Evaluation of the frequency and factors predictive of hernia incarceration following transjugular intrahepatic portosystemic shunt placement

AIM

To examine the frequency and predictive factors for bowel incarceration following transjugular intrahepatic portosystemic shunts (TIPS) placement to treat refractory cirrhosis-induced ascites.

MATERIALS AND METHODS

Ninety-nine patients with known hernias at the time of TIPS placement were identified. Their electronic medical records were reviewed and pertinent pre-procedural, procedural, and outcome variables were recorded. Patients were divided between those that suffered incarceration (study group) and a control group of those with a hernia who did not suffer incarceration.

RESULTS

Twelve of the 99 patients (12.1%) suffered hernia incarceration, of which seven (7.1%) suffered incarceration in the first 90 days. One patient who suffered incarceration ultimately died from complications of the incarceration. When comparing all patients who suffered incarceration to controls, incarceration patients were found to have significantly higher albumin levels (mean 3.13 versus 2.73, p=0.02). When just considering those who had incarcerations in the first 90 days to controls, incarceration patients were less likely to have improvement in their ascites (p=0.04).

CONCLUSIONS

Incarcerated hernias occur frequently after TIPS placement and can lead to significant morbidity and mortality. Clinicians should be aware of this complication and counsel patients on presenting symptoms prior to placement.

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

Mutational and biochemical findings in adults with persistent hypophosphatasemia

A majority of adults with persistently low serum alkaline phosphatase values carry a pathogenic or likely pathogenic variant in the ALPL gene and also have elevated alkaline phosphatase substrate values in serum and urine. These adults may fall within the spectrum of the adult form of hypophosphatasia.

INTRODUCTION

The primary objective of this study was to determine what proportion of adults with persistently low serum alkaline phosphatase values (hypophosphatasemia) harbor mutations in the ALPL gene or have elevated alkaline phosphatase (ALP) substrates. Some adults with persistent hypophosphatasemia share clinical and radiographic features with the adult form of hypophosphatasia (HPP). In HPP, ALPL mutations result in persistent hypophosphatasemia and ALP substrate accumulation in plasma (pyridoxal-5-phosphate (PLP)) and urine (phosphoethanolamine (PEA)).

METHODS

Biochemical analyses, including serum ALP activity, bone-specific ALP, plasma PLP, and urine PEA, were performed in adults with persistent hypophosphatasemia. Mutational analyses were performed using PCR and Sanger sequencing methods. Gene variants were classified as pathogenic (P), likely pathogenic (LP), variants of uncertain significance (VUS), likely benign (LB), and benign (B). P and LP variants were further grouped as "Positive ALPL variants" and LB and B grouped as "Negative ALPL variants."

RESULTS

Fifty subjects completed all mutational and biochemical analyses. Sixteen percent carried only Negative ALPL variants. Of the remaining 42 subjects, 67% were heterozygous for a P variant, 19% for an LP variant, and 14% for a VUS. Biochemical results were highly inter-correlated and consistent with the expected inverse relationship between ALP and its substrates. Subjects harboring Positive ALPL variants showed lower ALP and BSAP and higher PLP and PEA values compared with subjects harboring only Negative ALPL variants. Approximately half of all subjects harboring Positive ALPL variants or ALPL VUS showed elevations in plasma PLP, and three quarters showed elevations in urine PEA.

CONCLUSION

Adults with persistent hypophosphatasemia frequently harbor ALPL mutations and have elevated ALP substrates. These adults may fall within the spectrum of the adult form of hypophosphatasia. Clinicians should take note of persistent hypophosphatasemia in their patients and be cautious in prescribing bisphosphonates when present.

Clinical manifestations of obstructive sleep apnoea in pregnancy: more than snoring and witnessed apnoeas

Sleep disordered breathing and its symptoms have been associated with a multitude of fetal and maternal complications including gestational hypertensive disorders, gestational diabetes and possibly pre-term labour and other markers of alterations in fetal wellbeing. The disease remains underdiagnosed in the general population but likely also in pregnancy, mostly because providers do not appropriately screen for the disorder. Sleep disordered breathing may manifest differently in women, since women report more fatigue and less snoring than men do. This paper discusses typical presentations of sleep disordered breathing but also reports some less obvious presentations to help providers recognise those manifestations and screen for the disorder when warranted. Our case series describes patients with diagnoses such as chronic hypertension, pre-eclampsia, pulmonary hypertension, nocturnal asthma and panic attacks, who were diagnosed with sleep disordered breathing and offered treatment with CPAP during pregnancy.

The applicability of a helicopter patrol procedure to diverse areas: A cost-benefit evaluation

The residential burglary deterrent effects of a helicopter patrol procedure were investigated in four separate areas with a multiple baseline technology. The helicopter was flown during an 8:00 a.m. to 4:00 p.m. period in two high density population areas of approximately 9.82 and 14.71 square miles and two low density population areas of 117.49 and 89.97 square miles. The helicopter patrol reduced residential burglaries without crime displacement in the two high density areas but had no deterrent effects in the low density areas. The costs of the helicopter patrol were justified by the benefits that resulted from the reduced home burglaries in the two high density areas. Because the helicopter patrol program is funded by general tax revenues, there is a disparity between those people paying for the procedure (all residents of Nashville) and those citizens that receive the burglary deterrent benefits (only residents of high-density areas). This distribution of benefit limitation suggests two courses of action: (1) The helicopter should be flown only in high population density areas even though the low population density areas are also victimized by high burglary rates. (2) A more comprehensive burglary reduction program must be developed so that effective deterrence can be realized in low density areas. These latter techniques would supplement helicopter patrol strategies and thus form a comprehensive burglary deterrent package that has an equitable benefit distribution.

Creating the patient safety mindset

Two health care systems--Intermountain Health Care in Salt Lake City and Baptist Memorial Health Care in Memphis--have made patient safety an organization-wide priority, which has given both systems comprehensive cultures of safety.

Your CEO. Are you short-staffed or short-sighted?

Hiring the right CEO is the board's most important job. You may want to look outside of the usual hierarchy for your next chief exec--but be sure you know what you want. And don't leave succession planning until you are left leaderless.

The humanity of palliative care

Contrary to popular belief, palliative care is not just for dying patients. It's a comprehensive, compassionate system of caring for patients with painful, chronic conditions. A national program, the Center to Advance Palliative Care, maintains that this treatment option belongs in all U.S. hospitals.

Natural selection

Complementary and alternative medicine (CAM) is a consumer-driven mode of care whose time has come. As one expert puts it: "Your biggest risk is not getting involved, not finding out what patients are doing." Learn how to integrate CAM into your other services and how to get your physicians' support.

How many hats are too many?

In rural communities, where the pool of leaders is limited, boards often struggle with conflicts of interest. Trustees and governance experts offer tips on how to prevent, or at least deal with, a potential problem that can undermine effective governance.

Meeting in the middle. Lessons from an interfaith merger

Success stories of mergers between Catholic and non-Catholic hospitals are few and far between. Such mergers involve all of the usual complications in addition to potential conflicts of mission and control. But with the proper planning and flexibility, it's possible for such a merger to work. This case study shows you how it's done.

Rebuilding patient trust. Jump in

Many people think of hospitals more as businesses than as care providers, and they are wary. As the best connection to their communities, trustees can go a long way to restoring the trust that's gotten lost among the mergers, employee layoffs, and insurance problems. But first, they have to seek community feedback and trust what they hear.

Creating healthy futures. 2000 NOVA Award winners

Winners of this year's NOVA awards, sponsored by the American Hospital Association and H&HN magazine, all share a broad definition of health. These five stars of community benefit also understand that a community and a health care organization share responsibility for what creates health, and that collaborative efforts are the only way to sustain innovative programs.

An elementary question. Why would a health care system run a school?

INTEGRIS Health System in Oklahoma may be in a class by itself when it comes to improving community health. Its latest effort--a collaboration with the Oklahoma City school system to co-manage a struggling elementary school--has begun a dramatic turnaround for the school and for the health and well-being of its students.

Peek-a-boo fragile site at 16d associated with Tourette syndrome, bipolar disorder, autistic disorder, and mental retardation

Five patients with a fragile site at 16q22-23 and neuropsychiatric disorders are reported. Three of five had Tourette disorder, three had mental retardation, two had bipolar disorder, and one had autistic disorder. During our attempts to study the fragile sites in more detail we were unable to reproduce the fragile sites found several years earlier. The potential relationship between the fragile sites and the neuropsychiatric disorders in these patients is discussed. Am. J. Med. Genet. (Neuropsychiatr. Genet.) 96:69-73, 2000.

Ending the culture of blame. A look at why medical errors happen--and what needs to change

A group of high-profile hospital leaders is working to find solutions to medical errors that target systemic problems rather than individuals. Their actions are highlighted here.

Genomics. Medicine's future in our molecules

Decoding the messages contained within our DNA and applying them to clinical therapies will revolutionize medicine and health care delivery. But what does it all mean and what are the implications for providers?

Rural rescue--a vision in time

Remaining a stand-alone hospital in a small, rural community puts a lot of pressure on both the board and management to be visionary leaders. Gibson Area Hospital and Health Services in Illinois has thrived under its risk-taking CEO and board.

The right thing to do: an ethical framework helps trustees lead the way

Organizational ethics provides a process to consciously and consistently incorporate the hospital's values and the good of patients into all decisions. That responsibility falls squarely on the board. "Trustees are standing in two worlds," says Robert Potter. "One foot is in the hospital and one foot is in the community. No other group of people can fairly balance the interests of both."

What every board should know

Even the most experienced trustees can learn something new. Ther's no way you can do your job well without updating your knowledge of the field. Experts discuss what you need to know--and how you can go about learning it.

An internal operation. How Granada Hills reinvented its management

When the board of a California community hospital found that it had drastically miscalculated its earnings for 1998 and was actually in the red, trustees knew they had to act fast. Resisting the "cut and slash" advice of a turnaround specialist, the board chose to "reinvent" its management structure. That's how it could maintain its community health mission and still end up in the black.

Can the Platelet Function Analyzer (PFA)-100 test substitute for the template bleeding time in routine clinical practice?

The bleeding time (BT) is widely used in clinical medicine as a screening test of platelet function, although its deficiencies in such a role are well recognized. The Platelet Function Analyzer (PFA)-100 measures the ability of platelets activated in a high-shear environment to occlude an aperture in a membrane treated with collagen and epinephrine (CEPI) or collagen and ADP (CADP). The time taken for flow across the membrane to stop (closure time) is recorded. This study compared the PFA-100 with the BT as a screening test of platelet dysfunction in 113 hospital inpatients. The PFA-100 test was performed initially using the CEPI cartridge; CADP tests were performed on those with abnormal (> 163 s) CEPI closure times. Whole blood platelet aggregation studies and chart review were performed on patients in whom the BT and PFA-100 results did not agree.Abnormal bleeding times and PFA-100 results were obtained in 20.4% and 35.4% of patients, respectively. The results of BT and PFA-100 agreed in 74.3% of patients. Of the 29 patients in whom the BT and PFA-100 results were discordant, whole blood platelet aggregation studies supported the PFA-100 result in 25 (86.2%). The PFA-100 was more sensitive to aspirin-induced platelet dysfunction and was more rapidly and cheaply performed than the BT. Since the PFA-100 test reflects platelet function better than the BT, we conclude that this test could replace the BT as a first-line screening test for platelet dysfunction in clinical practice.

Rebuilding the lives of the homeless

Drawing on the community's health care, business, and social service resources, the I.M. Sulzbacher Center for the Homeless in Jacksonville, Fla., goes beyond just meeting the food, shelter, and medical needs of the city's destitute. As one center resident puts it: "Homelessness is feeling like you're less of a human being. I really don't feel homeless; I feel like this is my home."