Cholecystectomy after Endoscopic Papillotomy for Choledocholithiasis in the Elderly—Is It Necessary?

2019 ◽  
Vol 85 (11) ◽  
pp. 1234-1238
Author(s):  
Alex Zendel ◽  
Eyal Mor ◽  
David Goitein ◽  
David Hazzan ◽  
Aviram Nissan ◽  
...  
Keyword(s):  
Medical Center ◽  
The Elderly ◽  
Biliary Complications ◽  
Study Cohort ◽  
Endoscopic Papillotomy ◽  
Cbd Stones ◽  
Patient Database ◽  
Elective Laparoscopic Cholecystectomy ◽  
Cbd Stone

Although elective laparoscopic cholecystectomy is the accepted strategy after endoscopic retrograde cholangiopancreatography (ERCP), papillotomy, and common bile duct (CBD) clearance, the decision to perform a cholecystectomy in high-risk elderly comorbid patients remains subjective and is controversial. The aim of this study was to examine the outcome of elderly patients with cholecystectomy deferral after successful initial endoscopic removal of CBD stones. The study examined a retrospective patient database, which included all patients aged >60 years who underwent an ERCP for CBD stones at the Chaim Sheba Medical Center. The study cohort was divided according to whether a subsequent cholecystectomy was performed and also by age 60 to 80 or >80 years. All biliary-related complications were recorded. The primary outcome measures were biliary complications, perioperative and periprocedural mortality, CBD stone recurrence, and the need for future surgical intervention. There were 111 patients (mean age 79.4 ± 9.1 years) who underwent ERCP with follow-up. After excluding 11 patients, 100 patients were left for analysis, 46 of whom underwent a cholecystectomy and 54 were observed without operation. There were significant longer term biliary complications in five of the operated patients (10.9%) and in four of the unoperated cases (7.4%). All biliary-related complications were managed successfully by conservative means except for one fatality in the nonoperated group. Biliary-related complications after successful ERCP for CBD stones were unaffected by surgery but were more commonly observed in older cases. A watch and wait policy may be justified in elderly comorbid patients.

Abstract 140: Effects of Smoking Co-Morbidities and Obesity on NonHemorrhagic Stroke Outcomes

2017 ◽  
Vol 10 (suppl_3) ◽  
Author(s):  
Danielle Amato ◽  
Justin Pieper ◽  
Michael Ashamalla ◽  
Mikhail Torosoff
Keyword(s):  
Renal Disease ◽  
Hemorrhagic Stroke ◽  
Chronic Renal Disease ◽  
Medical Center ◽  
Academic Medical Center ◽  
Study Cohort ◽  
Younger Age ◽  
Social Security Death Index ◽  
The Mean

Background: Smoking is a known risk factor for ischemic stroke, while increased BMI has been associated with improved outcomes in patients with cardiovascular disease. We investigated the relationship between smoking, BMI, and outcomes in patients with non-hemorrhagic stroke. Methods: Study cohort consisted of 610 consecutive patients treated for non-hemorrhagic stroke at a single academic medical center. Retrospective chart review was conducted. Long-term outcomes were ascertained through Social Security Death Index. The study was approved by the institutional IRB. Results: The prevalence of smoking was 42%. There were more male smokers (48% vs. 35% females, p<0.001). The mean BMI was similar in smokers and non-smokers (29+/-12.7 vs. 28.8+/-14, p=0.842). Similarly, associations between smoking and hypertension, peripheral vascular disease, dyslipidemia, end-stage renal disease, and systemic evidence of atherosclerosis by TTE were not statistically significant. However, age of a smoker at the time of admission for non-hemorrhagic stroke was 5 years younger than in a non-smoker (60.7+/-15 vs. non-smokers 65.3+/-17.5, p<0.001). The mean follow up length was 51.4+/-1.3 months in smokers and 48.6+/-1.0 months in non-smokers. Observed crude mortality of 22.2% in smokers and 24.3% in non-smokers (p=0.559) was not significantly different in patients with normal, or increased BMI. However, smokers with non-hemorrhagic stroke died at significantly younger age (64.8+/-14.6 vs. 69.2+/-17.1, p=0.001). Additionally, there were trends towards increased mortality in smokers with BMI <18.5 kg/m2 (10.2 vs. 5.3% in non-smokers, p=0.226), dyslipidemia (38% vs. 24% in non-smokers, p=0.054) and chronic renal disease (64% vs. 36% in non-smokers, p=0.889). Conclusion: Smokers present with non-hemorrhagic stroke at a significantly younger age than non-smokers and die at much younger age during follow-up. While in our cohort smoking was not linked to other traditional risk factors for non-hemorrhagic stroke, it was associated with increased mortality in patients with decreased BMI, dyslipidemia, and with renal disease. “Protective” effect of increased BMI was not observed in smokers.

scholarly journals High effectiveness of multimodal infection control interventions in preventing SARS−CoV−2 infections in healthcare professionals: a prospective longitudinal seroconversion study

2020 ◽  
Author(s):  
Thomas Theo Brehm ◽  
Dorothee Schwinge ◽  
Sibylle Lampalzer ◽  
Veronika Schlicker ◽  
Julia Kuechen ◽  
...  
Keyword(s):  
Infection Control ◽  
Healthcare Professionals ◽  
Medical Center ◽  
Seroconversion Rate ◽  
Tertiary Care ◽  
Study Cohort ◽  
Igg Antibody ◽  
Tertiary Care Centre ◽  
Prospective Longitudinal

Objective: To assess the effectiveness of multimodal infection control interventions in the prevention of SARS−CoV−2 infections in healthcare professionals. Design: Sequential follow−up study. Setting: Largest tertiary care centre in northern Germany. Participants: 1253 employees of the University Medical Center Hamburg−Eppendorf were sequentially assessed for the presence of SARS−CoV−2 IgG antibodies at the beginning of the covid−19 epidemic (20 March − 9 April), one month (20 April − 8 May), and another two months later (22 June − 24 July). Of those, 1026 were healthcare workers (HCWs) of whom 292 were directly involved in the care of covid−19 patients. During the study period, infection control interventions were deployed, those included i) strict barrier nursing of all known covid−19 patients including FFP2 (N95) masks, goggles, gloves, hoods and protective gowns, ii) visitor restrictions with access control at all hospital entries, iii) mandatory wearing of disposable face masks in all clinical settings, and iv) universal RT−PCR admission screening of patients. Main Outcome Measures: SARS−CoV−2 IgG seroconversion rate. Results: At the initial screening, ten participants displayed significant IgG antibody ratios. Another ten individuals showed seroconversion at the second time point one month later, only two further participants seroconverted during the subsequent two months. The overall SARS−CoV−2 seroprevalence in the study cohort at the last follow−up was 1.8%, the seroconversion rate dropped from 0.81% to 0.08% per month despite a longer observation period. Amongst HCWs seropositivity was increased in those directly involved in the care of patients with SARS−CoV−2 infections (3.8%, n=11) compared to other HCWs (1.4%, n=10, P=0.025). However, after the adoption of all multimodal infection control interventions seroconversions were observed in only two more HCWs, neither of whom were involved in inpatient care. Conclusion: Multimodal infection control and prevention interventions are highly effective in mitigating SARS−CoV−2 infections of healthcare professionals.

scholarly journals Integrity of clinical information in radiology reports documenting pulmonary nodules

2020 ◽  
Author(s):  
Ronilda Lacson ◽  
Laila Cochon ◽  
Patrick R Ching ◽  
Eseosa Odigie ◽  
Neena Kapoor ◽  
...  
Keyword(s):  
Language Processing ◽  
Pulmonary Nodule ◽  
Medical Center ◽  
Academic Medical Center ◽  
Pulmonary Nodules ◽  
Clinical Information ◽  
Clinical Decision ◽  
Study Cohort ◽  
Radiology Reports

Abstract Objective Quantify the integrity, measured as completeness and concordance with a thoracic radiologist, of documenting pulmonary nodule characteristics in CT reports and assess impact on making follow-up recommendations. Materials and Methods This Institutional Review Board-approved, retrospective cohort study was performed at an academic medical center. Natural language processing was performed on radiology reports of CT scans of chest, abdomen, or spine completed in 2016 to assess presence of pulmonary nodules, excluding patients with lung cancer, of which 300 reports were randomly sampled to form the study cohort. Documentation of nodule characteristics were manually extracted from reports by 2 authors with 20% overlap. CT images corresponding to 60 randomly selected reports were further reviewed by a thoracic radiologist to record nodule characteristics. Documentation completeness for all characteristics were reported in percentage and compared using χ2 analysis. Concordance with a thoracic radiologist was reported as percentage agreement; impact on making follow-up recommendations was assessed using kappa. Results Documentation completeness for pulmonary nodule characteristics differed across variables (range = 2%–90%, P &lt; .001). Concordance with a thoracic radiologist was 75% for documenting nodule laterality and 29% for size. Follow-up recommendations were in agreement in 67% and 49% of reports when there was lack of completeness and concordance in documenting nodule size, respectively. Discussion Essential pulmonary nodule characteristics were under-reported, potentially impacting recommendations for pulmonary nodule follow-up. Conclusion Lack of documentation of pulmonary nodule characteristics in radiology reports is common, with potential for compromising patient care and clinical decision support tools.

Factors Predicting Urethral Stricture Recurrence after Dorsal Onlay Augmented, Buccal Mucosal Graft Urethroplasty

2020 ◽  
pp. 1-9
Author(s):  
Osama Shalkamy ◽  
Hassan Abdelazim ◽  
Ahmed Elshazly ◽  
Ahmed Soliman ◽  
Mohammed Agha ◽  
...  
Keyword(s):  
Urethral Stricture ◽  
Cox Regression ◽  
Medical Center ◽  
Study Cohort ◽  
Cox Regression Analysis ◽  
Buccal Mucosal Graft ◽  
Time To Recurrence ◽  
Dorsal Onlay ◽  
Stricture Recurrence

<b><i>Introduction:</i></b> This study was carried out to identify the predictors of urethral stricture recurrence after dorsal onlay buccal mucosal graft (BMG) urethroplasty. <b><i>Materials and Methods:</i></b> The medical records of patients with anterior urethral stricture who underwent dorsal onlay BMG urethroplasty at a single tertiary medical center during the period from March 2010 to January 2018 were reviewed. Only patients with ≥2-year follow-up were included. Data regarding patient demographics, clinical characteristics, stricture characteristics, postoperative course, and adverse events were recorded. Kaplan-Meier analysis was used to assess the recurrence-free survival and likelihood of stricture recurrence. Cox regression analysis was used to identify potential independent predictors of stricture recurrence. <b><i>Results:</i></b> This study included 266 patients with a mean age of 37.71 years and a mean follow-up period of 49.77 months. From the overall study cohort, 34 (12.8%) reported stricture recurrence and 232 (87.2%) were not. The mean recurrence-free time was 79.93 months and mean time to recurrence was 21.59 months. On multivariate analysis, obesity (hazard ratio (HR): 6.02; 95% conference interval (CI): 1.91, 19.03: <i>p</i> = 0.002), inflammatory aetiology (HR: 9.13; 95% CI: 3.50, 23.81; <i>p</i> &#x3c; 0.001), prior urethroplasty (HR: 8.81; 95% CI: 3.26, 23.86; <i>p</i> &#x3c; 0.001), penile stricture location (HR: 3.09; 95% CI: 1.10, 8.71; <i>p</i> = 0.033), and stricture length &#x3e;4.5 cm (HR: 6.83; 95% CI: 1.69, 27.62; <i>p</i> = 0.007) were the significant independent predictors of stricture recurrence. <b><i>Conclusions:</i></b> Dorsal onlay BMG urethroplasty has a reasonable recurrence-free rate with acceptable postoperative complications. Obesity, inflammatory etiology, prior urethroplasty, penile stricture location, and longer stricture were the factors associated with urethral stricture recurrence.

scholarly journals Comparison of the Long-Term Outcomes of Endoscopic Papillary Large Balloon Dilation Alone versus Endoscopic Sphincterotomy for Removal of Bile Duct Stones

2018 ◽  
Vol 2018 ◽  
pp. 1-8 ◽  
Author(s):  
Tao Li ◽  
Jun Wen ◽  
Like Bie ◽  
Biao Gong
Keyword(s):  
Balloon Dilation ◽  
Biliary Complications ◽  
Long Term Outcomes ◽  
Mechanical Lithotripsy ◽  
Cbd Stones ◽  
Long Term Follow Up ◽  
Large Balloon ◽  
Large Balloon Dilation

Background and Aims. Endoscopic papillary large balloon dilation (EPLBD) alone is an alternative to endoscopic sphincterotomy (EST) for treatment of common bile duct (CBD) stones. However, limited data exists regarding comparison of the long-term outcomes for these techniques. In this study, we compared the long-term outcomes after EST with those after EPLBD alone for removal of CBD stones. Methods. The records of patients with EST or EPLBD alone referred for CBD stones retrieval between June 2008 and July 2015 were retrospectively reviewed. Complete stone clearance, ERCP-related adverse events, and late biliary complications during long-term follow-up were analyzed. Results. Basic patient characteristics were similar between the groups that underwent EST (n=60) and EPLBD alone (n=161). EPLBD compared with EST resulted in similar outcomes in terms of complete stone clearance (99.4% versus 100%, P=0.54) and ERCP-related adverse events (6.8% versus 6.7%, P=1.00). The mean duration of the follow-up was 74.5 months and 71.6 months who underwent EST and EPLBD alone, respectively (P=0.42). Late biliary complications were occurred frequently in the EST group than in the EPLBD alone group (11 [18.6%] versus 16 [10.2%]), although the difference did not reach statistical significance (P=0.11). Multivariate analysis showed that mechanical lithotripsy ([OR], 2.815; 95% CI, 1.148–6.902; P=0.024) was significantly associated with late biliary complications. Conclusion. As an alternative to EST, EPLBD has similar efficacy and safety for managing CBD stones. During long-term follow-up, patients who underwent EPLBD alone may have fewer late biliary complications compared with those after EST. In addition, mechanical lithotripsy may be an independent risk factor for late biliary complications.

scholarly journals Initiation of droxidopa during hospital admission for management of refractory neurogenic orthostatic hypotension in severely ill patients

2018 ◽  
Author(s):  
Katherine E. McDonell ◽  
Brock A. Preheim ◽  
Andre’ Diedrich ◽  
James A.S. Muldowney ◽  
Amanda C. Peltier ◽  
...  
Keyword(s):  
Hospital Admission ◽  
Orthostatic Hypotension ◽  
Medical Center ◽  
The Elderly ◽  
Outpatient Setting ◽  
Cardiovascular Comorbidities ◽  
Complex Patients ◽  
End Stage ◽  
Vanderbilt University

AbstractIntroductionOrthostatic hypotension (OH) is a common cause of hospitalization, particularly in the elderly. Hospitalized patients with OH are often severely ill, with complex medical comorbidities and high rates of disability. Droxidopa is a norepinephrine precursor approved for the treatment of neurogenic OH (nOH) associated with autonomic failure that is commonly used in the outpatient setting, but there is currently no data regarding the safety and efficacy of droxidopa initiation in medically complex patients.MethodsWe performed a retrospective review of patients started on droxidopa for refractory nOH while hospitalized at Vanderbilt University Medical Center between October 2014 and May 2017. Primary outcome measures were safety, change in physician global impression of illness severity from admission to discharge, and persistence on medication after 180-day follow-up.ResultsA total of 20 patients were identified through chart review. Patients were medically complex with high rates of cardiovascular comorbidities and a diverse array of underlying autonomic diagnoses. Rapid titration of droxidopa was safe and well-tolerated in this cohort, with no cardiovascular events or new onset arrhythmias. Supine hypertension requiring treatment occurred in four patients. One death occurred during hospital admission due to organ failure associated with end-stage amyloidosis. Treating physicians noted improvements in presyncopal symptoms in 80% of patients. After 6 months, 13 patients (65%) continued on droxidopa therapy.ConclusionIn a retrospective cohort of hospitalized, severely ill patients with refractory nOH, supervised rapid titration of droxidopa was safe and effective. Treatment persistence was high, suggesting that symptomatic benefit extended beyond acute intervention.

scholarly journals The Diagnostic Accuracy of Linear Endoscopic Ultrasound for Evaluating Symptoms Suggestive of Common Bile Duct Stones

2016 ◽  
Vol 2016 ◽  
pp. 1-5 ◽  
Author(s):  
Min Wang ◽  
Xu He ◽  
Chuan Tian ◽  
Jian Li ◽  
Feng Min ◽  
...  
Keyword(s):  
High Risk ◽  
Diagnostic Accuracy ◽  
False Negative ◽  
Common Bile Duct Stones ◽  
Risk Groups ◽  
Predictive Values ◽  
Cbd Stones ◽  
Cbd Stone ◽  
Sensitivity Specificity

Background. In order to assess the diagnostic accuracy of linear EUS for evaluating clinically suggestive CBD stones in high-risk groups.Methods. 202 patients with clinically suggestive CBD stones in high-risk groups who underwent linear EUS examination between January 2012 and January 2015 were retrospectively reviewed. Endoscopic retrograde cholangiopancreatography (ERCP) with stone extraction or surgical choledochoscopy was only performed when a CBD stone was detected by linear EUS. Cases that were negative for CBD stones were followed up for at least 6 months.Results. Of 202 enrolled patients, 126 were positive for CBD stones according to linear EUS findings. 124 patients successfully underwent ERCP, and ERCP failed in 2 who were later successfully treated by surgical intervention. There were 2 false-positive cases with positive findings for CBD stones on ERCP. Among 76 patients without CBD stones, no false-negative cases were identified during the mean 6-month follow-up. Linear EUS had sensitivity, specificity, and positive and negative predictive values for the detection of CBD stones of 100%, 92.88%, 98.21%, and 100%, respectively.Conclusions. Linear EUS is a safe and efficacious diagnostic tool for evaluating clinically suggestive CBD stones with high risk of choledocholithiasis. Performing linear EUS prior to ERCP in patients with symptoms suggestive of CBD stones can reduce unnecessary ERCP procedures.

scholarly journals Effectiveness of a direct-to-consumer written health education program in the reduction of benzodiazepine and sedative-hypnotic use in an elderly population at a single Veterans Affairs medical center

2018 ◽  
Vol 8 (3) ◽  
pp. 100-104 ◽  
Author(s):  
William J. Erwin ◽  
Courtney Goodman ◽  
Tammy Smith
Keyword(s):  
Motor Vehicle ◽  
Medical Center ◽  
Significant Risk ◽  
The Elderly ◽  
Consumer Education ◽  
Improvement Project ◽  
Vehicle Accidents ◽  
Direct To Consumer ◽  
Sedative Hypnotics

Abstract Introduction: The use of benzodiazepines and sedative-hypnotics in the elderly is associated with a significant risk of delirium, falls, fractures, cognitive impairment, and motor vehicle accidents. This quality improvement project applies a direct-to-consumer intervention to an elderly veteran population to reduce the use of these medications. Methods: Patients aged 75 and older currently taking a benzodiazepine and/or a sedative-hypnotic were included in the project. Direct-to-consumer education intervention letters were mailed to patients within 30 days of their next appointment. Their providers were emailed a questionnaire after the patient's appointment. Providers were asked if the letter prompted a conversation regarding medication use, whether the provider initiated discussion regarding a taper, and whether a specific taper plan was developed. Medical records were reviewed to determine if a reduction in dose or discontinuation occurred. Results: Fifty-nine direct-to-consumer education letters were mailed to the patients. Follow-up questionnaires were e-mailed to 44 providers, and 27 providers responded. Twenty-two percent of patients had their benzodiazepine and/or sedative hypnotic dose reduced or discontinued after their follow-up appointment. Sixty-seven percent of veterans initiated a conversation with their provider regarding their medication with 74% of providers discussing dose reduction. Fifty-six percent of recipients developed a specific taper plan with their provider. Discussion: The data from this project suggests that direct-to-consumer patient education can reduce the exposure to benzodiazepines and sedative-hypnotics in an elderly veteran population. More data is needed on larger populations to further explore the benefit of direct-to-consumer interventions.

scholarly journals Homocysteine increases the risk of mortality in elderly individuals

2007 ◽  
Vol 97 (6) ◽  
pp. 1138-1143 ◽  
Author(s):  
Sonia González ◽  
José M. Huerta ◽  
Serafina Fernández ◽  
Ángeles M. Patterson ◽  
Cristina Lasheras
Keyword(s):  
Cox Regression ◽  
Elderly Care ◽  
The Elderly ◽  
Elderly Subjects ◽  
Vitamin B ◽  
Study Cohort ◽  
Risk Of Death ◽  
Risk Of Mortality ◽  
Increased Risk

Although total plasma homocysteine (tHcy) has been extensively studied as a risk factor of CVD, longitudinal evidence on its association with mortality is scarce, especially among the elderly. The study cohort consisted of 215 subjects (eighty-eight male and 127 female), aged 60 years or older, recruited in fourteen elderly care institutions from Asturias (Spain). All participants were free of major chronic pathology and took no vitamin and/or mineral supplements. Baseline determinations included tHcy in plasma and folate, vitamin B12and Se in serum. Survival analyses were performed by quintiles of these factors after 6 years (mean follow-up time 4·3 years) by means of Cox regression models. During follow-up time sixty participants died. tHcy above 16·7 μmol/l was associated with an increased risk of mortality in the sample (relative risk 2·30 (95 % CI 1·02, 5·17)). Among the nutritional determinants of tHcy evaluated, folate and Se were not predictive of death risk of the cohort, while vitamin B12showed inconsistent results. Nevertheless, mortality was significantly lower at higher serum Se levels (upper quintile), but this effect was restricted to women. Higher tHcy in both sexes and lower serum Se in women were found to be independently associated with an increased risk of death in elderly subjects.

Evaluation of R-CHOP and R-CVP in the treatment of elderly patient with non-Hodgkin lymphoma

MedPharmRes ◽  
2019 ◽  
Vol 3 (3) ◽  
pp. 1-6
Author(s):  
Truc Phan ◽  
Tram Huynh ◽  
Tuan Q. Tran ◽  
Dung Co ◽  
Khoi M. Tran
Keyword(s):  
Elderly Patients ◽  
Hodgkin Lymphoma ◽  
B Cell Lymphoma ◽  
Complete Response ◽  
The Elderly ◽  
Free Survival ◽  
Non Hodgkin Lymphoma ◽  
Common Sign ◽  
Related Mortality

Introduction: Little information is available on the outcomes of R-CHOP (rituximab with cyclophosphamide, doxorubicin, vincristine and prednisone) and R-CVP (rituximab with cyclophosphamide, vincristine and prednisone) in treatment of the elderly patients with non-Hodgkin lymphoma (NHL), especially in Vietnam. Material and methods: All patients were newly diagnosed with CD20-positive non-Hodgkin lymphoma (NHL) at Blood Transfusion and Hematology Hospital, Ho Chi Minh city (BTH) between 01/2013 and 01/2018 who were age 60 years or older at diagnosis. A retrospective analysis of these patients was perfomed. Results: Twenty-one Vietnamese patients (6 males and 15 females) were identified and the median age was 68.9 (range 60-80). Most of patients have comorbidities and intermediate-risk. The most common sign was lymphadenopathy (over 95%). The proportion of diffuse large B cell lymphoma (DLBCL) was highest (71%). The percentage of patients reaching complete response (CR) after six cycle of chemotherapy was 76.2%. The median follow-up was 26 months, event-free survival (EFS) was 60% and overall survival (OS) was 75%. Adverse effects of rituximab were unremarkable, treatment-related mortality accounted for less than 10%. There was no difference in drug toxicity between two regimens. Conclusions: R-CHOP, R-CVP yielded a good result and acceptable toxicity in treatment of elderly patients with non-Hodgkin lymphoma. In patients with known cardiac history, omission of anthracyclines is reasonable and R-CVP provides a competitive complete response rate.

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