RocScholar (Rochester Regional Health)
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Endoscopic Sphincterotomy Increases the Risk of Pyogenic Liver Abscess: A Retrospective Study Using Real-World Data
No full textIntroduction: Pyogenic liver abscess (PLA) after Endoscopic Retrograde Cholangiopancreatography (ERCP) is a rare infectious adverse event. The association between post-ERCP PLA and endoscopic sphincterotomy has not been extensively studied.
Methods: We conducted a retrospective study using the TriNetX platform by including patients without history of PLA who received ERCP between October 2015 and December 2020. Two groups were made: the endoscopic sphincterotomy (ES) group (patients who received ES during ERCP) and the control group (patients who did not receive ES). The primary outcome was the risk of developing PLA within 1 year of the index ERCP. The secondary outcomes included sepsis, broad-spectrum antibiotics use, need for PLA drainage, and post-ERCP mortality within one year of the index ERCP.
Results: There were 169 patients (1.43%) in the ES group who developed PLA compared to 123 patients (1.04%) in the control group, Relative Risk (RR): 1.37, P-value = 0.007. A total of 241 patients (2.05%) in the ES group developed sepsis compared to 176 patients (1.49%) in the control group, RR: 1.37, P-value = 0.001. A total of 2,954 patients (25.1%) in the ES group received treatment with broad-spectrum antibiotics compared to 2,132 patients (18.1%) in the control group, RR: 1.5, P-value \u3c 0.0001. There was no statistically significant difference in the need for PLA drainage (RR: 1.19, P-value = 0.34) or mortality (RR: 0.969, P-value = 0.49).
Conclusion: ES during ERCP was associated with an increased risk for PLA, sepsis, and broad-spectrum antibiotics use. No mortality difference was found
Long-Term Follow-Up of Giant Paraesophageal Hernia Repair With Restoration of Normal Anatomy Without Fundoplication
No full textBackground: While some have reported performing gastropexy after paraesophageal hernia repair, the risk for development of severe reflux is being defined. Although we have observed good short-term outcomes after restoration of normal anatomy in patients with predominantly obstructive symptoms, long-term outcomes are unknown.
Methods: Retrospective review of patients without significant reflux (heartburn, regurgitation, pulmonary symptoms) who underwent normal anatomy restoration was performed. Standard minimally invasive paraesophageal hernia repair was performed, then the short gastric line was sutured to the left hemidiaphragm to restore normal anatomy. Patients with follow-up \u3e 3 years were included. A recurrence was defined as hernia size \u3e 2 cm or \u3e 10% of the stomach reherniated.
Results: There were 81 patients. Elective repair was performed in 55 (67.9%) patients, with urgent repair performed in 25 (32.1%) patients. All procedures were performed minimally invasively with median postoperative length of stay of 4 days. At a median follow-up of 5.4 years (range, 3.0-15.4 years), obstructive symptom relief persisted. A recurrent hiatal hernia was present in 15 patients (18.5%). Reoperation was required in 1 patient after a forceful vomiting episode. There were 7 patients who reported heartburn with symptoms well controlled by antisecretory medications. No patient required reoperation for severe reflux.
Conclusions: Long-term follow-up in patients with giant paraesophageal hernia who underwent restoration of normal anatomy had good symptomatic outcome without significant reflux. Hiatal hernias were common but most were asymptomatic. This approach may avoid the morbidity of fundoplication in carefully selected patients
Transjugular Transcatheter Tricuspid Valve Replacement With the Evoque System: A Case Series and Technical Considerations
No full textTranscatheter tricuspid valve replacement (TTVR) with the Evoque tricuspid valve replacement system using a transfemoral (TF) approach has demonstrated safety and efficacy in patients with severe symptomatic tricuspid regurgitation. However, anatomical constraints may preclude TF delivery, necessitating alternative approaches. We present a step-by-step guide for performing TTVR via the transjugular (TJ) route based on 2 successful cases. In the first case, TJ access was selected upfront owing to the presence of an Adams-DeWeese inferior vena cava clip, which created a mechanical obstruction to femoral access. In the second case, TF access was attempted but abandoned owing to unfavorable trajectory, making valve deployment unsuccessful despite attempts from both the right and left femoral veins. This guide provides detailed procedural steps, technical considerations, and an algorithm for patient selection to help operators successfully perform TJ TTVR when TF access is not suitable
635. \u27Urine\u27 the Know: A Simple Approach for Detecting Candida auris Sooner, and the Emergence of Clade III Candida auris in NY
No full textMechanistic Basis for Differential Effects of Interatrial Shunt Treatment in HFrEF vs HFpEF: The RELIEVE-HF Trial
No full textBackground: The RELIEVE-HF (REducing Lung congestion symptoms using the v-wavE shunt in adVancEd Heart Failure) trial randomized 508 patients with heart failure (HF) to interatrial shunt treatment vs placebo procedure. Randomization was stratified into 2 patient groups: heart failure with reduced ejection fraction (HFrEF) (left ventricular ejection fraction [LVEF] ≤ 40%); and heart failure with preserved ejection fraction (HFpEF) (LVEF \u3e 40%). HF event rates (all-cause death, transplantation or left ventricular (LV) assist device, HF hospitalization or outpatient worsening) after shunt treatment during 2-year follow-up were directionally opposite: decreased by 51% in HFrEF, increased by 69% in HFpEF.
Objectives: This study aims to examine differences in cardiac structure and function before and after interatrial shunt placement in patients with HFrEF vs HFpEF that could underlie these discordant clinical outcomes.
Methods: Serial changes from baseline to 12 months in 17 transthoracic echocardiographic parameters in shunt-treated vs control patients in HFrEF vs HFpEF were assessed and compared by ANCOVA (analysis of covariance).
Results: In shunt-treated vs control patients with HFrEF, there were reductions in median LV end-diastolic volumes (-11.9 mL/m2 [Q1-Q3: -21.3 to -2.5 mL/m2]; P = 0.01) and LV end-systolic volumes (-8.9 mL/m2 [Q1-Q3: -17.2 to -20.7 mL/m2]; P = 0.01) indicative of reverse LV remodeling. There were no significant changes in right ventricular (RV), right atrial, or inferior vena cava sizes or pulmonary artery systolic pressure (PASP). In contrast, shunt-treated vs control patients with HFpEF did not have LV remodeling, but they had increased RV, right atrial, and inferior vena cava dimensions, and PASP also increased (4.7 mm Hg [Q1-Q3: 0.9-8.5 mm Hg]; P = 0.02). LV and RV diastolic compliance were decreased in HFpEF vs HFrEF at baseline and decreased further after shunt treatment in HFpEF.
Conclusions: Differential changes in left-sided and right-sided heart remodeling and PASP following interatrial shunt placement in patients with HFrEF vs HFpEF provide a mechanistic basis for the variable effects on clinical outcomes observed in RELIEVE-HF. (REducing Lung congestion symptoms using the v-wavE shunt in adVancEd Heart Failure [RELIEVE-HF]; NCT03499236)
Geographic distribution and equity in access to gastrointestinal cancer clinical trials in the United States
No full textRevisiting New Data on the Mortality Benefit of Rapid Correction of Hyponatremia: Déjà Vu All Over Again
No full textStudies in the 1980s linking rapid correction of severe, chronic hyponatremia to the osmotic demyelination syndrome (ODS) led to a major controversy that eventually gave way to consensus guidelines. Efforts to limit correction to ≤8 mmol/L per day in patients at high risk of developing ODS became common practice. Recent studies have questioned these guidelines, suggesting that ODS is rare and that slow correction may increase mortality. In this review, we revisit the history of the controversy and find that these claims have persisted for 4 decades. Older studies supporting faster correction are flawed by referral bias while newer studies are limited by confounding as comorbidities influence rates of both mortality and hyponatremia correction. Although both old and new studies emphasize the rarity of magnetic resonance imaging-documented ODS after rapid correction, they were not conducted in hyponatremic patients who were at risk for ODS. Old studies reporting hyponatremic deaths due to cerebral edema overestimate its true incidence, and new studies reporting an association of mortality and slow rates of sodium correction do not document cerebral edema as a common contributor to death. Further research is required to better define the incidence of both ODS and cerebral edema in patients at risk for these complications. Until then, we conclude that the risks of rapid correction-including irreversible neurological damage-necessitate caution. Clinicians should continue to prioritize slow, controlled sodium correction to protect high-risk patients from harm
CKM-Cardiac Kidney Metabolic: A Collaborative Approach Primary Care and Specialty
No full textCKM-Cardiac Kidney Metabolic: A Collaborative Approach Primary Care and Specialty. Dr. Lorinda Parks, Medical Director, Primary Care Institute
Objectives: To learn about a new collaborative approach at RRH To appreciate the steps we can take to reduce the long term affects of metabolic disease on the heart and kidney
Anorectal Diseases in Rheumatology
No full textAlthough rare, anorectal involvement in rheumatic diseases (RD) can significantly impair quality of life. This chapter outlines normal anorectal anatomy and discusses how systemic sclerosis (SSc) causes sphincter dysfunction, neuropathy, and fecal incontinence through multiple mechanisms. Sarcoidosis, systemic lupus erythematosus (SLE), and antiphospholipid syndrome may present with anorectal plaques, ulcers, stenosis, or hemorrhoidal disease, often driven by granulomatous or vascular pathology. Treatment often focuses on sphincter muscle training in fecal incontinence form SSc and steroid therapy for SLE-related pathology, though further research is still needed. Recognizing anorectal symptoms may aid early diagnosis and facilitate coordinated care