Occurrence of and risk factors for complications after endoscopic dilation in eosinophilic esophagitis.

BACKGROUND: Several small series have suggested an increased risk of complications associated with esophageal dilation in patients with eosinophilic esophagitis (EoE). OBJECTIVE: To quantitate the risk and identify risk factors for esophageal complications in dilation in EoE patients. DESIGN: Retrospective, uncontrolled, single-center study. SETTING: Tertiary referral hospital. PATIENTS: A total of 161 EoE patients (mean ± standard deviation age 44.3 ± 15.3 years, 112 men, 49 women, 150 white patients, 10 unknown, 1 Asian). INTERVENTIONS: Through-the-scope balloon or Savary dilation of EoE. MAIN OUTCOME MEASUREMENTS: The rate of complications defined as deep mucosal tear, major bleeding, or perforation, and determination of risk factors for complications. RESULTS: A total of 293 dilations were performed in 161 patients. Complications reported were deep mucosal tear in 9.2% (n = 27), major bleeding in 0.3% (n = 1), and immediate perforation in 1.0% (n = 3). All patients with perforations were successfully treated medically without surgery (mean ± standard deviation hospital stay 5.3 ± 3.2 days). Factors associated with an increased risk of complications were luminal narrowing in the upper (odds ratio [OR], 5.62; 95% CI, 2.07-15.26; P < .001) and middle third of the esophagus (OR, 4.93; 95% CI, 1.64-14.83; P < .005) compared with lower third, luminal stricture unable to be traversed with a standard upper endoscope (OR, 2.48; 95% CI, 1.06-5.83; P = .037), and use of Savary dilator (OR, 2.63; 95% CI, 1.18-5.83; P = .018). LIMITATIONS: Retrospective design, uncontrolled study. CONCLUSIONS: Deep mucosal tears are common after dilation (9%), but the risk of immediate transluminal perforation with EoE is approximately 1%. The risk of severe complications is increased in patients with more proximal stricture and strictures that initially prevent endoscope passage.

Favorable changes in cardiac geometry and function following gastric bypass surgery: 2-year follow-up in the Utah obesity study.

OBJECTIVES: The objective of this study was to test the hypothesis that gastric bypass surgery (GBS) would favorably impact cardiac remodeling and function. BACKGROUND: GBS is increasingly used to treat severe obesity, but there are limited outcome data. METHODS: We prospectively studied 423 severely obese patients undergoing GBS and a reference group of severely obese subjects that did not have surgery (n = 733). RESULTS: At a 2-year follow up, GBS subjects had a large reduction in body mass index compared with the reference group (-15.4 ± 7.2 kg/m(2) vs. -0.03 ± 4.0 kg/m(2); p < 0.0001), as well as significant reductions in waist circumference, systolic blood pressure, heart rate, triglycerides, low-density lipoprotein cholesterol, and insulin resistance. High-density lipoprotein cholesterol increased. The GBS group had reductions in left ventricular (LV) mass index and right ventricular (RV) cavity area. Left atrial volume did not change in GBS but increased in reference subjects. In conjunction with reduced chamber sizes, GBS subjects also had increased LV midwall fractional shortening and RV fractional area change. In multivariable analysis, age, change in body mass index, severity of nocturnal hypoxemia, E/E', and sex were independently associated with LV mass index, whereas surgical status, change in waist circumference, and change in insulin resistance were not. CONCLUSIONS: Marked weight loss in patients undergoing GBS was associated with reverse cardiac remodeling and improved LV and RV function. These data support the use of bariatric surgery to prevent cardiovascular complications in severe obesity.

Vasculogenesis drives pulmonary vascular growth in the developing chick embryo.

Formation of the pulmonary vasculature has been described as occurring by outgrowth of existing vessels (angiogenesis), de novo formation of new vessels (vasculogenesis), or a combination of both processes. Uncertainty about the contribution of angiogenesis and vasculogenesis to pulmonary vascular formation is partly due to methodologic approaches. Evidence in favor of angiogenesis stems from studies that used vascular-filling methods. Such methods identify only directly continuous lumina. Evidence for vasculogenesis has been provided by the use of molecular markers of blood vessel endothelium. Use of both methods has not been combined in the same species, however. We hypothesized, based on published evidence from quail and mouse, that chick pulmonary vascular formation occurs by vasculogenesis. To test that hypothesis, we used vascular filling, serial section, and immunohistochemical methods to analyze the developing lungs of chick embryos from Hamburger and Hamilton stages 20 to 43. Vascular filling suggested that the lumen of the pulmonary arteries sprouted from the sixth pharyngeal arch arteries. However, serial sections and immunohistochemical localization of fetal liver kinase-1 protein, the receptor for vascular endothelial growth factor, showed that the pulmonary arterial tree formed from endothelial cell precursors and coalescence of isolated blood vessels in the mediastinal splanchnic mesenchyme centrally to the developing lung tissue distally. Pulmonary veins grew from the left atrium to the developing lungs. Pulmonary blood vessel formation occurred continuously throughout the embryonic period studied. Our results show that vasculogenesis is the main process by which the pulmonary vasculature forms in the developing chick embryo.

Peer support in the community: initial findings of a mentoring program for individuals with traumatic brain injury and their families.

OBJECTIVES: To evaluate the impact of a community-based peer support program for individuals and their family members following traumatic brain injury (TBI). SETTINGS: Community-based sample of family members and individuals with traumatic brain injury. PARTICIPANTS: Twenty individuals who had participated in the peer support program (11 individuals with TBI and 9 family members). MAIN OUTCOME MEASURES: Quantitative and qualitative approaches were used: a retrospective structured interview assessing self-reported impacts of peer support on empowerment, quality of life, mood, skills and knowledge, and social supports; an in-depth qualitative interview with a subgroup of family members focused on the specific benefits/limitations of the peer support program. RESULTS: Participants in the peer support program reported positive impacts of peer support on increasing their knowledge of TBI, enhancing their overall quality of life, improving their general outlook, and enhancing their ability to cope with depression post TBI. The peer support program was reported to have had a minimal impact on enhancing social support from families, friends, and the community, with varying impacts noted on levels of happiness, coping with anger and anxiety, communication with professionals, and control over one's life. Qualitative analysis suggests the merits of this type of community-based support and areas of improvement for the peer support program itself. CONCLUSIONS: Preliminary data suggest that peer support is a promising approach to enhancing coping for both individuals and their family members after TBI.