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ABSTRACT: What causes appendicitis is not known; however, studies have suggested a relationship between viral diseases and appendicitis. Building on evidence of cyclic patterns of appendicitis with apparent outbreaks consistent with an infectious etiology, we hypothesized that there is a relationship between population rates of appendicitis and several infectious diseases.
Epidemiologic study.
The National Hospital Discharge Survey
Estimated US hospitalized population.
International Classification of Diseases, Ninth Revision, Clinical Modification discharge diagnosis codes of the National Hospital Discharge Survey were queried from 1970 to 2006 to identify admissions for appendicitis, influenza, rotavirus, and enteric infections. Cointegration analysis of time series data was used to determine if the disease incidence trends for these various disease entities varied over time together.
Rates of influenza and nonperforating appendicitis declined progressively from the late 1970s to 1995 and rose thereafter, but influenza rates exhibited more distinct seasonal variation than appendicitis rates. Rotavirus infection showed no association with the incidence of nonperforating appendicitis. Perforating appendicitis showed a dissimilar trend to both nonperforating appendicitis and viral infection. Hospital admissions for enteric infections substantially increased over the years but were not related to appendicitis cases.
Neither influenza nor rotavirus are likely proximate causes of appendicitis given the lack of a seasonal relationship between these disease entities. However, because of significant cointegration between the annual incidence rates of influenza and nonperforated appendicitis, it is possible that these diseases share common etiologic determinates, pathogenetic mechanisms, or environmental factors that similarly affect their incidence.
Archives of surgery (Chicago, Ill.: 1960) 01/2010; 145(1):63-71. · 4.32 Impact Factor
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Jennifer Blumetti,
Myda Luu, George Sarosi,
Kathleen Hartless,
Jackie McFarlin,
Betty Parker,
Sean Dineen,
Sergio Huerta,
Massimo Asolati,
Esteban Varela,
Thomas Anthony
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ABSTRACT: The purpose of this study was to compare risk factors for the development of incisional versus organ/space infections in patients undergoing colorectal surgery.
An institutional review board-approved retrospective review was performed examining a 4-year period (January 2002 to December 2005). Patients were included if they had undergone abdominal operations (open or laparoscopic) in which the colon/rectum was surgically manipulated. Patients were excluded if the surgical wound was not closed primarily. A standardized definition of incisional and organ/space infection was employed.
A total of 428 operations were performed. Overall, 105 infections were identified (25%); 73 involved the incision and 32 were classified as organ/space. Multivariate analysis suggested that incisional infection was independently associated with body mass index (odds ratio [OR], 1.07; 95% confidence interval [CI], 1.02-1.11) and creation/revision/reversal of an ostomy (OR, 2.2; 95% CI, 1.3-3.9). Organ/space infection was independently associated with perioperative transfusion (OR, 2.3; 95% CI, 1.1-5.5) and with previous abdominal surgery (OR, 2.5; 95% CI, 1.2-5.3).
Factors associated with infection differed based on the type of surgical site infection being considered. The lack of overlap between factors associated with incisional infection and organ/space infection suggests that separate risk models and treatment strategies should be developed.
Surgery 12/2007; 142(5):704-11. · 3.10 Impact Factor
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08/2007: pages 215-247;
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ABSTRACT: Different medical and social conditions have been associated with primary and recurrent hernias. Possible predictors of recurrence after elective umbilical hernia repair have not been defined clearly. The aim of this study was to determine factors that predict recurrence in patients after elective repair of umbilical hernias.
A 6-year retrospective review of patients with elective umbilical hernia repair at the Dallas VA Medical Center was performed. Clinical and pathologic data were evaluated by univariate analysis to identify predictive factors for recurrence.
A total of 244 patients underwent elective hernia repair within the study period (male, 96%; mean age, 56 y; Caucasian, 74%; African American, 14%; Hispanic, 8%). Because 15 patients were not compliant with follow-up requirements, 229 were eligible for the study. Ninety-seven underwent suture repair (42.4%) and 132 underwent mesh repair (57.3%). Eleven recurrences were identified (4.8%): 7 in the suture repair group (7.7%) and 4 in the mesh repair group (3%). Univariate analysis showed that patients likely to develop recurrences were as follows: African American (15.6% vs. 3.5%; P = .017), type II diabetics (14.2% vs. 2.6%; P = .002), patients with hyperlipidemia (9.2% vs. 2.6%; P = .028), and human immunodeficiency virus-positive patients (66.6% vs. 3.9%; P = .000).
Smoking, obesity, size of hernia, type of repair, or chronic obstructive pulmonary disease do not seem to predict recurrence of hernias in our VA population. African Americans, patients with type II diabetes, hyperlipidemia, and positive for human immunodeficiency virus, may have a higher risk for recurrence after elective umbilical hernia repair.
American journal of surgery 12/2006; 192(5):627-30. · 2.36 Impact Factor
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ABSTRACT: Transmetatarsal amputation (TMA) is an operation designed to remove a limited area of irremediable tissue ischemia and/or infection and preserve limb function. Patients are selected for TMA based on degree of tissue loss/infection, adequacy of tissue perfusion at the transmetatarsal level, current ambulatory status, and estimation of the likelihood of postprocedure ambulation. The purpose of this study was to assess the validity of these selection criteria.
An institutional review board-approved retrospective review was conducted of all patients undergoing TMA from January 1, 1997, until January 1, 2006. Information was collected on patient demographics, medical comorbidity, and clinical and surgical variables. Outcome measures included the proportion of patients requiring amputation revision to a more proximal level and ambulatory status at last follow-up.
Fifty-two TMAs were performed. In 35 procedures, the skin was left open, and in 17 TMA was closed primarily. Primary indications for the procedure were vascular insufficiency or infection in 50 of 52 patients, whereas 2 patients required amputation for malignancy. The majority (46/52, 89%) of patients were diabetic. After the index TMA, 85 additional operations were required. Only 9 patients (18%) underwent a single operation. Revision of the TMA to a more proximal level was required in 29 of 52 (56%) patients, resulting in 4 Syme, 20 transtibial, and 5 transfemoral amputations. Non-insulin-dependent diabetes was associated with an increased likelihood of revision to a more proximal amputation (odds ratio [OR] = 5.4; 95% confidence interval [CI], 1.2-24). At the time of last follow-up (median 18 months), 37 of 50 (74%) patients were ambulatory (83% for TMAs and 67% for more proximal amputations, P = 0.18). Prior vascular procedures were associated with a significantly decreased likelihood of ambulation (OR = 14; 95% CI, 1.9-103).
Although most patients retain the ability to ambulate after TMA, multiple operations should be anticipated in the majority of patients and revision of a TMA to a more proximal level may be required. These data suggest that current selection criteria for TMA may be inadequate.
American journal of surgery 12/2006; 192(5):e8-11. · 2.36 Impact Factor
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ABSTRACT: The incidence of complications after reversal of Hartmann's procedure is unknown. This study compares the morbidity of Hartmann's reversal versus loop ileostomy reversal.
Two groups of 20 patients were studied retrospectively over a 5-year period. One group underwent Hartmann's takedown, and the other underwent loop ileostomy takedown. Postoperative complications were compared between the 2 groups.
Similar demographics were noted between each group. The most common initial indications for Hartmann's procedure were diverticulosis (11 patients, 55%) and colon cancer (4 patients, 20%). For patients who had undergone colectomy with primary anastomosis and ileostomy, colon cancer was the most common indication (12 patients, 60%) followed by diverticulosis (3 patients, 15%). Complications were more common after Hartmann reversal than loop ileostomy reversal (16 complications/11 patients versus 6 complications/4 patients, P = .047).
Segmental colonic excision with anastomosis and loop ileostomy may be an attractive alternative to minimize morbidity with stoma reversal.
The American Journal of Surgery 12/2005; 190(5):717-20. · 2.78 Impact Factor
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ABSTRACT: Vascular endothelial activation is an early step during leukocyte/endothelial adhesion and transendothelial leukocyte migration in inflammatory states. Leukocyte transmigration occurs through intercellular gaps between endothelial cells. Vascular endothelial cadherin (VE-cadherin) is a predominant component of endothelial adherens junctions that regulates intercellular gap formation. We found that tumor necrosis factor (TNF) caused tyrosine phosphorylation of VE-cadherin, separation of lateral cell-cell junctions, and intercellular gap formation in human umbilical vein endothelial cell (HUVEC) monolayers. These events appear to be regulated by intracellular oxidant production through endothelial NAD(P)H (nicotinamide adenine dinucleotide phosphate) oxidase because antioxidants and expression of a transdominant inhibitor of the NADPH oxidase, p67(V204A), effectively blocked the effects of TNF on all 3 parameters of junctional integrity. Antioxidants and p67(V204A) also decreased TNF-induced JNK activation. Dominant-negative JNK abrogated VE-cadherin phosphorylation and junctional separation, suggesting a downstream role for JNK. Finally, adenoviral delivery of the kinase dead PAK1(K298A) decreased TNF-induced JNK activation, VE-cadherin phosphorylation, and lateral junctional separation, consistent with the proposed involvement of PAK1 upstream of the NADPH oxidase. Thus, PAK-1 acts in concert with oxidase during TNF-induced oxidant production and loss of endothelial cell junctional integrity.
Blood 12/2004; 104(10):3214-20. · 9.90 Impact Factor
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ABSTRACT: Many patients with rheumatoid arthritis are being treated with immunosuppressive regimens that include an agent directed at blocking tumor necrosis factor (TNF)-alpha. Although reportedly safe, tuberculous and fungal infections have emerged as significant complications of therapy. We report a case of pulmonary cryptococcosis soon after the initiation of therapy with the anti-TNF-alpha antibody, infliximab. A diagnosis was made early in the disease course, and the patient responded quickly to antifungal therapy. This case should alert clinicians to the increased incidence of pulmonary mycoses in patients receiving anti-TNF-alpha therapy.
Chest 01/2004; 124(6):2395-7. · 5.25 Impact Factor
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ABSTRACT: The purpose of this study was to define the association between pretreatment health-related quality of life (HRQL) and surgical complications for patients with colorectal cancer.
For patients with colorectal cancer, surgical complications arise from an interaction between underlying medical comorbidity, colorectal cancer severity, and quality and type of treatment provided. Measurement of HRQL provides a summarization of well-being in the context of medical comorbidity and colorectal cancer severity. The summarization of these factors may be useful in prospective risk assessment of patients about to undergo surgery for colorectal cancer.
A single-institution, prospective, cohort study of patients with colorectal adenocarcinoma was performed from August 1, 1999, to March 31, 2002. Before treatment, all participants completed Medical Outcomes Survey SF-36 (SF-36); after the first year of the study, patients also completed the colorectal cancer module of the Functional Assessment of Cancer Therapy survey (FACT-C). Information was collected on demographics, treatment, tumor variables, and complications.
Ninety-seven patients have undergone open resection of their colorectal cancer. All patients completed SF-36; 65 completed FACT-C. Thirty patients (31%) experienced complications, including 4 (4%) deaths. Age, race, albumin level, American Society of Anesthesia class, specialty surgical training, tumor location, and stage were not associated with complications in univariate analysis. Patients experiencing surgical complications had significantly lower HRQL scores on SF-36 Social Functioning, General Health Perception, and Mental Health Index scales as well as the Mental Health Component summary score. FACT-C Social/Family, Emotional, Functional Well-Being scores, and the Colorectal Cancer Concerns score were also significantly lower for patients sustaining complications. When these HRQL scales were examined in a multivariate model including albumin level, tumor location, and ASA class, SF-36 Social Functioning (Odds Ratio [OR] = 0.98; 95% Confidence Interval [CI] = 0.97-0.99) and FACT-C Colorectal Cancer Concerns (OR = 0.89; 95% CI = 0.79-0.99) scales retained a significant association with complications.
Pretreatment HRQL scores as measured by several scales of SF-36 and FACT-C were significantly associated with complications. Future studies should concentrate on defining the predictive role of HRQL in determining surgical outcome for patients with colorectal cancer.
Annals of Surgery 12/2003; 238(5):690-6. · 7.49 Impact Factor
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ABSTRACT: Length of stay (LOS) after surgery is a major determinant of resource utilization for colorectal cancer (CRC). The purpose of this study was to examine the association between pretreatment health-related quality of life (HRQL) scores and postoperative hospital LOS in a cohort of patients undergoing surgery for CRC.
Seventy patients with biopsy-proven CRC were enrolled in an IRB-approved, prospective study. Information was collected concerning standard perioperative variables. Prior to surgery, all patients also completed the CRC-specific module of the Functional Assessment of Cancer Therapy (FACT-C). Perioperative variables and FACT-C scores were compared with LOS in both univariate and multivariate analysis. LOS for those patients scoring in the lowest quartile on FACT-C was compared with LOS for patients scoring in the remaining quartiles.
Median length of stay for the entire group was 6 (range 3-25) days. In univariate analysis, surgical complications (10.6 vs 6.6 days; P = 0.001) and with poorer FACT-C individual scale scores for Physical Well-Being (9.1 vs 7.3 days; P = 0.04), Functional Well-Being (9.6 vs 7.1 days; P = 0.006), and Colorectal Cancer Concerns (9.5 vs 7.1 days; P = 0.01) were all significantly associated with increased length of stay. In multivariate analysis, surgical morbidity (OR = 5.6; 95% CI 1.5-21.4), age >72 (OR = 6.0; 95% CI 1.6-23.5), and low FACT-C total score (OR = 4.2; 95% CI 1.1-15.6) were independently associated with increased LOS.
Pretreatment HRQL scores as measured by FACT-C may be of benefit in the prediction of LOS. Such information may be an important and currently neglected means of risk-adjusting populations undergoing surgery for colorectal cancer for this outcome.
Journal of Surgical Research 12/2002; 108(2):273-8. · 2.25 Impact Factor
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ABSTRACT: This study examines the hypotheses that TNF-alpha causes a dose-dependent increase in the microvascular permeability of ex vivo buffer perfused lungs that is quantitatively similar to that caused by lipopolysaccharide (LPS) or thromboxane A2 (TxA2). We also postulated that TNF-alpha potentiates the effect of interleukin-1beta (IL-1beta) or TxA2 receptor activation on pulmonary microvascular permeability. Lungs harvested from Wistar rats were perfused ex vivo with Krebs-Henseleit buffer containing 0, 10, 100, or 1000 ng/mL recombinant rat TNF-alpha. Twenty minutes later pulmonary microvascular permeability was determined by measuring the capillary filtration coefficient (Kf) using a gravimetric technique. The effect of TNF-alpha (100 ng/mL) on pulmonary Kf was compared with that of lungs exposed to LPS (400 microg/mL; E. coli 0111:B4) or a TxA2 receptor agonist (U-46619; 7 x 10(-8)). In other experiments, perfused lungs were exposed to TNF-alpha plus IL-1beta (1 ng/mL) or TNF-alpha plus U-46619 after which Kf was measured. Exposure of ex vivo buffer perfused lungs to 10-1000 ng/mL TNF-alpha had no effect on Kf whereas LPS and U-46619 was associated with a two- and six-fold increase in Kf, respectively (P < 0.05). The Kf of lungs exposed to TNF-alpha plus IL-1 was similar to that of lungs exposed to TNF-alpha alone. Lastly, the Kf of lungs exposed to TNF-alpha plus U-46619 was not different than that of lungs exposed to U-46619 alone. In conclusion, TNF-alpha at least when administered for a relatively brief period of time does not affect microvascular permeability in an isolated, buffer-perfused lung model.
Shock 07/2002; 18(1):75-81. · 2.85 Impact Factor
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ABSTRACT: The endemic mycoses are restricted geographically based on environmental and other factors that favor the growth of these organisms in the soil. Histoplasmosis and blastomycosis mostly afflict patients in the Mississippi and Ohio River Valleys whereas coccidioidomycosis occurs primarily in the desert southwest United States. Cryptococcosis also may present as pulmonary disease, particularly in persons with cellular immune impairment. These mycoses are increasing in importance as causes for opportunistic disease in immunocompromised patients, especially those with acquired immune deficiency syndrome (AIDS). Aspergillus is a common cause of serious invasive fungal infection in granulocytopenic patients, and may cause lung infection in persons with preexisting pulmonary diseases or atopy. Infections with less virulent fungi, such as Trichosporon, Fusarium, Alternaria, Pseudallescheria, and dematiaceous fungi, are being recognized more frequently. The lung is the portal of entry for most of these pathogens, and often is prominently involved in the clinical syndrome. This article focuses on the recognition, diagnosis, and management of these important pulmonary mycoses.
Seminars in Respiratory Infections 07/2002; 17(2):158-81.
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Journal of Gastrointestinal Surgery 10(8):1170-9. · 2.83 Impact Factor
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ABSTRACT: This systematic review examines the evidence for commonly employed strategies of managing patients with recurrent ulcer disease after acid-reducing operations. Particular attention is given to recent evidence relating Helicobacter pylori (H. pylori ) and nonsteroidal anti-inflammatory drugs (NSAIDs) to ulcer recurrence after operative therapy. MEDLINE word searches of the literature from 1966 to 2001 identified 895 articles that cross-reference the terms "peptic ulcer disease (PUD)," "surgery," and "recurrence." Articles were selected for systematic review of evidence relating incomplete vagotomy, NSAIDs, and H. pylori to postoperative ulcer recurrence and evidence supporting common medical and surgical strategies. The relationship between incomplete vagotomy and recurrent ulcer disease is suggested by randomized controlled trials and well-designed prospective case series. The evidence that NSAID use is an important pathogenic factor in recurrent ulcer disease includes the relationship between NSAIDs and primary PUD, the occurrence of NSAID-induced ulcers in patients taking proton pump inhibitors, and case series demonstrating virulent ulcer disease in patients taking aspirin despite prior acid-reducing operations. The relationship between H. pylori infection and postoperative ulcer recurrence remains uncertain despite multiple controlled trials and well-designed case series that have documented high rates of H. pylori infection in postoperative patients. The initial management of patients with recurrent ulcer disease after acid-reducing operations consists of a protein pump inhibitor or a histamine-2 receptor antagonist and antibiotics directed at H. pylori, if present. Evidence for this regimen includes prospective randomized trials demonstrating the efficacy of cimetidine in healing ulcers after acid-reducing operations and prospective, randomized studies documenting the efficacy of histamine-2 receptor antagonists and protein pump inhibitors in the management of patients with primary PUD. The critical role that H. pylori infection plays in primary PUD and the minimal risks associated with H. pylori eradication strongly support the initiation of antibiotic therapy when H. pylori is present. The principal indication for operative management of recurrent PUD is the occurrence of ulcer complications that cannot be managed by medical or endoscopic means. The operative management of patients with failed acid-reducing operations is based on ulcer recurrence rates and morbidity and mortality rates in randomized and nonrandomized prospective trials of patients with primary PUD and retrospective case series of patients undergoing remedial operative procedures after various failed acid-reducing operations.
Journal of Gastrointestinal Surgery 7(5):606-26. · 2.83 Impact Factor
