To Scope or Not to Scope? The Safety of Upper Endoscopy in the Setting of Pulmonary Embolism.

OBJECTIVES: We aimed to describe the frequency of upper endoscopy and associated outcomes in subjects hospitalized with upper GI bleeding (UGIB) and pulmonary embolism (PE). METHODS: We performed a cross-sectional study using the Nationwide Inpatient Sample from 2007 to 2014. The association between upper endoscopy and in-hospital mortality was evaluated using propensity score matching. RESULTS: A total of 44,412 subjects had a coexistent PE and UGIB. 63.5% had an inpatient upper endoscopy with a lower likelihood of in-hospital death and a shorter length of stay. CONCLUSIONS: A substantial proportion of inpatients with PE and UGIB undergo endoscopy with a relatively lowmortality rate.

Factors Associated With Health Care Utilization of Recurrent Clostridium difficile Infection in New York State.

BACKGROUND: The incidence of infection due to Clostridium difficile infection (CDI) and subsequent economic burden are substantial. GOALS: The impact of changing practice patterns on demographics at risk and utilization of health care resources for recurrence of CDI remains unclear. STUDY: A total of 291,163 patients hospitalized for CDI were identified from 1995 to 2014 from the New York SPARCS database. The χ test, the Welch t test, and multivariable logistic regression analysis were performed to evaluate factors related to readmission. RESULTS: Hospital admissions and readmissions for CDI peaked in 2008 at 20,487 and 13,795, respectively, and have since decreased (linear trend, 0.9706 and 0.9464, respectively; P<0.0001). In total, 60,077 (21%) patients required ≥2 admissions. Risk factors for readmission included: age 55 to 74, government insurance, hypertension, diabetes, anemia, hypothyroidism, chronic pulmonary disease, rheumatoid arthritis, renal failure, peripheral vascular disease, and depression (all P<0.05). Trends in surgery showed a similar peak in 2008 at 165 and have since decreased (linear trend, 0.8660; P<0.0001). A total of 1830 (0.63%) patients with CDI underwent surgery, with emergent being more common than elective (71% vs. 29%). CONCLUSIONS: Hospital admissions and readmissions for CDI peaked in 2008 and have since been steadily declining. These trends may be secondary to improved diagnostic capabilities and evolving antibiotic regimens. More than 1 in 5 hospitalized patients had at least 1 readmission. Numerous risk factors for these patients have been identified. Although <1% of all patients with CDI undergo surgery, these rates have also been declining.

NOTCH2 and FLT3 gene mis-splicings are common events in patients with acute myeloid leukemia (AML): new potential targets in AML.

Our previous studies revealed an increase in alternative splicing of multiple RNAs in cells from patients with acute myeloid leukemia (AML) compared with CD34(+) bone marrow cells from normal donors. Aberrantly spliced genes included a number of oncogenes, tumor suppressor genes, and genes involved in regulation of apoptosis, cell cycle, and cell differentiation. Among the most commonly mis-spliced genes (>70% of AML patients) were 2, NOTCH2 and FLT3, that encode myeloid cell surface proteins. The splice variants of NOTCH2 and FLT3 resulted from complete or partial exon skipping and utilization of cryptic splice sites. Longitudinal analyses suggested that NOTCH2 and FLT3 aberrant splicing correlated with disease status. Correlation analyses between splice variants of these genes and clinical features of patients showed an association between NOTCH2-Va splice variant and overall survival of patients. Our results suggest that NOTCH2 and FLT3 mis-splicing is a common characteristic of AML and has the potential to generate transcripts encoding proteins with altered function. Thus, splice variants of these genes might provide disease markers and targets for novel therapeutics.

Reported proton pump inhibitor side effects: what are physician and patient perspectives and behaviour patterns?

BACKGROUND: Proton pump inhibitors (PPI) are among the most commonly prescribed medications and studies are reporting potentially harmful PPI-related adverse events. While these studies' findings are controversial, their impact on patients and physicians remains unknown. AIM: To determine patient and physician awareness of PPI-related adverse events, source of information, and subsequent effect on patient behaviour and physician practice. METHODS: A 20-item questionnaire was administered to English speaking adult patients and physicians in primary care and specialty clinics about topics including knowledge of PPI-related adverse events, change in behaviour of patients on PPIs and physician management of patients on PPIs. RESULTS: Of 277 patients surveyed, 45% reported knowledge of side effects related to PPIs. Patients were more likely to hear about PPI side effects from non-physician sources (66%) than physicians (38%). Of patients who had heard about PPI side effects, bone fractures and osteoporosis were the most common concerns, 42% and 44% respectively. Of PPI users, 38% changed their behaviour based upon concerns about PPI-related adverse events. Change in patient behaviour due to concern about PPI side effects was associated with age ≥ 65 years (odds ratio [OR] 4.07 [1.19-13.94]; P = 0.03) and concern about long-term side effects (OR 2.31 [1.03-5.17]; P = 0.04). Of 83 physicians surveyed, 60% reported concern about PPI-related adverse events, with bone fractures (46%) and osteoporosis (49%) being the most frequently reported. Overall, 37% of physicians reported changing their practice based upon their concerns. CONCLUSIONS: Nearly half of patients reported knowledge of PPI-related adverse events, most often from non-physician sources, and general concern regarding their impact. PPI users are changing their behaviour based upon these concerns, without physician input, and care providers are changing behaviour based on relatively weak evidence.

Recurrent Gastrointestinal Near-Tetraploid Diffuse Large B-Cell Lymphoma Causing Intussusception and Ileal Ulceration.

Polyploid karyotypes in diffuse large B-cell lymphoma (DLBCL) are rare and carry a poor prognosis. Extranodal polyploid lymphoma is uncommon. A 71-year-old man with back pain was found to have ileal intussusception. He underwent surgical resection and was diagnosed with DLBCL with a near-tetraploid karyotype. Despite rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone therapy, he developed recurrent disease for which he started a clinical trial. He then developed dark stools from an ileal ulcer due to progressive disease and died 2 weeks later. This is the first reported case of gastrointestinal DLBCL with polyploidy. These karyotypes require attention to extranodal disease and prompt initiation of therapy.

Simultaneous Estimation of Corneal Topography, Pachymetry, and Curvature.

Identification of objective criteria to correctly diagnose ectatic diseases of the cornea or to detect early stages of corneal ectasia is of great interest in ophthalmology and optometry. Metrics for diagnosis typically employed are curvature maps (axial/sagittal, tangential); elevation map of the anterior surface of the cornea with respect to a reference sphere; and pachymetry (thickness) map of the cornea. We present evidence that currently used curvature maps do not represent the actual curvatures (principal or mean) in a human cornea. A novel contribution of this paper is the computation of the true mean curvature over every point of a central region of the cornea. We show that the true mean curvature can accurately identify the location of the ectasia. We present a quartic smoothing spline algorithm for the simultaneous computation of elevation maps for anterior and posterior corneal surfaces, pachymetry, and true mean curvature. The input to the algorithm is data from a single measurement from imaging devices such as an anterior segment optical coherence tomographer or a Scheimpflug imager. We show that a different combination of metrics is useful for the diagnosis of existing ectasia (true mean curvature and anterior elevation map) as opposed to subclinical ectasia (pachymetry and posterior elevation map). We compare our results with existing algorithms, and present applications to a normal cornea, a forme fruste keratoconic cornea, and an advanced keratoconic cornea.

Patient Acuity and Operative Technique Associated with Post-Colectomy Mortality Across New York State: an Analysis of 160,792 Patients over 20 years.

This study sought to characterize in-hospital post-colectomy mortality in New York State. One hundred sixty thousand seven hundred ninety-two patients who underwent colectomy from 1995 to 2014 were analyzed from the all-payer New York Statewide Planning and Research Cooperative System (SPARCS) database. Linear trends of in-hospital mortality rate over 20 years were calculated using log-linear regression models. Chi-square tests were used to compare categorical variables between patients. Multivariable regression models were further used to calculate risk of in-hospital mortality associated with specific demographics, co-morbidities, and perioperative complications. From 1995 to 2014, 7308 (4.5%) in-hospital mortalities occurred within 30 days of surgery. Over this time period, the rate of overall in-hospital post-colectomy mortality decreased by 3.3% (6.3 to 3%, p < 0.0001). The risk of in-hospital mortality for patients receiving emergent and elective surgery decreased by 1% (RR 0.99 [0.98-1.00], p = 0.0005) and 5% (RR 0.95 [0.94-0.96], p < 0.0001) each year, respectively. Patients who underwent open surgeries were more likely to experience in-hospital mortality (adjusted OR 3.65 [3.16-4.21], p < 0.0001), with an increased risk of in-hospital mortality each year (RR 1.01 [1.00-1.03], p = 0.0387). Numerous other risk factors were identified. In-hospital post-colectomy mortality decreased at a slower rate in emergent versus elective surgeries. The risk of in-hospital mortality has increased in open colectomies.

Factors Associated with Repeated Health Resource Utilization in Patients with Diverticulitis.

Conservative management trends in diverticulitis may lead to increased hospitalizations secondary to repeated attacks. The study aimed to characterize trends in management and risk-assess patients with diverticulitis that required multiple admissions to identify high utilizers. A total of 265,724 patients with diverticulitis were identified from 1995 to 2014 from the New York SPARCS database. Patients with ≥2 hospital admissions were stratified across demographics, comorbidities, insurance status, and surgical intervention. In total, 42,850 patients had ≥2 hospital admissions. Risk factors for ≥2 admissions included younger age, White race, obesity, hypertension, pulmonary disease, hypothyroidism, rheumatoid arthritis, and depression. Fifty-two percent of these patients went on to have surgery. The percentage of elective cases increased from 59 to 70 %, while emergent cases conversely decreased from 41 to 30 %. One in five patients admitted with diverticulitis required two or more admissions. Numerous patient factors were correlated with increased risk of readmission. These factors may be used to guide treatment decisions and help reduce economic burden in frequent utilizers. Trends in surgery rates for these patients could reflect improved treatment options and/or changing clinical practice patterns.

20-Year Trends in the Management of Diverticulitis Across New York State: an Analysis of 265,724 Patients.

INTRODUCTION: Management of acute diverticulitis (AD) has considerably changed over time. This study evaluates practice patterns for diverticulitis across demographic populations in New York State. METHODS: Two hundred sixty-five thousand seven hundred twenty-four patients with acute diverticulitis were analyzed from 1995 to 2014 from the New York-Statewide Planning and Research Cooperative System database. The likelihood of having surgery over time was compared across patient demographic subgroups using logistic regression models to calculate estimated odds ratio with their 95 % confidence intervals. Using Chi-square test and Welch's t test, categorical and continuous variables were compared. RESULTS: From 1995 to 2014, there was an increase in newly diagnosed diverticulitis patients while the proportion of those patients undergoing operative management steadily decreased (31 to 10 %, p < 0.0001). Of those receiving surgery, emergent surgeries decreased (58 to 47 %, p < 0.0001) while elective surgeries increased (42 to 53 %, p < 0.0001) with the odds of having emergency surgery decreasing by 4 % annually (OR 0.96 (0.95-0.97), p < 0.0001). With the exception of patients greater than 80 years old, these linear trends were substantiated across patient subgroups. CONCLUSIONS: Over the past 20 years in New York State, there has been an increase in diverticulitis diagnoses and hospital admissions, with a decrease in surgeries performed reflecting a shift towards conservative management and more effective antibiotic treatment.

Prevention of bacterial colonization of contact lenses with covalently attached selenium and effects on the rabbit cornea.

PURPOSE: Although silicone hydrogel materials have produced many corneal health benefits to patients wearing contact lenses, bacteria that cause acute red eye or corneal ulcers are still a concern. A coating that inhibits bacterial colonization while not adversely affecting the cornea should improve the safety of contact lens wear. A covalent selenium (Se) coating on contact lenses was evaluated for safety using rabbits and prevention of bacterial colonization of the contact lenses in vitro. METHODS: Contact lenses coated with Se were worn on an extended-wear schedule for up to 2 months by 10 New Zealand White rabbits. Corneal health was evaluated with slit-lamp biomicroscopy, pachymetry, electron microscopy, and histology. Lenses worn by the rabbits were analyzed for protein and lipid deposits. In addition, the ability of Se to block bacterial colonization was tested in vitro by incubating lenses in a Pseudomonas aeruginosa broth followed by scanning electron microscopy of the contact lens surface. RESULTS: The covalent Se coating decreased bacterial colonization in vitro while not adversely affecting the corneal health of rabbits in vivo. The Se coating produced no noticeable negative effects as observed with slit-lamp biomicroscopy, pachymetry, electron microscopy, and histology. The Se coating did not affect protein or lipid deposition on the contact lenses. CONCLUSION: The data from this pilot study suggest that a Se coating on contact lenses might reduce acute red eye and bacterial ulceration because of an inhibition of bacterial colonization. In addition, our safety tests suggest that this positive effect can be produced without an adverse effect on corneal health.

Pupil size and the ablation zone in laser refractive surgery: considerations based on geometric optics.

PURPOSE: To determine whether the currently accepted method of selecting a minimum ablation zone size for refractive surgery based on dark-adapted pupil diameter is substantiated by geometric optical analysis. SETTING: Department of Ophthalmology and Visual Sciences, Texas Tech University Health Sciences Center, Lubbock, Texas, USA. METHODS: An optical model of the anterior segment was developed to calculate the effective corneal refractive diameter (ECRD), which is the diameter of the area of cornea that refracts all incident light rays arising from objects along the line of sight though the physical pupil (PP). The concept of the entrance pupil (EP) was reexamined and developed, and the ECRD was calculated over a range of corneal curvatures (K), anterior chamber depths (ACDs), and EP sizes. The model was generalized to include oblique light rays. Calculations were performed using MatLab Optimization Toolbox software (The MathWorks). RESULTS: For a given EP size, the ECRD was significantly influenced by K and slightly influenced by ACD. CONCLUSIONS: For objects on the line of sight, the ECRD was smaller than the EP in all cases. Regarding rays from objects in the periphery, the ECRD expanded rapidly as the angle of oblique incidence increased. For objects on the line of sight, the ECRD is always smaller than the clinically measured pupil (EP) because the EP is substantially magnified relative to the PP. Ablation zones larger than the EP should, in theory, prevent scattered or defocused light rays from contributing to the foveal image. When considering objects in the periphery, the increase in ECRD is sufficiently rapid that current refractive procedures cannot stop scattered light from these objects from contributing to the retinal image.

Opaque contact lens treatment for older children with amblyopia.

PURPOSE: To investigate the usefulness of daily-wear opaque contact lens treatment for older children with amblyopia. METHODS: A retrospective chart review of all children undergoing opaque contact lens therapy for amblyopia between 2000 and 2003 was performed. All patients were included except for those younger than 5 years of age, those undergoing maintenance treatment only, those lost to follow-up, or those unable to cooperate with Snellen visual acuity testing. RESULTS: Thirteen children were identified, and seven met the inclusion criteria. The seven patients had a mean age of 7.5 years (range, 5.7-8.7 years). The causes of amblyopia were anisometropia (five patients), cataract (one patient), and strabismus (one patient). For all seven patients, the mean logMAR improvement in visual acuity was 0.52 (range, 0.26-1.22). The average duration of opaque contact lens use was 9.3 months (range, 2-21 months). Compliance problems were encountered in three patients. No major complications occurred, but one patient had an episode of mild superficial punctate keratitis. CONCLUSIONS: Daily-wear opaque contact lens treatment is a useful occlusion method for amblyopia treatment in older children with various practical and social impediments to skin patching. Meaningful improvement in visual acuity can be obtained, even in children older than 8 years of age.