide evidence-based guidance in the management of dengue infections. The use of these guidelines is essential to ensure its recommendations are being practiced. However, the adherence to the guidelines for management of dengue (revised 2nd edition) by healthcare providers still remains unknown. Therefore, the aim of this study was to evaluate the proportion among healthcare providers that adhere to this Dengue CPG. A retrospective cohort study of dengue cases registered from 1 January 2014 to 1 June 2015 was conducted in public hospitals and health clinics in Selangor, Putrajaya and Kuala Lumpur. Adherence to the CPG recommendations were recorded by reviewing patients’ case notes. Overall proportion of adherence in clinical components of the recommendation were (7.1 to 100.0% versus 7.7 to 73.8%) in history taking, (6.7 to 100.0% versus 12.3 to 60.0%) in physical examinations, (18.4 to 100.0% versus 23.1 to 83.2%) in assessment of warning signs, (0.6 to 100.0% versus 12.3 to 87.7%) in assessment of haemodynamic status, (60.0 to 100.0% versus 27.7 to 40.0%) in diagnosis, (46.6 to 80.0% versus 52.3%) in case notifications, (73.2 to 100.0% versus 89.2 to 96.9%) in performing specific laboratory investigations and (7.9 to 100.0% versus 21.5%) in monitoring, for outpatient versus inpatient, respectively. Adherence trends were demonstrated to be higher in hospital settings compared to outpatient settings. Adherence to this Dengue CPG varies widely with overall good clinical outcomes observed.

Comparison of In-Hospital Maternal Mortality Between Hospital Systems in Queensland, Australia and Louisiana, United States.

It is well documented that the American maternal mortality ratio has increased during the years 2000-2015. The Australian maternal mortality ratio, in contrast, has decreased during the same time period, a trend common among most Western countries. This study was a retrospective cohort study of cases of in-hospital maternal deaths in the Ochsner Health System (Louisiana, United States) and the Queensland Health System (Australia) from 1995 to 2013. The aim was to determine if American and Australian women have a similar rate of preventable maternal death and if the deaths were attributable to the same factors. A multidisciplinary team assessed medical records to determine preventability. Sixteen eligible medical records were identified in the Ochsner Health System and 15 in the Queensland Health System. In the American cohort, deaths in the private insurance group (n=5) were least likely to be preventable (P=0.003). Australian maternal deaths were less likely to occur among women with late or no prenatal care than American maternal deaths; the risk difference was 44.5% for all deaths (95% confidence interval [CI]=9.7%, 79.4%; P=0.03) and 50.0% for potentially preventable deaths (95% CI=9.3%, 90.6%; P=0.04). Women from Louisiana, United States and Queensland, Australia have similar rates of preventable maternal death. No statistically significant factors explained trends in Australian maternal death; American maternal mortality was significantly associated with point of entry into prenatal care, likely influenced by insurance status. Furthermore, the majority of deaths in this group were complicated by hospital systems-based factors.

Effects of esketamine sedation compared to morphine analgesia on hydrostatic reduction of intussusception: A case-cohort comparison study.

Hydrostatic or pneumatic reduction of intussusception is an invasive procedure that is stressful and may be painful for a child. Resistance of the child may increase the duration of the procedure and decrease success rate of reduction. Analgesia can help to reduce pain, but not necessarily resistance. General anesthesia increases success rate of reduction. However, it requires the presence of an anesthesiologist, and may lead to anesthesia-related complications. Procedural sedation with esketamine could be a safe alternative. The aim of this study was to compare hydrostatic reduction using morphine analgesia compared to procedural sedation with esketamine in terms of success rate, adverse events, and duration of reduction. A retrospective case-cohort comparison study was performed with two groups of patients who had undergone hydrostatic reduction for ileocolic intussusception and received morphine analgesia (n=37) or esketamine sedation (n=20). Until July 2013, reduction was performed after intravenously administered morphine. Hereafter, a new protocol for procedural sedation was implemented and reduction was performed after administration of esketamine. Cases were matched for age and duration of symptoms. No adverse events requiring intervention other than administration of oxygen were reported for either group. Success rate of reduction using esketamine sedation was 90% vs 70% using morphine analgesia, risk ratio (RR) 1.29, 95% CI[0.93-1.77]. Recurrence rate using esketamine sedation was 10% vs 15% using morphine analgesia, RR 0.67, 95% CI[0.12-3.57]. Reduction time was shorter using esketamine sedation (Median 5minutes, IQR 9minutes) vs morphine analgesia (Median 8minutes, IQR 16minutes, P=.04, Median difference 3, 95% CI[-1.50-8.75]). Median hospital stay in the esketamine group was 1.5days (IQR 1.8) vs 2days (IQR 5.3) in the morphine group. No serious adverse events were recorded. In comparison to morphine analgesia, with esketamine there was weak evidence for a higher success rate, lower recurrence rate, shorter duration, and shorter length of hospital stay.

FV 7 High-frequency anterior thalamus stimulation increases alertness in epilepsy patients during alert- and drowsy-wakefulness

Objective Deep brain stimulation (DBS) of anterior thalamic nuclei (ANT) reduces frequency and intensity of epileptic partial and secondarily-generalized seizures. ANT-DBS disrupts sleep in epilepsy patients. We investigated the impact of ANT-DBS on alertness in wakeful epilepsy patients. This might help to better understand mechanisms of action of high frequency ANT-DBS in humans. Methods Four patients with different structural epileptic pathology were included in this retrospective case-cohort study. We analysed physiological parameters of alertness during stimulation-ON and -OFF intervals in short- and long-term electroencephalograms (EEG) of patients in states of alert- and drowsy-wakefulness. Results We demonstrate that ANT-DBS increases acutely and reproducible the alertness of wakeful patients during stimulation-ON intervals. Significance This is the first demonstration of such an effect in humans. The enhanced alertness might contribute to the antiepileptic effect of ANT-DBS. Corroborated with the sleep-disruption effect of ANT-DBS in epilepsy patients, our results deliver circumstantial evidences that high-frequency ANT-DBS activates thalamo-cortical connections that promote wakefulness. In addition, our data suggest that ANT-DBS might improve the post-ictal recovery of epileptic patients and counterbalance the antiepileptic-drug induced fatigue.

A retrospective case-cohort study comparing treatment outcomes in abacavir versus stavudine containing first line antiretroviral treatment regimens in children

IntroductionThe current World Health Organization guideline for first line antiretroviral therapy (ART) in HIV-infected children recommends the use of abacavir and lamivudine as nucleoside backbones and no longer includes stavudine. We compared treatment outcomes with abacavir (ABC) versus stavudine (d4T) in a cohort of HIV-1 infected children 6 and 12 months after antiretroviral therapy was initiated.MethodsThis was a retrospective case-cohort study, using programmatic data from children enrolled in the Paediatric Wellness Programme at the Perinatal HIV Research Unit in Soweto, South Africa between 2005 and 2013. Children on abacavir/stavudine who had initiated ART at age <3 years with a regimen including lamivudine and lopinavir/ritonavir and had at least one 6 or 12 month viral load result were eligible. All ABC cases identified were matched for age at ART initiation and gender to eligible d4T controls (1:2). Outcomes analysed at 6 and 12 months post ART initiation included virological failure, mortality, immunological failure and anthropometry. Chi-square tests compared categorical measures while Kruskal-Wallis compared continuous measures.ResultsWe identified 57 eligible ABC cases and selected 114 matched d4T controls. Overall, 57% were females and 89% started treatment at age <1year. The median age at ART initiation was 3.11 (IQR: 1.98–6.05) months. There was no difference in the proportion of children virologically suppressed between the groups at 6 (ABC 54.5% vs. d4T 67.0%, p = 0.125) and 12 (ABC 66.7% vs. d4T 71.6%, p = 0.53) months post ART-initiation. The proportion of children with adherence levels >90% for ABC and d4T were similar too (95% in ABC vs. 86% in d4T, p = 0.10). The proportion of children who died over 12 months was 3.5% in the ABC and 7.9% in the d4T group (p = 0.27). Similarly, the anthropometric measures were comparable.ConclusionsIt is reassuring that in the short term, in this group of patients, the treatment outcomes were similar.

Chemotherapy with radiotherapy influences time-to-development of radiation-induced sarcomas: a multicenter study

Background:An increasing number and proportion of cancer patients with apparently localised disease are treated with chemotherapy and radiation therapy in contemporary oncology practice. In a pilot study of radiation-induced sarcoma (RIS) patients, we demonstrated that chemotherapy was associated with a reduced time to development of RIS. We now present a multi-centre collaborative study to validate this association.Methods:This was a retrospective cohort study of RIS cases across five large international sarcoma centres between 1 January 2000 to 31 December 2014. The primary endpoint was time to development of RIS.Results:We identified 419 patients with RIS. Chemotherapy for the first malignancy was associated with a shorter time to RIS development (HR 1.37; 95% CI: 1.08–1.72; P=0.009). In the multi-variable model, older age (HR 2.11; 95% CI 1.83–2.43; P<0.001) and chemotherapy for the first malignancy (HR 1.61; 95% CI 1.26–2.05; P<0·001) were independently associated with a shorter time to RIS. Anthracyclines and alkylating agents significantly contribute to the effect.Conclusions:This study confirms an association between chemotherapy given for the first malignancy and a shorter time to development of RIS.

Acute Regression in Young People with Down Syndrome.

Adolescents and young adults with Down syndrome (DS) can present a rapid regression with loss of independence and daily skills. Causes of regression are unknown and treatment is most of the time symptomatic. We did a retrospective cohort study of regression cases: patients were born between 1959 and 2000, and were followed from 1984 to now. We found 30 DS patients aged 11 to 30 years old with history of regression. Regression occurred regardless of the cognitive level (severe, moderate, or mild intellectual disability (ID)). Patients presented psychiatric symptoms (catatonia, depression, delusions, stereotypies, etc.), partial or total loss of independence in activities of daily living (dressing, toilet, meals, and continence), language impairment (silence, whispered voice, etc.), and loss of academic skills. All patients experienced severe emotional stress prior to regression, which may be considered the trigger. Partial or total recovery was observed for about 50% of them. In our cohort, girls were more frequently affected than boys (64%). Neurobiological hypotheses are discussed as well as preventative and therapeutic approaches.

Does Polyhydramnios Predict Adverse Perinatal Outcome in Congenital Diaphragmatic Hernia? [10P

INTRODUCTION: To examine polyhydramnios as a predictor of adverse perinatal outcomes in prenatally diagnosed congenital diaphragmatic hernia (CDH). METHODS: A retrospective cohort study of CDH cases evaluated between 11/2008 and 6/2016. Perinatal outcomes including preterm birth and mode of delivery were compared between CDH cases with polyhydramnios (amniotic fluid index greater than 25 cm) and those with normal amniotic fluid index. Additional data compared between groups were fetal anatomic characteristics, intrauterine fetal demise (IUFD), gestational age at delivery, preterm birth, length of hospital stay, and neonatal death. Cases that resulted in termination were excluded. Chi square and Fischer's exact tests were used to compare proportions. RESULTS: 192 cases were identified, and 56 of these (29.2%) had polyhydramnios. No significant associations were observed in fetal anatomic characteristics between the polyhydramnios and normal amniotic fluid groups. Similarly, there were no differences in gestational age at delivery, preterm birth, vaginal delivery, or neonatal or infant death between these groups. However, cases with polyhydramnios demonstrated a trend toward a higher risk of IUFD (33.3% vs. 66.7%, p = 0.06), and were more likely to have a prolonged neonatal length of hospital stay (37 days versus 22 days, p= 0.03) compared to cases with normal amniotic fluid. CONCLUSION: Comparing CDH cases with polyhydramnios to those with normal amniotic fluid, similar rates of fetal anatomic characteristics, preterm birth, vaginal delivery, and neonatal or infant death were observed. There was a trend toward a higher risk of IUFD in the polyhydramnios group, suggesting that these cases may merit closer antepartum surveillance.

Evaluating the Cost and Utility of Mandating Schools to Stock Epinephrine Auto-injectors

Background: The Michigan Legislature mandated that all public schools stock epinephrine auto-injectors (EAIs). A minimal amount is known regarding the incremental value of EAIs in schools. Our primary objective was to describe the frequency of administration of epinephrine for EMS patients with acute allergic reactions in public schools. Our secondary objective was to estimate the cost of mandating public schools to stock EAIs. Methods: We performed a retrospective cohort study of EMS cases with an impression of allergic reaction and who received epinephrine recorded in the 2014 Michigan EMS Information System (MI-EMSIS). We abstracted patient demographics, incident location by address to identify public schools, source of epinephrine given, and suspected allergen if known. We calculated advanced life support (ALS) response times to assess temporal impact of school EAIs in communities with ALS systems. We estimated the unsubsidized annual procurement cost of this mandate for Michigan public schools (N = 4,039), using range of costs for the required 2 EAIs (adult and pediatric) as estimated by the legislature ($140/each) and recently reported costs for commercial sources ($1,200). Training costs were not included. Descriptive statistics are reported. Results: During this period, there were 1,550,009 EMS cases in the state with 631 receiving non-cardiac arrest epinephrine for presumed anaphylaxis, of which 23 cases were in public schools. Reported allergens were most often food 12 (51.2%), insect stings 4(22.2%) or unknown 7(30.4%). Among these patients, the source for epinephrine used was from the student, 7 (30.4%), EMS 7 (30.4%), school 7(30.4%), and unknown 2(8.7%). A majority (21, 91.3%) of the public school cases occurred in communities with ALS systems and ALS response was relatively rapid (median response 6 minutes, 90 percentile, 13 minutes). The unsubsidized annual cost of Michigan public schools to stock EAIs ranges from $565,460 to $4,846,800. Conclusion: In this study, few public school patients received epinephrine for anaphylaxis and the vast majority occurred in communities with rapid ALS response. The direct annual supply cost of the school EAI mandate is substantial.

Spleen-preserving lymphadenectomy versus splenectomy in laparoscopic total gastrectomy for advanced gastric cancer

BackgroundTo investigate the optimal approach for laparoscopic splenic hilum lymph node dissection in proximal advanced gastric cancer, we compared the operative outcomes between laparoscopic spleen-preserving total gastrectomy (sp-LTG) and laparoscopic total gastrectomy with splenectomy (sr-LTG). MethodsA retrospective case-cohort study was conducted between February 2006 and December 2012. The operative outcomes, the number of retrieved splenic hilum lymph node, complication, and patients' survivals were analyzed. Results112 patients who underwent laparoscopic total gastrectomy with or without splenectomy for advanced gastric cancer were enrolled (68 sp-LTGs and 44 sr-LTGs). The mean operation time (227 min vs. 224 min, p = 0.762), estimated blood loss (157 ml vs. 164 ml, p = 0.817), and complication rate (17.6% vs. 13.6%, p = 0.572) were not different between two groups. Regarding splenic lymph node dissection, there were significantly differences in the mean number of retrieved lymph nodes between sp-LTG and sr-LTG (LN no.10; 1.78 vs. 3.21, p = 0.033, LN no.11d; 1.41 vs. 2.76, p = 0.004). The 5-year survivals were 77.3% in sp-LTG and 65.9% in sr-LTG (p = 0.240). The hazard ratio of splenectomy was 1.139 (95% confidence interval 0.514–2.526, p = 0.748). ConclusionIn laparoscopic total gastrectomy for proximal advanced gastric cancer, spleen-preserving hilar dissection showed comparable short-term and long-term outcomes.

Frequency, presentation, and outcome of Takayasu arteritis in Western Australia

Objectives: Takayasu arteritis (TAK) is large-vessel vasculitis that predominantly affects young women. There is worldwide variation in the frequency of TAK depending on genetic and/or environmental factors. With Australian data lacking, we describe the epidemiology, clinical features and outcomes of TAK in Western Australia (WA).Methods: Retrospective case cohort study of incident TAK cases between 1 January 2000 and 30 June 2015 in WA identified from multiple sources. Data on disease presentation and outcome were extracted from medical records.Results: Eighteen patients received a clinical diagnosis with thirteen cases meeting 1990 ACR criteria for TAK (all female, 77% Caucasian, age at diagnosis 39 years) included in this analysis. Per million inhabitants the annual incidence and prevalence (2015) was 0.3 and 3.2 for Caucasians and 1.1 and 15 for Asians. Limb claudication and bruit were commonest symptoms; ESR or CRP was raised in 61% at diagnosis while aortic involvement Hata type IIb most prevalent (30%). Despite general combination therapy with corticosteroids and immunosuppressant drugs, four patients suffered a stroke, two patients developed myocardial infarction, and five patients required vascular intervention. Three Caucasian patients died during the study period.Conclusion: TAK is much more prevalent in the Asian than Caucasian population of WA and associates with significant long-term morbidity and mortality despite standard therapy.

Efficacy comparison of percutaneous pedicle instrumentation combined with vertebral fracture fixation or vertebral augmentation for treatment of osteoporotic thoracolumbar fractures in elderly patients

Objective To compare the outcomes of percutaneous pedicle instrumentation combined with vertebral augmentation or vertebra pedicle instrumentation for treatment of osteoporotic thoracolumbar fractures (OVCF) in elderly patients. Methods A retrospective case cohort study was conducted on 62 patients with OVCF manifesting non-neurological symptoms treated from January 2009 to January 2012. There were 22 males and 30 females, with a mean age of 61.3 years (range, 55 to 70 years). Fracture level was T11 in 8 patients, T12in 20, L1 in 22 and L2 in 12. Treatments included percutaneous pedicle instrumentation combined with vertebral fracture fixation in 36 patients (Group A) and percutaneous pedicle instrumentation combined with vertebral augmentation in 26 patients (Group B). Operation time, intraoperative blood loss, anterior vertebral body height, sagittal Cobb angle and visual analogue score (VAS) were compared between the two groups. Results All patients were followed up for average 46.5 months (range, 36 to 58 months). Operation time in Group A [(82.6±16.2)min] was shorter than that in Group B [(96.8±20.6) min] (P 0.05). At the final follow-up, the ratio of anterior vertebral height and Cobb angle in Group B [(87.8±2.5)%, (7.8±3.5)°] were better than these in Group A [(82.6±3.2)%, (9.1±1.8)°] (P 0.05). Bone cement leakage was seen in four patients in Group B. During the perioperative period, there were 3 patients with lung infection in Group A and 1 patient with lower limb deep vein thrombosis in Group B. No implant failure occurred in both groups. Conclusion Both procedures are effective in treating elderly patients with OVCF, but percutaneous pedicle instrumentation combined with vertebral augmentation is associated with better results in maintaining vertebral height and preventing kyphosis. Key words: Osteoporotic fractures; Spinal fractures; Fracture fixation, internal

Attributable mortality of hospital-acquired bloodstream infections in Ireland

To estimate the attributable mortality of hospital-acquired bloodstream infections (HA-BSI) in Ireland. A retrospective case-cohort study was conducted, based on notifications from Irish microbiology laboratories and administrative patient records from six Irish hospitals from January 2007 to December 2013. Probabilistic linkage was used to link 1252 cases of bloodstream infection from a cohort of 343,189 hospitalized patients. Independent predictors of mortality were determined using a multi-variable logistic regression model, and included: patient age, emergency or re-admission to hospital, length of stay in an intensive care unit, number of procedures, number of diagnoses, major diagnostic category and presence of HA-BSI. Attributable mortality was calculated from the crude mortality of case subjects after adjusting for other predictors of mortality, and was found to be 15.3% (95% confidence interval 14.8-15.8%). The study was further stratified according to the causative organism, including: Escherichia coli, Enterococcus faecium, Enterococcus faecalis, Pseudomonas aeruginosa, Klebsiella pneumoniae, Staphylococcus aureus and Streptococcus pneumoniae, and, where available, their antimicrobial resistance patterns. The highest attributable mortality among these organisms was reported for E.faecium at 18.1% and the lowest attributable mortality was reported for E.coli at 13.6%. A significantly higher attributable mortality was found for antimicrobial resistance patterns of some organisms, most notably for meticillin-resistant S.aureus at 19.5%, vs meticillin-susceptible S.aureus at 13.3%. HA-BSI is an important cause of mortality, and attributable mortality differs significantly among causative organisms and antimicrobial resistance patterns.

Increasing Incidence of Crohnʼs Disease with Familial Clustering in the Kingdom of Bahrain

The incidence of Crohn's disease has been increasing in developed countries; whether this trend has extended to countries in Middle East, especially in the Arab world, remains unclear. Our aim was to study the epidemiology, incidence, time trends and clustering of Crohn's disease within the population of the Kingdom of Bahrain. A retrospective case-cohort study was conducted on patients diagnosed with Crohn's disease at Bahrain Specialist Hospital between 1990 and 2015. The diagnosis was based on clinical, radiological, endoscopic, and histological examinations. Five hundred twenty-two cases were eligible for analysis; 14.5% were below the age of 19 with a male-to-female ratio of 1.1:1. The overall incidence was 4.8/100,000 person-years and significantly increased from 5.5/100,000 person-years during the 1990's to 8.0/100,000 person-years during the last study period [incidence rate ratio (IRR) 0.32, 95% CI = 0.26-0.42]. This trend was persistent for adults, children, men and women. There were 129 patients with at least one family member diagnosed with Crohn's disease consisting of 40 families. Three clusters were identified based on first or second degree relationship of the family member. The mean interval for diagnosis between family members was significantly shorter between siblings than second degree relatives; (2.0 ± 1.2 years) versus (5.0 ± 2.8 years), respectively; (P = 0.04). The incidence rate of Crohn's disease in Bahrain is comparable to the U.S.A and has increased for men and women in all age groups. Crohn's disease clusters were common among families and included up to 3 generations consistent with presence of a common source or common genetic factors.

Clinical characteristics and outcomes of tuberculosis in Douala, Cameroon: a 7-year retrospective cohort study.

Tuberculosis (TB) clinic, Douala Laquintinie Hospital, Douala, Cameroon. To describe the clinical characteristics of TB and to investigate predictors of poor treatment outcomes. A registry-based, retrospective cohort study of all TB cases recorded from 2007 to 2013 was conducted. Multinomial logistic regression models were used to identify predictors of poor outcomes. Of 8902 TB cases included, 5110 (57.4%) were males. The median age was 33 years. The prevalence of human immunodeficiency virus (HIV) infection was 37.6%, with a significant decline over the study years (P = 0.000). The main clinical form of TB was smear-positive TB (50.5%). The treatment success rate was 75.2%, while the mortality rate was 8.1%. The year of TB diagnosis, retreatment cases, sputum non-conversion at the end of month 2, HIV infection and HIV testing not done were associated with death. Retreatment and non-conversion of sputum were associated with treatment failure, while male sex, age, sputum non-conversion, HIV infection and HIV testing not done were associated with loss to follow-up. TB management objectives may be attained by focusing specifically on higher risk groups to prevent poor treatment outcomes.

Impact of physician compliance with colonoscopy surveillance guidelines on interval colorectal cancer

Interval colorectal cancer (iCRC) incidence is the criterion standard benchmark for measuring the effectiveness of colonoscopy. Colonoscopy surveillance guidelines are designed to minimize iCRC cases. Our aims were to describe characteristics of iCRC patients and to assess whether development of iCRC is related to colonoscopy surveillance guideline intervals. We performed a retrospective cohort study of postcolonoscopy iCRC cases in a large healthcare system. Guideline-based colonoscopy intervals were calculated based on the 2012 U.S. Multi-Society Task Force for Colorectal Cancer colonoscopy surveillance guidelines. Backward stepwise linear regression was used to determine predictors of iCRC before guideline-recommended follow-up intervals. We identified 245 iCRC cases (mean age, 69.4 years; 56.3% male) out of 5345 colon cancers evaluated for a prevalence of 4.60%. On index colonoscopy, 75.1% had an adequate preparation, 93.0% reached the cecum, and 52.5% had polyps. iCRC developed before the guideline-recommended interval in 59.1% of patients (94/159). Independent predictive factors of this finding were inadequate preparation (OR, .012; 95% CI, .003-.06; P< .0001) and≥3 polyps on index colonoscopy (OR, .2; 95% CI, .078-.52; P= .0009). An endoscopist-recommended follow-up interval past the guideline-recommended interval was seen in 23.9% of cases (38/159). Most (34/38, 89.5%) of these iCRCs had inadequate preparation and were diagnosed after the guideline-based follow-up interval. Current colonoscopy surveillance guidelines may be inadequate to prevent many iCRC cases. Physician noncompliance with guideline-based surveillance intervals may increase in iCRC cases, especially in patients with an initially inadequate bowel preparation.

Clinical predictors and outcome implications of early readmission in lung transplant recipients

The purpose of this study was to identify risk factors and outcome implications for 30-day hospital readmission in lung transplant recipients. We conducted a retrospective cohort study of lung transplant cases from a single, high-volume lung transplant program between January 2000 and March 2012. Demographic and health data were reviewed for all patients. Risk factors for 30-day readmission (defined as readmission within 30 days of discharge from index lung transplant hospitalization) were modeled using logistic regression, with selection of parameters by backward elimination. The sample comprised 795 patients after excluding scheduled readmissions and in-hospital deaths. Overall 30-day readmission rate was 45.4% (n = 361). Readmission rates were similar across different diagnosis categories and procedure types. By univariate analysis, post-operative complications that predisposed to 30-day readmission included pneumonia, any infection, and atrial fibrillation (all p < 0.05). In the final multivariate model, occurrence of any post-transplant complication was the most significant risk factor for 30-day readmission (odds ratio = 1.764; 95% confidence interval, 1.259-2.470). Even for patients with no documented perioperative complication, readmission rates were still >35%. Kaplan-Meier analysis and multi-variate regression modeling to assess readmission as a predictor of long-term outcomes showed that 30-day readmission was not a significant predictor of worse survival in lung recipients. Occurrence of at least 1 post-transplant complication increases risk for 30-day readmission in lung transplant recipients. In this patient population, 30-day readmission does not predispose to adverse long-term survival. Quality indicators other than 30-day readmission may be needed to assess hospitals that perform lung transplantation.

Systematic review shows that pathological lead points are important andfrequent in intussusception and are not limited to infants.

Pathological lead points were frequent in intussusceptions and not limited to infants.

Loss to follow-up among adolescents with tuberculosis in Gaborone, Botswana.

Nine high-burden public tuberculosis (TB) clinics in Gaborone, Botswana. To describe clinical characteristics and outcomes among adolescents with TB and compare loss to follow-up (LTFU) rates with that among youth and adult cases. Retrospective cohort study of TB cases registered from 2012 to 2014. Clinical characteristics and treatment outcomes were compared among adolescents (age 10-19 years), youth (20-24 years) and a systematic sample of adults (⩾25 years). We analyzed 120 adolescent, 210 youth, and 548 adult cases. Adolescents had twice the risk of LTFU over adults (RR 2.0, 95%CI 1.1-3.7, P = 0.03), and higher LTFU than youth; this was not significant (RR 1.4, 95%CI 0.7-2.9, P = 0.32). Of those with human immunodeficiency virus (HIV) infection, 8/35 (22.9%) adolescents were LTFU, compared with 3/51 (5.9%) youth, and 25/407 (6.1%) adults (P = 0.001). In a multivariable model, adolescence (OR 3.0, 95%CI 1.3-6.5, P < 0.01), HIV positivity (OR 2.2, 95%CI 1.1-4.5, P = 0.02), and extra-pulmonary TB (OR 2.2, 95%CI 1.2-4.0, P = 0.01) were each associated with LTFU. Adolescents treated for TB had greater LTFU than youth and adults, particularly in the setting of TB-HIV coinfection. Further work should clarify the generalizability of these findings and investigate poor outcomes among adolescents with TB.