Mark W. Russo

A national survey of practice patterns of gastroenterologists with comparison to the past two decades.

Previous surveys on the practice of gastroenterology collected limited data on practice demographics. Gastroenterology practices may have changed over the past decade as a result of changes in health care delivery. The authors sought to describe the practice composition and demographics of todays gastroenterologist, and also to make comparisons to prior studies to determine whether changes have occurred. A nationwide cross-sectional survey was performed in 1997 of 900 American Gastroenterological Association (AGA) members selected randomly from the AGA directory. A total of 767 AGA members were eligible for the study, and 376 responded (response rate, 49%). The mean age was 46 years old and the mean year training was completed was 1982. The majority of gastroenterologists were in solo or group practice (57%) and in an urban setting (55%). Respondents were fairly equally represented from different regions of the country. The most common diagnosis seen was irritable bowel syndrome ([IBS] 19%), followed by esophageal reflux (17%) and inflammatory bowel disease (14%). Functional disorders as a group (IBS, nonulcer dyspepsia, and other functional disorders) were, by far, the most common disorders (35%), which is similar to findings in prior studies of gastrointestinal practices. Only 3% of gastroenterologists believed that managed care has made it easier to deliver quality health care to patients with IBS. Despite changes that have occurred in health care over the past decade, the types of diagnoses seen in gastroenterology practices has remained the same. Most gastroenterologists feel that managed care has not made it easier to deliver quality health care.

Significant pulmonary toxicity associated with interferon and ribavirin therapy for hepatitis C

OBJECTIVE:The aim of this study was to analyze the clinical presentation and outcomes of significant pulmonary toxicity associated with interferon and ribavirin.METHODS:We conducted a retrospective review of patients enrolled in four clinical trials at three sites, two academic medical centers and one community practice, and reviewed the literature.RESULTS:Four patients, while on therapy with interferon α and ribavirin for chronic hepatitis C, developed significant pulmonary signs and symptoms. Further workup, which included lung biopsy in three, revealed bronchiolitis obliterans organizing pneumonia in two, and interstitial pneumonitis in two other cases. There were no other predisposing factors for lung disease identified. Resolution of symptoms occurred in all patients upon discontinuation of interferon and ribavirin, with or without corticosteroid therapy. One of the patients developed pulmonary complications while on a clinical trial of pegylated interferon and represents the first reported case associated with the use of long-acting interferon in chronic hepatitis C infection.CONCLUSIONS:A spectrum of significant pulmonary toxicity, including bronchiolitis obliterans organizing pneumonia and interstitial pneumonitis, can occur with interferon or pegylated interferon in combination with ribavirin. Though pulmonary toxicity of interferon is well known, these cases represent the first cases reported in the literature with combination therapy. It is likely that pulmonary toxicity may not be investigated in patients on combination therapy because of the frequent pulmonary symptoms with ribavirin. Though usually reversible, at least one case has required long-term steroids with inadequate resolution. Though pulmonary toxicity is rare, symptoms which are more than mild or progressive in nature should likely be investigated.

Interferon Alpha-2b and Ribavirin for Patients with Chronic Hepatitis C and Normal ALT

OBJECTIVES:Most studies establishing the role of antiviral therapy in patients with chronic hepatitis C (CHC) excluded the patients with normal ALT levels. Small trials with interferon monotherapy suggested a limited efficacy and/or de novo ALT elevations. We sought to evaluate the efficacy of two doses of interferon alpha-2b (IFN) with ribavirin (RBV) in patients with normal ALT.METHODS:Patients with biopsy-proven CHC with detectable HCV RNA and at least two normal ALT levels three or more months apart were randomized to receive either 3 or 5 million units of IFN thrice a week plus RBV 1,000–1,200 mg. Therapy was stopped at 24 wk if HCV RNA remained detectable and continued for an additional 24 wk if HCV RNA was undetectable. A final HCV RNA level was obtained 24 wk after discontinuation of therapy.RESULTS:Fifty-six patients were randomized and received at least one dose of treatment. The overall rate of sustained virologic response (SVR) was 32%. SVR rates were higher in genotype 2 and 3 patients (80%) than in genotype 1 patients (24%, p = 0.002). There was a tendency toward higher SVR in genotype 1 patients treated with the higher IFN dose (36% vs 10%, p = 0.07). Five patients had mild, transient ALT elevations. No sustained ALT elevations were noted.CONCLUSIONS:Patients with normal ALT had a rate of SVR comparable to that reported in patients with elevated ALT. Higher dose of interferon tended to be more effective in genotype 1 infected patients. De novo ALT elevations were transient and not clinically significant. Patients with CHC should not be excluded from treatment on the basis of ALT alone. Combination therapy with pegylated interferon and ribavirin should be evaluated in these patients.

Incidence and Predictors of Pacemaker Placement After Surgical Ablation for Atrial Fibrillation

BACKGROUNDnBradyarrhythmia requiring pacemaker placement is a relatively common complication after surgical ablation for atrial fibrillation (AF). We report our experience with surgical ablation procedures using various energy modalities and lesion sets in an attempt to identify the risk factors associated with postoperative pacemaker requirement.nnnMETHODSnIntraoperative data were collected prospectively, and preoperative and postoperative data were collected retrospectively. Energy modality and lesion sets used were dependent on availability on the date of the procedure and surgeon preference.nnnRESULTSnFrom October 1999 to October 2009, 701 patients underwent surgical ablation for AF at our institution. Forty-five patients (7.6%) required early postoperative pacemaker placement. There were no significant differences in baseline characteristics or associated procedures between patients who required pacemaker placement and those who did not. Ninety-day mortality was greater in patients requiring pacemaker placement (15.6% versus 6.6%; p = 0.025). In multivariable analysis, a pacemaker requirement was more likely with the use of microwave energy (odds ratio [OR] 2.87; confidence interval [CI], 1.41 to 5.84; p = 0.004) and a right atrial lesion set (OR, 2.82; CI, 1.07 to 7.45; p = 0.036).nnnCONCLUSIONSnIn conclusion, over our 10-year experience with surgical AF ablations, the incidence of pacemaker requirement was much lower than that reported in series of classic cut and sew Maze procedures, even among patients undergoing full biatrial ablations. Although biatrial ablation is currently our favored approach to patients with long-standing or persistent AF, right atrial lesion sets increase the risk of this complication and should be used judiciously.

Use of carotid-subclavian arterial bypass and thoracic endovascular aortic repair to minimize cerebral ischemia in total aortic arch reconstruction.

OBJECTIVEnTotal aortic arch replacement typically requires hypothermic circulatory arrest, carrying risks of cerebral ischemia. We recently introduced left carotid-subclavian bypass before total aortic arch replacement with thoracic stent grafting to achieve hybrid arch reconstruction with short periods of selective antegrade cerebral perfusion.nnnMETHODSnFrom 2004 to 2009, 332 patients underwent ascending aorta or arch replacements. Of these, 37 underwent total aortic arch replacement. In 2008, we began performing left carotid-subclavian bypass before subtotal arch replacement, with side-graft anastomoses to innominate and left carotid arteries. Patients then underwent aortic graft stent deployment to complete arch reconstruction. Twenty-eight patients underwent conventional arch replacement (group I); 9 underwent hybrid arch replacement (group II).nnnRESULTSnSelective antegrade cerebral perfusion time in group I was 33.3 +/- 13.7 minutes versus 18.9 +/- 9.2 minutes in group II (P = .007). Among group I patients, 82% required hypothermic circulatory arrest (vs 0% in group II, P < .001). Mean cardiopulmonary bypass and aortic crossclamp times were longer in group I than group II (P < .05). Incidence of neurologic complications was 14% in group I (4/28) versus 0% (0/9) in group II, although this finding did not reach statistical significance (P = .55).nnnCONCLUSIONSnLeft carotid-subclavian bypass before arch replacement with staged thoracic stent grafting to achieve hybrid arch reconstruction was associated with decreased selective antegrade cerebral perfusion, cardiopulmonary bypass, and aortic crossclamp times and eliminated hypothermic circulatory arrest. This technique may minimize neurologic complications associated with arch replacement and provide a viable hybrid approach to patients with arch aneurysms and dissections.