Daisha J. Cipher

Angiographic Success and Procedural Complications in Patients Undergoing Percutaneous Coronary Chronic Total Occlusion Interventions : A Weighted Meta-Analysis of 18,061 Patients From 65 Studies

OBJECTIVES This study sought to perform a weighted meta-analysis of the complication risk during chronic total occlusion (CTO) percutaneous coronary intervention (PCI). BACKGROUND The safety profile of CTO PCI has received limited study. METHODS We conducted a meta-analysis of 65 studies published between 2000 and 2011 reporting procedural complications of CTO PCI. Data on the frequency of death, emergent coronary artery bypass graft surgery, stroke, myocardial infarction, perforation, tamponade, stent thrombosis, major vascular or bleeding events, contrast nephropathy, and radiation skin injury were collected. RESULTS A total of 65 studies with 18,061 patients and 18,941 target CTO vessels were included. Pooled estimates of outcomes were as follows: angiographic success 77% (95% confidence interval [CI]: 74.3% to 79.6%); death 0.2% (95% CI: 0.1% to 0.3%); emergent coronary artery bypass graft surgery 0.1% (95% CI: 0.0% to 0.2%); stroke <0.01% (95% CI: 0.0% to 0.1%); myocardial infarction 2.5% (95% CI: 1.9% to 3.0%); Q-wave myocardial infarction 0.2% (95% CI: 0.1% to 0.3%); coronary perforation 2.9% (95% CI: 2.2% to 3.6%); tamponade 0.3% (95% CI: 0.2% to 0.5%); and contrast nephropathy 3.8% (95% CI: 2.4% to 5.3%). Compared with successful procedures, unsuccessful procedures had higher rates of death (0.42% vs. 1.54%, p < 0.0001), perforation (3.65% vs. 10.70%, p < 0.0001), and tamponade (0% vs. 1.65%, p < 0.0001). Among 886 lesions treated with the retrograde approach, success rate was 79.8% with no deaths and low rates of emergent coronary artery bypass graft surgery (0.17%) and tamponade (1.2%). CONCLUSIONS CTO PCI carries low risk for procedural complications despite high success rates.

Duration of the interval between the completion of bowel preparation and the start of colonoscopy predicts bowel- preparation quality

BACKGROUND Recent studies suggest that colonoscopies done in the morning have better-quality bowel preparations than those done in the afternoon. OBJECTIVE We aimed to determine how the duration of the interval between the end of the preparation and the start of the colonoscopy affects preparation quality. DESIGN We prospectively studied consecutive outpatients who had colonoscopies performed at our hospital within a 3-month period. The time of day when the colonoscopy started and the time interval from the last dose of preparation agent to the start of the colonoscopy were recorded. The endoscopist graded the quality of the preparation in the right side of the colon by using a 5-point visual scale. PATIENTS We studied 378 patients (96% men, mean age 62.2 years) who received preparations of polyethylene glycol electrolyte-based (PEG) and sodium phosphate (SP) solution (71%), oral PEG and magnesium citrate (23%), or SP alone (6%). RESULTS Compared with patients whose preparations were graded as 2/3/4 (fair/poor/inadequate), those whose preparations were graded as 0/1 (excellent/good) had a significantly shorter interval between the time of the last preparation agent dose and the start of the colonoscopy (P = .013). LIMITATIONS We used a nonvalidated scale to assess the quality of bowel preparation. CONCLUSIONS Bowel-preparation quality varies inversely with the duration of the interval between the last dose of the bowel-preparation agent and the start of colonoscopy. This interval appears to be a better predictor of bowel-preparation quality than the time of day when colonoscopy is performed.

The impact of surgical site infection on the development of incisional hernia and small bowel obstruction in colorectal surgery

INTRODUCTION The purpose of this study was to evaluate the long-term complications of surgical site infection (SSI) in the colorectal population, specifically its association with incisional hernia and small bowel obstruction. METHODS Using standardized definitions of SSI, a retrospective review of patients undergoing transabdominal colorectal surgery from January 2002 to December 2005 was performed. Primary outcomes included incisional hernia and small bowel obstruction in patients with SSIs. RESULTS A total of 443 patients were analyzed. The median surgical follow-up was 12 months (2-3,091 days). Infections were identified in 101 (23%) cases. There were 99 cases (22%) of incisional hernia and 32 cases (7%) of small bowel obstruction. Logistic regression revealed SSI to be independently associated with incisional hernia after adjusting for clinical covariates (adjusted odds ratio = 2.23, P = .003; 95% confidence interval, 1.3-3.8). Patients with incisional hernia were 1.9 times more likely to have had an SSI (36.3% vs 18.8%, P ≤ .01). They required a longer operative time (224 minutes vs 198 minutes, P = .03), had an increased body mass index (29.0 vs 26.8, P ≤ .01), and had increased estimated blood loss (363 vs 289, mL, P = .03). Small bowel obstruction was significantly associated with operations involving the rectum (11.5% in operations involving the rectum vs 5.9% in nonrectal operations, P = .05), increased estimated blood loss (409 ml vs 297 ml, P = .04), and red blood cell transfusion (15.5% with transfusion vs 5.7% without, P = .01). SSI was not an independent predictor of small bowel obstruction (adjusted odds ratio = 1.05, P = .91; 95% confidence interval, .45-2.5). CONCLUSIONS Patients with an SSI were 1.9 times more likely to have an incisional hernia than those without an SSI. An SSI after colorectal surgery was a risk factor for the development of incisional hernia but was not a risk factor for small bowel obstruction in our population.

Prescribing trends by nurse practitioners and physician assistants in the United States

Purpose: As an important step in analyzing the role of nurse practitioners (NPs) and physician assistants (PAs), we examined their prescribing behavior. The intent is to study the characteristics of providers and patients, and the type of prescriptions written by NPs and PAs in primary care and to compare these activities to physicians. Data sources: The National Ambulatory Medical Care Survey (NAMCS) database was examined for prescriptions written by primary care clinicians (family and general medicine, internal medicine, and general pediatrics). A representative sample of 88,346 primary care visits over a 6‐year period (1997–2002) was analyzed in which a prescription was written by an NP, a PA, or a physician in an urban or rural setting. Conclusions: The characteristics of all the patients seen were similar for geographical region of visit, age, and gender, but differed by ethnicity and race. An NP or a PA was the provider of record for 5% of the primary care visits in the NAMCS database. The three clinician types were likely to write at least one prescription for 70% of all visits, and the mean number of prescriptions was 1.3–1.5 per visit (range 0–5) depending on the provider. PAs were more likely to prescribe a controlled substance for a visit than a physician or an NP (19.5%, 12.4%, 10.9%, respectively). Only in nonmetropolitan settings did differences emerge. In rural areas, NPs wrote significantly more prescriptions than physicians and PAs. Implications for practice: We suggest that NPs and PAs may provide a role that is similar to that of physicians in primary care based on prescribing behavior. The prescribing behavior of PAs and NPs parallels that of physicians by the number of medications per visit, the types of therapeutic classes, and the type of patient. However, in nonmetropolitan areas, prescribing differences emerge between the three types of providers that bear further exploration.

Association of Acute Gastroesophageal Reflux Disease With Esophageal Histologic Changes

IMPORTANCE The histologic changes associated with acute gastroesophageal reflux disease (GERD) have not been studied prospectively in humans. Recent studies in animals have challenged the traditional notion that reflux esophagitis develops when esophageal surface epithelial cells are exposed to lethal chemical injury from refluxed acid. OBJECTIVE To evaluate histologic features of esophageal inflammation in acute GERD to study its pathogenesis. DESIGN, SETTING, AND PARTICIPANTS Patients from the Dallas Veterans Affairs Medical Center who had reflux esophagitis successfully treated with proton pump inhibitors (PPIs) began 24-hour esophageal pH and impedance monitoring and esophagoscopy (including confocal laser endomicroscopy [CLE]) with biopsies from noneroded areas of distal esophagus at baseline (taking PPIs) and at 1 week and 2 weeks after stopping the PPI medication. Enrollment began May 2013 and follow-up ended July 2015. INTERVENTIONS PPIs stopped for 2 weeks. MAIN OUTCOMES AND MEASURES Twelve patients (men, 11; mean age, 57.6 year [SD, 13.1]) completed the study. Primary outcome was change in esophageal inflammation 2 weeks after stopping the PPI medication, determined by comparing lymphocyte, eosinophil, and neutrophil infiltrates (each scored on a 0-3 scale) in esophageal biopsies. Also evaluated were changes in epithelial basal cell and papillary hyperplasia, surface erosions, intercellular space width, endoscopic grade of esophagitis, esophageal acid exposure, and mucosal impedance (an index of mucosal integrity). RESULTS At 1 week and 2 weeks after discontinuation of PPIs, biopsies showed significant increases in intraepithelial lymphocytes, which were predominantly T cells (median [range]: 0 (0-2) at baseline vs 1 (1-2) at both 1 week [P = .005] and 2 weeks [P = .002]); neutrophils and eosinophils were few or absent. Biopsies also showed widening of intercellular spaces (confirmed by CLE), and basal cell and papillary hyperplasia developed without surface erosions. Two weeks after stopping the PPI medication, esophageal acid exposure increased (median: 1.2% at baseline to 17.8% at 2 weeks; Δ, 16.2% [95% CI, 4.4%-26.5%], P = .005), mucosal impedance decreased (mean: 2671.3 Ω at baseline to 1508.4 Ω at 2 weeks; Δ, 1162.9 Ω [95% CI, 629.9-1695.9], P = .001), and all patients had evidence of esophagitis. CONCLUSIONS AND RELEVANCE In this preliminary study of 12 patients with severe reflux esophagitis successfully treated with PPI therapy, stopping PPI medication was associated with T lymphocyte-predominant esophageal inflammation and basal cell and papillary hyperplasia without loss of surface cells. If replicated, these findings suggest that the pathogenesis of reflux esophagitis may be cytokine-mediated rather than the result of chemical injury. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01733810.

Periprocedural Myocardial Injury in Chronic Total Occlusion Percutaneous Interventions: a Systematic Cardiac Biomarker Evaluation Study

OBJECTIVES This study sought to evaluate the incidence, correlates, and clinical implications of periprocedural myocardial injury (PMI) during percutaneous coronary intervention (PCI) of chronic total occlusions (CTO). BACKGROUND The risk of PMI during CTO PCI may be underestimated because systematic cardiac biomarker measurement was not performed in published studies. METHODS We retrospectively examined PMI among 325 consecutive CTO PCI performed at our institution between 2005 and 2012. Creatine kinase-myocardial band fraction and troponin were measured before PCI and 8 to 12 h and 18 to 24 h after PCI in all patients. PMI was defined as creatine kinase-myocardial band increase ≥ 3 x the upper limit of normal. Major adverse cardiac events during mid-term follow-up were evaluated. RESULTS Mean age was 64 ± 8 years. The retrograde approach was used in 26.8% of all procedures. The technical and procedural success was 77.8% and 76.6%, respectively. PMI occurred in 28 patients (8.6%, 95% confidence intervals: 5.8% to 12.2%), with symptomatic ischemia in 7 of those patients. The incidence of PMI was higher in patients treated with the retrograde than the antegrade approach (13.8% vs. 6.7%, p = 0.04). During a median follow-up of 2.3 years, compared with patients without PMI, those with PMI had a higher incidence of major adverse cardiac events (hazard ratio [HR]: 2.25, p = 0.006). Patients with only asymptomatic PMI also had a higher incidence of major adverse cardiac events on follow-up (HR: 2.26, p = 0.013). CONCLUSIONS Systematic measurement of cardiac biomarkers post-CTO PCI demonstrates that PMI occurs in 8.6% of patients, is more common with the retrograde approach, and is associated with worse subsequent clinical outcomes during mid-term follow-up.

Effectiveness of Supported Employment for Veterans With Spinal Cord Injuries: Results From a Randomized Multisite Study

OBJECTIVE To examine whether supported employment (SE) is more effective than treatment as usual (TAU) in returning veterans to competitive employment after spinal cord injury (SCI). DESIGN Prospective, randomized, controlled, multisite trial of SE versus TAU for vocational issues with 12 months of follow-up data. SETTING SCI centers in the Veterans Health Administration. PARTICIPANTS Subjects (N=201) were enrolled and completed baseline interviews. In interventional sites, subjects were randomly assigned to the SE condition (n=81) or the TAU condition (treatment as usual-interventional site [TAU-IS], n=76). In observational sites where the SE program was not available, 44 subjects were enrolled in a nonrandomized TAU condition (treatment as usual-observational site [TAU-OS]). INTERVENTIONS The intervention consisted of an SE vocational rehabilitation program called the Spinal Cord Injury Vocational Integration Program, which adhered as closely as possible to principles of SE as developed and described in the individual placement and support model of SE for persons with mental illness. MAIN OUTCOME MEASURES The primary study outcome measurement was competitive employment in the community. RESULTS Subjects in the SE group were 2.5 times more likely than the TAU-IS group and 11.4 times more likely than the TAU-OS group to obtain competitive employment. CONCLUSIONS To the best of our knowledge, this is the first and only controlled study of a specific vocational rehabilitation program to report improved employment outcomes for persons with SCI. SE, a well-prescribed method of integrated vocational care, was superior to usual practices in improving employment outcomes for veterans with SCI.

Clinical Utility of the Japan–Chronic Total Occlusion Score in Coronary Chronic Total Occlusion Interventions Results from a Multicenter Registry

Background—The performance of the Japan–chronic total occlusion (J-CTO) score in predicting success and efficiency of CTO percutaneous coronary intervention has received limited study. Methods and Results—We examined the records of 650 consecutive patients who underwent CTO percutaneous coronary intervention between 2011 and 2014 at 6 experienced centers in the United States. Six hundred and fifty-seven lesions were classified as easy (J-CTO=0), intermediate (J-CTO=1), difficult (J-CTO=2), and very difficult (J-CTO≥3). The impact of the J-CTO score on technical success and procedure time was evaluated with univariable logistic and linear regression, respectively. The performance of the logistic regression model was assessed with the Hosmer–Lemeshow statistic and receiver operator characteristic curves. Antegrade wiring techniques were used more frequently in easy lesions (97%) than very difficult lesions (58%), whereas the retrograde approach became more frequent with increased lesion difficulty (41% for very difficult lesions versus 13% for easy lesions). The logistic regression model for technical success demonstrated satisfactory calibration and discrimination (P for Hosmer–Lemeshow =0.743 and area under curve =0.705). The J-CTO score was associated with a 2-fold increase in the odds of technical failure (odds ratio 2.04, 95% confidence interval 1.52–2.80, P<0.001). Procedure time increased by ≈20 minutes for every 1-point increase of the J-CTO score (regression coefficient 22.33, 95% confidence interval 17.45–27.22, P<0.001). Conclusions—J-CTO score was strongly associated with final success and efficiency in this study, supporting its expanded use in CTO interventions. Clinical Trial Registration—URL: http://www.clinicaltrials.gov. Unique identifier: NCT02061436.

Cardiovascular Outcomes in Male Veterans With Rheumatoid Arthritis

In men with rheumatoid arthritis (RA), the confounding effect of adverse cardiovascular risk profile on the independent association of RA disease activity score (DAS) and major adverse cardiovascular events (MACEs) continues to be debated. The aim was to analyze the association of RA DAS with MACEs in a prospective cohort of men with RA enrolled in the VARA Registry at the Dallas site from January 2003 to October 2006. All subjects met American College of Rheumatology criteria for RA. All events were obtained by reviewing patient clinical data. DAS was categorized as low, 0 to 3.2; moderate, 3.2 to 5.09; and high, > or =5.1. Of 282 men (mean age 66 +/- 11.1 years), 231 had valid DASs (150, low; 60, moderate; and 21, high DAS) and were followed up for 4.4 +/- 2 years. Ninety-two subjects (32.6%; 95% confidence interval 27 to 38) experienced an MACE, a composite end point of death (9 patients; 10%), acute coronary syndrome (38 patients; 42%), coronary revascularization (47 patients; 49%), new-onset heart failure (37 patients; 40%), and stroke (15 patients; 16%). DAS was a significant predictor of MACEs (hazard ratio 1.31, 95% confidence interval 1.1 to 1.6, p = 0.01) independent of traditional risk factors. Compared with patients with low or moderate DASs, patients with high DASs had a lower mean event-free period (35 and 30 vs 19 years, respectively; p = 0.03). In conclusion, in a population of male US veterans aged >50 years, (1) patients with RA were at high risk of MACEs, and (2) RA DAS was a significant predictor of MACEs independent of traditional cardiovascular risk factors.

Emergency medicine services: Interprofessional care trends

To understand trends in emergency medicine and interprofessional roles in delivering this care, we analyzed a 10-year period (1995 – 2004) by provider, patient characteristics, and diagnoses. The focus was on how doctors, physician assistants (PAs) and nurse practitioners (NPs) share emergency medicine visits. The National Hospital Ambulatory Medical Care Survey of over 1 billion “weighted” emergency room visits for 1995 to 2004 was analyzed. The majority of patients were female (53.2%); the mean age of all patients was 35.3 years old. By 2004, physicians were the provider of record for emergency visits at 92.6%, with PAs at 5.7% and NPs at 1.7%. Emergency visits increased for all three providers over the ten years with PA growth doubling during this same period. Medications were prescribed for three-quarters of the visits and were consistent in the mean number of prescriptions written across the three prescribers. No significant differences emerged when urban and rural settings were compared. Expansion of the roles and interprofessional care provided by NPs and PAs include increasing acceptance, clarification of legal and regulatory aspects of practice, shared roles, team approaches to shortages of fully-trained doctors, and the limitation of working hours of physician postgraduate trainees. The US forecast for emergency department visits is expected to outpace the growth of the population and the supply of emergency medicine providers. In view of an increasing emergency medical demand and a continuing shortage of physician personnel, policies are needed for workforce planning to meet the demand.