Pouch Function Over Time and With Advancing Age.

BACKGROUND: No long-term pouch studies have included follow-up >30 years or an analysis in patients >80 years old. OBJECTIVE: This study aimed to investigate pouch function and pouch failure in patients with a pouch in situ >30 years and in patients >80 years old. DESIGN: This is a retrospective review. SETTING: This study was conducted at an IBD referral center. PATIENTS: Adult patients with ulcerative colitis who underwent an IPAA between 1983 and 1990 were selected. MAIN OUTCOME MEASURES: The primary outcomes measured were pouch function and pouch failure rates. METHODS: Data collection included diagnosis, age at IPAA, indication for IPAA, medications at IPAA, pathology at the time of IPAA, postoperative morbidity, functional outcomes, quality of life, pouch excision or ileostomy and indication, and date of last follow-up. All living patients were contacted in April 2020 to retrieve functional data and pouch failure rates. RESULTS: A total of 566 patients had a pouch constructed between 1983 and 1990; of the 145 at most recent contact, 75 had their pouch in situ ≥30 years and 14 were ≥80 years old. Mean age at diagnosis was 25.8 years (10.6 SD), age at surgery was 34.7 years (11.3 SD), and age at last follow-up was 60.5 years (13.2 SD). At a median of 30 years (IQR, 21-32), 145 patients responded to the functional survey. Significantly increased rates of urgency (always, mostly, sometimes: 71.5% vs 23.5%) and seepage during the day (71.4% vs 22.4%) were observed in patients ≥80 years. In patients ≥80 years with a pouch in situ ≥30 years, urgency and incontinence were sometimes experienced by nearly 50% and pouch failure occurred in one third of patients. The overall rate of pouch failure was 19.4% (n = 110) at a median follow-up of 15 years; risk factors were female sex, 3-stage approach, and pelvic sepsis. LIMITATIONS: A retrospective database was used. CONCLUSION: Patients with IPAA maintain good pouch function even after 30 years and in patients over the age of 80 years. Pouch function declines with time and failure rates increase over time. See Video Abstract at http://links.lww.com/DCR/B684.Función De La Bolsa Ileal En El Tiempo Y En Pacientes De Edad Avanzada. ANTECEDENTES: No se han efectuado estudios en pacientes con bolsa a largo plazo que incluyan un seguimiento por treinta años o más y en pacientes mayores de 80 años. OBJETIVO: Investigar la funcionalidad o la falla de la bolsa en pacientes bolsa in situ por mas de treinta años y en pacientes mayors de 80 años. DISEO: Revisión retrospective. ESCENARIO: Centro de referencia de Enfermedad Inflamatoria Intestinal. PACIENTES: Pacientes adultos con diagnóstico de colitis ulcerative sometidos a anastomosis bolsa ileal anal (IPAA) entre 1983 y 1990. PRINCIPALES PARAMETROS DE RESULTADOS: Indices de efectividad y disfunción de la bolsa ileal. METODOS: Recopilación de la información incluyendo diagnóstico, edad del procedimiento (IPAA), indicaciones para IPAA, medicamentos para IPAA, patología en el transcurso del IPAA, morbilidad postoperatoria, resultados funcionales, calidad de vida, excisión de la bolsa o ileostomía y su indicación y fecha de seguimiento mas reciente. Se contactaron a todos los pacientes vivos en abril de 202 para recuperar la información de los índices de funcionalidad o disfunción de la bolsa. RESULTADOS: Se les construyó una bolsa a un total de 566 pacientes entre 1983 y 1990; de los 145 mas recientemente contactados, 75 permanecían con su bolsa in situ ≥ 30 años y 14 eran mayores de 80 años. La edad media en el momento de diagnóstico fue de 25.8 años (con desviación estándar de 10.6, sd), edad al momento de la cirugía fue de 34.7 años (11.3sd), y la edad en el último seguimiento de 60.5 años (13.2,sd). A una media de 30 años (IQR: 21,32), 145 pacientes respondieron al cuestionario de funcionalidad. En pacientes mayores de 80 años se observaron tasas aumentadas de urgencia (siempre, la mayor parte de las veces, algunas veces: 71.5% vs 23.5%) y fuga durante el día (71.4% versus 22.4%). En pacientes mayores de 80 años con una bolsa in situ durante 30 años o más, experimentaron urgencia e incontinencia en cerca del 50% y disfunción de la bolsa en un tercio de los pacientes. La tasa global de fallo de la bolsa fue de 19.4% (n = 110) en un seguimiento a 15 años; los factores de riesgo asociados fueron: sexo femenino, abordaje de tres tiempos y sepsis pélvica. LIMITACIONES: Información retrospective. CONCLUSIONES: Los pacientes con IPAA continúan con una función adecuada de la bolsa aún después de 30 años de efectuada así como en pacientes mayores de 80 años. La funcionalidad de la bolsa disminuye con el tiempo y las tasa de falla aumentan de igual forma con el tiempo. Consulte Video Resumen en http://links.lww.com/DCR/B684. (Traducción- Dr. Miguel Esquivel-Herrera).

The Fate of Unifocal Versus Multifocal Low-Grade Dysplasia at the Time of Colonoscopy in Patients With IBD.

BACKGROUND: Recommendations regarding management of colorectal dysplasia in the setting of IBD continue to evolve. OBJECTIVE: This study aimed to determine the rate of progression from dysplasia to adenocarcinoma, specifically focusing on the differences in unifocal and multifocal low-grade dysplasia and dysplasia found on random biopsy versus targeted biopsies. DESIGN: This is a retrospective review. SETTING: This study was conducted at an IBD referral center. PATIENTS: All adult patients (≥18 years of age) with a known diagnosis of either ulcerative colitis or Crohn's disease, who underwent a surveillance colonoscopy between January 1, 2010 and January 1, 2019, were selected. MAIN OUTCOMES MEASURES: The primary outcomes measured were the progression of dysplasia and the risk factors for progression. RESULTS: A total of 23,751 surveillance colonoscopies were performed among 12,289 patients between January 1, 2010 and January 1, 2019. The mean age at colonoscopy was 52.1 years (SD 16.9 years), 307 patients (2.5%) had a history of primary sclerosing cholangitis, and 3887 (3.15%) had a family history of colorectal cancer. There was a total of 668 patients (5.4%) with low-grade dysplasia, 76 patients (0.62%) with high-grade dysplasia, and 68 patients (0.55%) with adenocarcinoma in the series. The 1-, 2-, and 5-year cumulative incidence rate of progressing from low-grade dysplasia to high-grade dysplasia were 1.6%, 4.8%, and 7.8%. The 1- and 2-year cumulative incidence rates of progressing from low-grade dysplasia to adenocarcinoma were 0.7% and 1.6%. There were no significant differences in unifocal and multifocal progression. Primary sclerosing cholangitis, ulcerative colitis, male sex, and advanced age were all found to be significant risk factors for neoplasia on multivariable analysis. LIMITATIONS: A retrospective database was a source of information. CONCLUSION: Progression of low-grade dysplasia to adenocarcinoma, regardless of its being unifocal or multifocal, remains very low in the setting of adequate surveillance and medical management. The presence of multifocal low-grade dysplasia should not change the decision making to pursue ongoing endoscopic surveillance versus proctocolectomy. Patients who had primary sclerosing cholangitis with dysplasia found on random biopsies may be at highest risk for dysplasia progression. See Video Abstract at http://links.lww.com/DCR/A649. EL DESENLACE DE LA DISPLASIA DE BAJO GRADO UNIFOCAL VERSUS MULTIFOCAL DURANTE LA COLONOSCOPIA EN PACIENTES CON ENFERMEDAD INFLAMATORIA INTESTINAL: ANTECEDENTES:Las recomendaciones para el tratamiento de la displasia colorrectal en el contexto de la enfermedad inflamatoria intestinal siguen evolucionando.OBJETIVO:Determinar la tasa de progresión de displasia a adenocarcinoma, centrándose específicamente en las diferencias en displasia de bajo grado unifocal y multifocal, y displasia encontradas en biopsias aleatorias versus biopsias dirigidas.DISEÑO:Revisión retrospectiva.ÁMBITO:Centro de referencia de EII.PACIENTES:Todos los pacientes adultos (> 18 años) con un diagnóstico comprobado de colitis ulcerosa o enfermedad de Crohn que se sometieron a una colonoscopia de vigilancia entre el 1 de enero de 2010 y el 1 de enero de 2019.PRINCIPALES VARIABLES ANALIZADAS:Progresión de la displasia y factores de riesgo de progresión.RESULTADOS:Se realizaron un total de 23.751 colonoscopias de vigilancia en 12.289 pacientes entre el 1/1/2010 y el 1/1/2019. La edad media en el momento de la colonoscopia fue de 52,1 años (DE 16,9 años), 307 pacientes (2,5%) tenían antecedentes de colangitis esclerosante primaria y 3887 (3,15%) tenían antecedentes familiares de cáncer colorrectal. Hubo un total de 668 pacientes (5,4%) con displasia de bajo grado, 76 pacientes (0,62%) con displasia de alto grado y 68 pacientes (0,55%) con adenocarcinoma en la serie. La tasa de incidencia acumulada de 1, 2, 5 años de progresión de displasia de bajo grado a displasia de alto grado fue del 1,6%, 4,8% y 7,8%. Las tasas de incidencia acumulada de 1 y 2 años de progresión de displasia de bajo grado a adenocarcinoma fueron 0,7% y 1,6%, respectivamente. No hubo diferencias significativas en la progresión unifocal y multifocal. Se encontró que la colangitis esclerosante primaria, la colitis ulcerosa, el sexo masculino y la edad avanzada eran factores de riesgo significativos de neoplasia en el análisis multivariable.LIMITACIONES:Base de datos retrospectiva.CONCLUSIÓN:La progresión de la displasia de bajo grado a adenocarcinoma, independientemente de que sea unifocal o multifocal, sigue siendo muy baja en el contexto de una vigilancia y un tratamiento médico adecuados. La presencia de displasia multifocal de bajo grado no debería cambiar la toma de decisión para continuar con vigilancia endoscópica continua o realizar la proctocolectomía. Los pacientes con colangitis esclerosante primaria y displasia encontrada en biopsias aleatorias pueden tener una mayor progresión de la displasia. Consulte Video Resumen en http://links.lww.com/DCR/A649.

Surgical Start Time Impact on Hospital Length of Stay for Elective Inpatient Procedures.

Background Hospital length of stay (LOS) remains an important, albeit nonspecific, metric in the analysis of surgical services. Modifiable factors to reduce LOS are few in number and the ability to practically take action is limited. Surgical scheduling of elective cases remains an important task in optimizing workflow and may impact the post-surgical LOS. Methods Retrospective data from a single tertiary care academic institution were analyzed from elective adult surgical cases performed from 2017 through 2019. Emergent or urgent add-on cases were excluded. Variables included primary procedure, age, diabetes status, American Society of Anesthesiologists (ASA) class, and surgical start time. Analysis of the median LOS following surgery was performed using Mann-Whitney tests and Cox hazards model. Matched-cohort analysis of mean total hospitalization costs was performed using the Student's t-test.  Results 9,258 patients were analyzed across five surgical service lines, of which 777 patients had surgical start time after 3 PM. The median LOS for the after 3 PM group was 1 day longer than the before 3 PM start time cohort (3.0 vs 2.1, p < 0.001). Service line analysis revealed increased LOS for Orthopedics and Neurosurgery (3.0 vs 1.9, p < 0.001; 3.0 vs 2.0, p < 0.05). Multivariate analysis confirmed that start time before 3 PM predicted shorter LOS (HR = 1.214, 1.126-1.309; p < 0.001). Case-matched cost analysis for frequently performed orthopedic and neurosurgical cases with an after 3 PM start time failed to demonstrate a significant difference in total hospital charges.  Conclusion Optimization of surgical services scheduling to increase the proportion of elective surgical cases started before 3 PM has the potential to decrease post-surgical LOS for adult patients undergoing Orthopedic or Neurosurgical procedures.

Description and preliminary evaluation of a Multiagent Intelligent Dosing System (MAIDS) to manage combination insulin-oral agent therapy in type 2 diabetes.

BACKGROUND: Computer decision support systems are potentially effective methods for adjusting insulin, but current models do not take into account simultaneous changes of more than one agent. We describe the development of the Multiagent Intelligent Dosing System (MAIDS, Dimensional Dosing Systems, Wexford, PA) for predicting glycemic outcome in response to concurrent dose adjustments in oral hypoglycemic agents and insulin. METHODS: Retrospective data from a patient cohort with type 2 diabetes who had simultaneous changes in insulin and metformin were analyzed. Glycemic markers (fasting glucose, random glucose, or hemoglobin A1c) expected at the visit subsequent to dose changes were calculated using two methods: the previously reported Intelligent Dosing System (IDStrade mark, Dimensional Dosing Systems), which accounts for changes in only one agent, and the MAIDS. Expected results from both systems were correlated with levels actually observed. RESULTS: We analyzed 32 patients with 40 paired visits. For fasting glucose (n = 8 paired visits), the correlation between expected and observed values was 0.07 when using the IDS but 0.78 when using the MAIDS. For random glucose (n = 16 paired visits) the correlation between expected and observed levels was 0.49 for the IDS but 0.79 for the MAIDS. With hemoglobin A1c as the marker (n = 16 paired visits), the correlation was 0.40 when using the IDS but 0.60 with the MAIDS. CONCLUSIONS: The MAIDS allows better prediction of glycemic outcome in circumstances where both insulin and an oral hypoglycemic drug are changed concurrently. Application of the MAIDS to other clinical scenarios, such as simultaneous adjustment of insulin and carbohydrate intake, requires further study.

The Intelligent Dosing System: application for insulin therapy and diabetes management.

Diabetes mellitus is an increasing public health problem. Insulin is an essential tool in the management of hyperglycemia, but methods of dose adjustment are purely empirical. The Intelligent Dosing System (IDS, Dimensional Dosing Systems, Inc., Wexford, PA) is a software suite that incorporates patient-specific, dose-response data in a mathematical model and then calculates the new dose of the medication needed to achieve the next desired therapeutic goal. We discuss the application of the IDS in insulin management. The IDS concept and the initial modeling used to construct an insulin doser are reviewed first. Additional data are then provided on the use of the IDS for titrating insulin therapy in a clinical setting. Finally, recent modifications in the IDS software and future applications of this technology for insulin dosing and diabetes management are discussed.

Management of insulin therapy in urban diabetes patients is facilitated by use of an intelligent dosing system.

The Intelligent Dosing System (IDS, Dimensional Dosing Systems, Inc., Wexford, PA) is a software suite that incorporates patient-specific, dose-response data in a mathematical model, and then calculates the new dose of agent needed to achieve the next desired therapeutic goal. We evaluated use of the IDS for titrating insulin therapy. The IDS was placed on handheld platforms and provided to practitioners to use in adjusting total daily insulin dose. Fasting glucose, random glucose, and hemoglobin A1c were used as markers against which insulin could be adjusted. Values of markers expected at the next follow-up visit, as predicted by the model, were compared with levels actually observed. For 264 patients, 334 paired visits were analyzed. Average age was 54 years, diabetes' duration was 10 years, and body mass index was 33.2 kg/m(2); 57% were female, 88% were African American, and 92% had type 2 diabetes. The correlation between IDS suggested and actual prescribed total daily dose was high (r = 0.99), suggesting good acceptability of the IDS by practitioners. Significant decreases in fasting glucose, random glucose, and hemoglobin A1c levels were seen (all P < 0.0001). No significant difference between average expected and observed follow-up fasting glucose values was found (145 vs. 149 mg/dL, P = 0.42), and correlation was high (r = 0.79). Mean observed random glucose value at follow-up was comparable to the IDS predicted level (167 vs. 168 mg/dL, P = 0.97), and correlation was high (r = 0.73). Observed follow-up hemoglobin A1c was higher than the value expected (7.9% vs. 7.4%, P < 0.0055), but correlation was good (r = 0.70). These analyses suggest the IDS is a useful adjunct for decisions regarding insulin therapy even when using a variety of markers of glucose control, and can be used by practitioners to assist in attainment of glycemic goals.