Christine A. Welch

Angioplasty/stenting of the superior mesenteric artery and celiac trunk: early and late outcomes.

Purpose: To analyze the early results and durability of angioplasty/stenting of the superior mesenteric artery (SMA) and celiac trunk (CT). Methods: Twenty-two patients (19 women; mean age 69.2 years, range 52–88) with 24 symptomatic SMA or CT stenotic lesions were treated with dilation/stenting over a recent 4.5-year period. Two patients had lesions in both the SMA and CT treated. Clinical follow-up and duplex exams were done to evaluate long-term patency. Kaplan-Meier life-table analyses estimated the freedom from recurrent stenosis and recurrent symptoms, as well as survival rates. Results: The initial technical and clinical success rates were 96% (23/24) and 95% (21/22), respectively, with no perioperative mortality or major morbidity. During a mean follow-up of 26 months (range 1–54), the primary late clinical success rate was 61% (11/18; 4 lost to follow-up), and freedom from recurrent stenosis (≥70%) was 30% (6/20). The freedom from recurrent stenosis at 1, 2, 3, and 4 years were 65%, 47%, 39%, and 13%; freedom from recurrent symptoms was 67% at all 4 intervals. The survival rates were 93%, 93%, 80%, and 53% at 1 to 4 years, respectively. Conclusions: Angioplasty/stenting of SMA and CT stenoses has a high initial technical success rate and acceptable early and late clinical outcomes; however, it is associated with a high incidence of late restenosis based on strict Doppler criteria.

Gastrointestinal Norovirus Infection Associated With Exacerbation of Inflammatory Bowel Disease

Objective:In this study we aimed to determine, in pediatric patients, whether norovirus infection could be associated with exacerbations of inflammatory bowel disease (IBD) and ascertain whether the clinical expression of norovirus gastroenteritis was similar in patients with IBD compared with non-IBD controls. Materials and Methods:We performed a case-control retrospective chart review, over a 10-month interval, of patients with IBD with an exacerbation of their disease. The presence of norovirus in stool and/or rectal swab samples, as determined by an enzyme-linked immunoassay, was assessed. In addition, sex, age, type of IBD, presence or absence of diarrhea, hematochezia, and the need for hospitalization were determined. A similar number of control patients who did not have IBD were used as controls. Results:Nine patients with IBD (8 ulcerative colitis/1 Crohn disease) had exacerbations with diarrhea. Eight had norovirus antigen in at least 1 sample. All 9 patients with IBD presented with bloody diarrhea and 6 of the 8 norovirus-positive patients with IBD required hospitalization. All of the control patients experienced diarrhea; however, no hematochezia was noted and no hospitalization was required. Several patients with IBD and controls remained positive for norovirus months after the initial positive stool and/or rectal swab sample. The virus appeared to be more common during winter months. Conclusions:We conclude that norovirus may be associated with exacerbations of IBD. When norovirus accompanies IBD it is more likely to be associated with hematochezia than when the infection occurs in the absence of IBD.

Viral gastroenteritis in Charleston, West Virginia, in 2007: from birth to 99 years of age.

OBJECTIVE To describe factors associated with a rectal swab or stool sample positive for norovirus, rotavirus, or adenovirus. DESIGN Retrospective study. SETTING Charleston Area Medical Center, a regional academic medical center in Charleston, West Virginia. METHODS Rectal swab or stool samples were obtained from patients suspected of having viral gastroenteritis. These samples were sent to the Charleston Area Medical Center virology laboratory for testing in 2007. Viral antigen in rectal swab and stool samples is detected by use of commercially available immunoassay kits for each virus. Data were extracted from the virology laboratory database for the following 1-year time period: January 1, 2007, through December 31, 2007. When necessary, additional information was obtained from electronic administrative data on patients. RESULTS There were 2,867 rectal swab and stool samples available for viral testing. Of these samples, 1,261 (44%) were positive for a virus. Of these positive samples, 972 (77%) were positive for norovirus, 182 (14%) were positive for rotavirus, and 110 (9%) were positive for adenovirus. The patients in the youngest age group had the highest number of test results positive for all 3 viruses. When the test results for the youngest age group (0-9 years) were compared with those for all the other age groups combined (10-99 years), the proportion of positive cases was highest for the youngest age group (P<.001). There were significant seasonal trends for all 3 viruses. Multivariate analysis of norovirus showed that season, source, sex, and age were significant predictors of a positive test result. Multivariate analysis of rotavirus showed that season and source were significant predictors of a positive test result. Multivariate analysis of adenovirus showed that season and age were significant predictors of a positive test result. CONCLUSIONS We conclude (1) that these 3 viruses are common causes of gastroenteritis in Charleston, West Virginia; (2) that infants and young children are more likely to test positive for these viruses than are older individuals; (3) that norovirus was the most common cause of gastroenteritis; and (4) that there are seasonal trends for all 3 viruses.

An approach to identify rural women aged 60 to 64 for osteoporosis treatment.

Objectives The US Preventive Services Task Force recently recommended that women younger than 65 years undergo a bone mineral density screening if clinical risk factors (CRFs) of a major osteoporotic fracture are ≥9.3% for a period of 10 years. We sought the most cost-effective approach to identify older, rural women who are eligible for osteoporosis treatment. Methods We evaluated CRFs and peripheral forearm densitometry (pDXA) in 277 rural women aged 60 to 64 years for treatment eligibility. We compared three strategies of universal screening—pDXA, CRFs, and exclusion of pDXA in specific situations (prior fracture and CRFs ≥20%)—followed by CRF evaluation with pDXA confirmation in the residual population. Results Our sample showed that 37.5% of women had CRFs at a ≥9.3% cutoff threshold. Only osteoporotic pDXA values were significantly higher at this threshold. Current estrogen use was significantly associated with diminished treatment eligibility (P = 0.001). Body mass index correlated poorly with pDXA values (r = 0.12) and CRFs (r = 0.21). Although a cost-savings strategy nonsignificantly identified more women who were eligible for treatment using the three strategies (P = 0.25), significantly fewer pDXA examinations were required (P < 0.001). Conclusions Initiating treatment in rural women aged 60 to 64 years who had a prior fracture or CRFs ≥20% without pDXA confirmation, followed by pDXA evaluations in the residual population with CRFs between ≥9.3% and 20%, significantly reduced the number of pDXA examinations and the cost of screening.

Changes in Nonosteoporotic Bone Density and Subsequent Fractures in Women.

Objectives Osteopenia is considerably more common than osteoporosis and accounts for most of the fracture burden in women older than 50 years. It is uncertain when to initiate treatment in osteopenia. We sought to determine in women with osteopenia what effect transitioning to lower categories had on subsequent fracturing. Methods We surveyed 1150 women from office-based practices who had initial normal or osteopenic bone mineral densities (BMDs) and who were retested after 5.75 years. We classified categories related to baseline T scores as follows: normal (>−1.0), mild osteopenia (−1.0 to −1.49), moderate osteopenia (−1.5 to −1.99), and severe osteopenia (−2.0 to −2.49). We determined during a 9.6-year follow-up period the fracture occurrence in those who maintained their initial category status or transitioned into lower categories. Results Transitioning to lower categories was not significantly different among baseline osteopenic categories but significantly more than normal baseline BMDs. Total fractures, individuals fracturing, and major fractures were significantly more, with baseline T scores of ⩽−1.5 (<0.001). Although only 10.2% transitioned to osteoporosis, 90.5% of these transitions occurred with baseline T scores ⩽−1.5 and accounted for significantly more fractures than baseline T scores of >−1.5. Conclusions Most subsequent fractures and transitions to osteoporosis occurred with baseline T scores ⩽−1.5. Clinical risk factors need to be used to determine at what T score threshold treatment would be cost effective.

Significance of high- and low-distal energy forearm fractures.

Objective To determine in men and women aged 50 years or older the proportion of distal forearm fractures related to high- or low-energy events and subsequent fracturing. Methods We reviewed records of patients presenting to emergency departments and urgent care facilities with distal forearm fractures occurring during a 7-year entry period and studied for an additional 3.5 years. Results High-energy events proportionally were 3.25 times more likely in men, whereas low-energy distal forearm fractures proportionally were 7.98 times more likely in women. Although 25% received bone densitometry evaluations, only 3.59% were performed within the first year after a distal forearm fracture. Osteoporosis and osteopenia did not differ between high- and low-energy distal forearm fractures. In logistic regression, subsequent fractures were associated with prior fracture and age 80 years or older. The occurrence of individuals subsequently fracturing was similar in men and women. Compared with controls, the odds ratio of individuals subsequently fracturing was 1.74 (95% confidence interval 1.32–2.30) in women and 1.9 (95% confidence interval 1.07–3.43) in men. Approximately 60% of total subsequent fractures occurred within 3 years. Osteoporosis was significantly more in patients with distal forearm fractures than controls (P < 0.001), but control patients had significantly more osteopenia (P < 0.001). No differences were noted in therapeutic intervention between those with prior distal forearm fractures and controls. Conclusions Regardless of trauma occurrence, both men and women age 50 years and older with recent distal forearm fractures should be evaluated early for treatment by bone densitometry and clinical risk factors because the majority of recurrent fractures occur within 3 years.

A study of in-patient oncology satisfaction.

205 Background: The European Organization for Research and Treatment in Cancer (EORTC) developed the EORTC-IN-PATSAT32 survey for in-patient satisfaction (use permission granted). METHODS The EORTC-IN-PATSAT32 survey administered after consent, at discharge on an oncology floor at a large university affiliated community hospital. Comparisons were made to Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), which were collected during the same time period. RESULTS The average age of those completing the 282 surveys was 60.2 ± 12.3. Males made up 50.2% of the population, 96% were Caucasian, 66% were married, and 49% had a high school education or less, 4% were enrolled in a clinical trial and 75% had researched illness on the internet. Physicians and nurses were ranked highest for there technical skill 90 ±16 and 87±17, respectively and lowest for their availability, 85±2 and 81±24, respectively. The services and care organization was ranked highest for other hospital staff interpersonal skills, 80±20 and lowest for hospital access, 70±25. Even though 87% of the population ranked there overall stay as very good or excellent there were differences seen between groups. Males were more satisfied with the information they received about care (p = 0.04), and their overall hospital stay (p = 0.03) than females. Patients treated by a medical oncologist were more satisfied with the information the received (p = 0.03) compared to other specialties. Married patients found access to facilities was better (p = 0.03) than unmarried patients. Those ≥ 65 were more satisfied with the exams, interest, and comfort of the nursing staff (p =.03) than their younger counterparts. HCAHPS (always rank) was higher than EORTC (excellent rank) for information (p <.0001), personnel listening ( p < 0.0001), and hospital cleanliness (p = 0.008), however no difference was seen in overall rating of care (p = 0.45). CONCLUSIONS The majority of patients were satisfied with their care. Patients gender, marital status, age and the specialty of the physician were significant factors in determining satisfaction. Survey administration differences may contribute to difference between EORTC and HCAHPS. Hospital staff need to be cognizant of possible unintended bias towards various groups of patients.