Chengshi Jin

Significance of Frailty among Dialysis Patients

The construct of frailty has been associated with adverse outcomes among elderly individuals, but the prevalence and significance of frailty among patients with end-stage renal disease have not been established. The aim of the current study was to determine the prevalence and predictors of frailty

Association of Large Serrated Polyps With Synchronous Advanced Colorectal Neoplasia

OBJECTIVES:Serrated polyps of the colorectum are a histologically and genetically heterogeneous group of lesions, which include classic hyperplasic polyps, sessile serrated adenomas (SSAs), and traditional serrated adenomas. Accumulating evidence suggests that they may have different malignancy potentials. This study sought to determine the association between the presence of large serrated colorectal polyps and synchronous advanced colorectal neoplasia.METHODS:Among 4,714 asymptomatic subjects who underwent screening colonoscopy, cases of advanced colorectal neoplasia (tubular adenoma ≥1 cm, adenoma with any villous histology, adenoma with carcinoma in situ / high-grade dysplasia, or invasive adenocarcinoma) were compared with controls without advanced neoplasia with respect to candidate predictors, including age, sex, family history of colorectal cancer, body mass index, the presence and number of small tubular adenomas (<1 cm), the presence of multiple small serrated polyps (<1 cm), and the presence of large serrated polyps (≥1 cm). Independent predictors of advanced neoplasia were determined by multivariate logistic regression analysis.RESULTS:Among 467 cases and 4,247 controls, independent predictors of advanced colorectal neoplasia were increasing age (odds ratio (OR)=4.51; 95% confidence interval (CI), 1.43–14.3; P=0.01 for subjects ≥80 years vs. 50–54 years of age); non-advanced tubular adenomas (OR=2.33; 95% CI 1.37–3.96, P=0.0017 for 3 or more); and large serrated polyps (OR=3.24; 95% CI 2.05–5.13, P<0.0001). In total, 109 subjects (2.3% of the study population) had large serrated polyps. Right- and left-sided large serrated polyps had a similar association with advanced colorectal neoplasia (OR=3.38 vs. 2.66, P=0.62).CONCLUSIONS:Large serrated polyps are strongly and independently associated with synchronous advanced colorectal neoplasia. Our results suggest that large serrated polyps may be a marker for advanced colorectal neoplasia. Further studies are needed to determine whether the association with advanced neoplasia differs among subsets of serrated polyps, particularly SSAs and classic hyperplastic polyps.

Risk of Thyroid Cancer Based on Thyroid Ultrasound Imaging Characteristics: Results of a Population-Based Study

IMPORTANCE There is wide variation in the management of thyroid nodules identified on ultrasound imaging. OBJECTIVE To quantify the risk of thyroid cancer associated with thyroid nodules based on ultrasound imaging characteristics. METHODS Retrospective case-control study of patients who underwent thyroid ultrasound imaging from January 1, 2000, through March 30, 2005. Thyroid cancers were identified through linkage with the California Cancer Registry. RESULTS A total of 8806 patients underwent 11,618 thyroid ultrasound examinations during the study period, including 105 subsequently diagnosed as having thyroid cancer. Thyroid nodules were common in patients diagnosed as having cancer (96.9%) and patients not diagnosed as having thyroid cancer (56.4%). Three ultrasound nodule characteristics--microcalcifications (odds ratio [OR], 8.1; 95% CI, 3.8-17.3), size greater than 2 cm (OR, 3.6; 95% CI, 1.7-7.6), and an entirely solid composition (OR, 4.0; 95% CI, 1.7-9.2)--were the only findings associated with the risk of thyroid cancer. If 1 characteristic is used as an indication for biopsy, most cases of thyroid cancer would be detected (sensitivity, 0.88; 95% CI, 0.80-0.94), with a high false-positive rate (0.44; 95% CI, 0.43-0.45) and a low positive likelihood ratio (2.0; 95% CI, 1.8-2.2), and 56 biopsies will be performed per cancer diagnosed. If 2 characteristics were required for biopsy, the sensitivity and false-positive rates would be lower (sensitivity, 0.52; 95% CI, 0.42-0.62; false-positive rate, 0.07; 95% CI, 0.07-0.08), the positive likelihood ratio would be higher (7.1; 95% CI, 6.2-8.2), and only 16 biopsies will be performed per cancer diagnosed. Compared with performing biopsy of all thyroid nodules larger than 5 mm, adoption of this more stringent rule requiring 2 abnormal nodule characteristics to prompt biopsy would reduce unnecessary biopsies by 90% while maintaining a low risk of cancer (5 per 1000 patients for whom biopsy is deferred). CONCLUSIONS AND RELEVANCE Thyroid ultrasound imaging could be used to identify patients who have a low risk of cancer for whom biopsy could be deferred. On the basis of these results, these findings should be validated in a large prospective cohort.

Influence of cannabis use on severity of hepatitis C disease.

BACKGROUND & AIMS Complications of HCV infection are primarily related to the development of advanced fibrosis and whether cannabis use is a risk factor for more severe fibrosis is controversial. METHODS Baseline data from a prospective cohort study of 204 persons with chronic HCV infection were used for analysis. The outcome was fibrosis score on biopsy, and the primary predictor evaluated was daily cannabis use. RESULTS The median age of the cohort was 46.8 years, 69.1% were male, 49.0% were white, and the presumed route of infection was injection drug use in 70.1%. The median lifetime duration and average daily use of alcohol were 29.1 years and 1.94 drink equivalents per day, respectively. Cannabis use frequency (within prior 12 months) was daily in 13.7%, occasional in 45.1%, and never in 41.2%. Fibrosis stage, assessed by the Ishak method, was F0, F1-2, and F3-6 in 27.5%, 55.4%, and 17.2% of subjects, respectively. Daily compared with non-daily cannabis use was significantly associated with moderate to severe fibrosis (F3-6 vs F1-2) in univariate (odds ratio [OR], 3.21; 95% confidence interval [CI], 1.20-8.56, P = .020) and multivariate analyses (OR, 6.78; 95% CI, 1.89-24.31, P = .003). Other independent predictors of F3-6 were >or=11 portal tracts (compared with <5, OR, 6.92; 95% CI, 1.34-35.7, P = .021) and lifetime duration of moderate to heavy alcohol use (OR per decade, 1.72; 95% CI, 1.02-2.90, P = .044). CONCLUSIONS Daily cannabis use is strongly associated with moderate to severe fibrosis, and HCV-infected individuals should be counseled to reduce or abstain from cannabis use.

Has recognition of the relationship between mortality rates and hospital volume for major cancer surgery in California made a difference?: A follow-up analysis of another decade.

Background:Previous reports showed that in California during the early 1990s, operative mortality rates for esophageal, pancreatic, and hepatic cancers were inversely related to hospital volume. It is unknown whether this information has affected referral patterns or operative mortality rates. Objectives:Data were analyzed for the 10 years that followed the period covered in the initial studies to determine if: (a) the operative mortality rates had decreased; and (b) a greater proportion of patients with esophageal, pancreatic, and hepatic cancers were treated at high-volume centers. Methods:Hospital discharge data were obtained for 8901 patients who had resections for cancer of the esophagus, 2404 patients; pancreas, 5294 patients; and liver, 1203 patients in California between 1995 and 2004. Logistic regression models were used to calculate adjusted mortality rates at high- and low-volume centers by year. The data were compared with the published results for California during the years 1990–1994. Results:Operative mortality rates decreased for esophageal, pancreatic, and hepatic resections during the more recent 10 years. Concomitantly, the proportion of patients treated at high-volume centers increased, as did the number of high-volume centers. There was a substantial increase in the proportion of esophagectomies performed in high-volume hospitals, while the overall number of esophagectomies dropped by 22%. For the other 2 operations, total volume and the volume in high-volume hospitals increased greatly, and the volume in low-volume hospitals was about the same during the 3 periods. The mortality rates decreased at all levels of the volume range. Finally, the performance from one period to the next in individual hospitals was mostly similar, but an occasional outlier was also noted. Conclusions:More resections for esophageal, pancreatic, and hepatic cancer were performed at high volume centers, but mortality rates decreased for all hospital categories. The data suggest that modern hospitals act as complex adaptive systems, whose outputs are determined from the interactions between internal agents and are resistant to analysis by isolating and studying the individual contributions. It is tempting to attribute the desirable changes in these data (eg, more operations being done in high volume centers and better mortality rates at all levels) as consequences of pressures over the past few decades on hospitals to assume greater responsibility for their quality of care and to become more integrated internally. Thus, many factors appear to influence the volume-outcome relationships, and the identity and individual contributions of these influences may be immune to reductionist analysis. There is substantial evidence that high volume should be part of high quality for these complex operations. Nevertheless, measuring outcomes directly, rather than concentrating on their correlates, may be a more reliable index of hospital performance.

Citalopram Provides Little or No Benefit in Nondepressed Patients With Irritable Bowel Syndrome

BACKGROUND & AIMS Data on the benefit of selective serotonin reuptake inhibitors (SSRIs) in irritable bowel syndrome (IBS) are conflicting. The longitudinal relationship between clinical symptoms and sensitivity to barostat-mediated rectal distension in IBS remains unclear. We assessed the benefit of citalopram and explored the relationships between symptoms, quality of life (QOL), and rectal sensitivity to barostat distension in non-depressed IBS patients. METHODS Patients from primary, secondary, and tertiary care settings were randomly assigned to receive citalopram (20 mg/day for 4 weeks, then 40 mg/day for 4 weeks) or placebo in a study with double-masking and concealed allocation. Symptoms were assessed weekly, and IBS-QOL and rectal sensation by barostat were assessed at the beginning and end of the study. RESULTS Patients receiving citalopram did not achieve a higher rate of adequate relief of IBS symptoms than patients receiving placebo (12/27 [44%] vs 15/27 [56%]; P = .59), regardless of IBS subtype. The odds ratio for weekly response with citalopram vs placebo was 0.80 (95% confidence interval, 0.61-1.04). Improvements in specific symptom and IBS-QOL scores were not superior for citalopram. Changes in IBS-QOL score and pressure eliciting pain showed a modest correlation (r = 0.33; 95% confidence interval, 0.03-0.57), but changes in symptoms and IBS-QOL scores or rectal sensitivity were not correlated substantially. CONCLUSIONS Citalopram was not superior to placebo in treating non-depressed IBS patients. Changes in symptoms were not substantially correlated with changes in rectal sensation assessed by barostat. Any benefit of citalopram in non-depressed IBS patients is likely to be modest at best.

Strong relationship between oral dose and tenofovir hair levels in a randomized trial: hair as a potential adherence measure for pre-exposure prophylaxis (PrEP).

Background Pre-exposure prophylaxis (PrEP) trials using tenofovir-based regimens have demonstrated that high levels of adherence are required to evaluate efficacy; the incorporation of objective biomarkers of adherence in trial design has been essential to interpretation, given the inaccuracy of self-report. Antiretroviral measurements in scalp hair have been useful as a marker of long-term exposure in the HIV treatment setting, and hair samples are relatively easy and inexpensive to collect, transport, and store for analysis. To evaluate the relationship between dose and tenofovir concentrations in hair, we examined the dose proportionality of tenofovir in hair in healthy, HIV-uninfected adults. Methods A phase I, crossover pharmacokinetic study was performed in 24 HIV-negative adults receiving directly-observed oral tenofovir tablets administered 2, 4, and 7 doses/week for 6 weeks, with a ≥3-week break between periods. Small samples of hair were collected after each six-week period and analyzed for tenofovir concentrations. Geometric-mean-ratios compared levels between each pair of dosing conditions. Intensive plasma pharmacokinetic studies were performed during the daily-dosing period to calculate areas-under-the-time-concentration curves (AUCs). Results Over 90% of doses were observed per protocol. Median tenofovir concentrations in hair increased monotonically with dose. A log-linear relationship was seen between dose and hair levels, with an estimated 76% (95% CI 60–93%) increase in hair level per 2-fold dose increase. Tenofovir plasma AUCs modestly predicted drug concentrations in hair. Conclusions This study found a strong linear relationship between frequency of dosing and tenofovir levels in scalp hair. The analysis of quantitative drug levels in hair has the potential to improve adherence measurement in the PrEP field and may be helpful in determining exposure thresholds for protection and explaining failures in PrEP trials. Hair measures for adherence monitoring may also facilitate adherence measurement in real-world settings and merit further investigation in upcoming PrEP implementation studies and programs. Trial Registration ClinicalTrials.gov +NCT00903084.

Integrated specialty mental health care among older minorities improves access but not outcomes: results of the PRISMe study.

In this secondary data analysis of Primary Care Research in Substance Abuse and Mental Health for the Elderly (PRIMSe) study, we hypothesized that older minorities who receive mental health services integrated in primary care settings would have greater service use and better mental health outcomes than older minorities referred to community services.

Impact of frailty on complications in patients undergoing common urological procedures: a study from the American College of Surgeons National Surgical Quality Improvement database

To evaluate the association of frailty, a measure of diminished physiological reserve, with both major and minor surgical complications among patients undergoing urological surgery.

Trauma, Transfusions, and Use of Recombinant Factor VIIa: A Multicenter Case Registry Report of 380 Patients from the Western Trauma Association

BACKGROUND This study describes the current use of recombinant activated factor VII (rFVIIa) for hemorrhage after trauma in the United States. We hypothesized that we could describe the setting in which rFVIIa would be most successful in arresting hemorrhage after injury. STUDY DESIGN This case registry study of patients with traumatic injuries at risk for death from hemorrhage at Level I and II trauma centers in the United States analyzed the administration of rFVIIa from admission to death from hemorrhage. Secondary outcomes measures of interest were the use of blood products, days in the ICU, organ failure, and thrombotic complications. RESULTS Three hundred and eighty injured patients who received rFVIIa as an adjunct for hemorrhage control were included in this analysis. The mean time from admission to administration of rFVIIa was 4.6 hours, with an average transfusion of 18 U blood before administration (range 0 to 99 U). Death from hemorrhage rate was 30%. Predictors of a poor response to rFVIIa were a pH <7.2 (p < 0.0001), a platelet count <100,000 (p = 0.046), and blood pressure ≤90 mmHg (p < 0.0001) at the time of administration. CONCLUSIONS Based on this case registry review, the precise role of rFVIIa in traumatic hemorrhage is unclear. Surgeons choosing to use this drug as an adjunctive measure to reverse coagulopathy are advised to first correct shock, acidosis, and thrombocytopenia.