Corneal Endothelial Cell Loss 9 Years After Excimer Laser Keratorefractive Surgery

December 3, 2009 – 2:28 pm

Dr. Sanjay Patel discusses long-term changes in corneal endothelim after LASIK and PRK in relation to potenital corneal transplant. This study appeared in the the November 2009 issue of Archives of Ophthalmology.

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ABSTRACT
Objective To determine the long-term changes in the corneal endothelium after laser in situ keratomileusis (LASIK) and photorefractive keratectomy (PRK).

Methods Twenty-nine eyes (16 patients) received myopic LASIK or PRK, with intended correction to emmetropia. Central endothelial photographs were taken before and 9 years after surgery and were analyzed by the same masked investigator after appropriate calibration for magnification. Comparisons were made by using generalized estimating equation models to account for any correlation between fellow eyes of the same patient. The annual exponential rate of cell loss was compared with cell loss during a 10-year period in 42 normal (unoperated) corneas of 42 subjects.

Results Endothelial cell density 9 years after LASIK and PRK had decreased by 5.3% from preoperative density (P < .001), whereas coefficient of variation of cell area (P = .24) and percentage of hexagonal cells (P = .19) did not change. The mean annual rate of cell loss after refractive surgery (0.6% [standard deviation, 0.8%]) was not different from that in normal corneas (0.6% [0.5%], P = .88; minimum detectable difference = 0.5%; = .05; β = .20).

Conclusions Laser in situ keratomileusis and PRK had no long-term effect on the corneal endothelium. Corneas that have undergone LASIK or PRK can be considered for use as donors for posterior lamellar keratoplasty procedures.

By Carol Lammers | Posted in Ophthalmology | Tagged , , , , , , | Leave a Comment

Endovascular Repair of Thoracic Aortic Aneurysm

November 19, 2009 – 2:16 pm

Kevin L. Greason, MD, disucsses the advances in endovascular repair of thoracic aortic aneurysm.

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Aneurysms affect an estimated 6 patients per 100,000 persons per year, an estimated 21,000 patients yearly in the United States. Unfortunately, these patients frequently have comorbid conditions such as chronic obstructive pulmonary disease, coronary artery disease, or renal insufficiency that can complicate standard open operative repair.

A new technology has emerged in the management of thoracic aortic aneurysm previously treated only with open surgery—the endovascular stent graft. Successful stent graft treatment of a descending thoracic aortic aneurysm has the potential to avoid the deleterious effects of a thoracotomy, aortic cross-clamp placement, and major blood loss.

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By Carol Lammers | Posted in Cardiovascular | Tagged , , , , | Leave a Comment

Mayo Clinic Doesn’t Change Mammography Screening Guidelines Despite New USPSTF Recommendations

November 18, 2009 – 3:59 pm

Mayo Clinic mammography screening recommendations remain the same, despite revised recommendations by the U.S. Preventive Services Task Force.

Sandhya Pruthi, M.D., director of the Breast Clinic at Mayo Clinic in Rochester, and leader of the task force explains Mayo’s recommendations.

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Mayo Clinic physicians and researchers state that the modeling data used in the analysis, along with input from recent clinical trials conducted outside of the United States, do not constitute strong enough data to change Mayo’s practice.

By Carol Lammers | Posted in Cancer | Tagged , , , , , | Leave a Comment

Longitudinal PSA and Prostate Volume Changes in Men Who Develop Prostate Cancer

November 13, 2009 – 4:39 pm

Rodney Breau, M.D., a Mayo Clinic urologic oncology fellow discusses new Mayo Clinic research that studied the association between prostate-specific antigen levels and prostate size and found that routine annual evaluation of prostate growth is not necessarily a predictor for the development of prostate cancer. These findings were presented at the North Central Section of the American Urological Association in Scottsdale, Ariz.

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ABSTRACT
Introduction: We evaluated the rate of prostate growth and the rate of change in PSA for men in a large population-based cohort.

Methods: In 1990, 616 men between 40 and 79 years of age without prostate disease were randomly selected from Olmsted County, Minnesota. Patients participated in biennial examinations for 14 years which included PSA and transrectal ultrasonographic prostate volume measurements. The ratios of longitudinal change in PSA and prostate volume were compared between groups.

Results: Of 616 men, 58 (9.4%) were diagnosed with prostate cancer. The median PSA velocity in patients with and without a prostate cancer diagnosis was 6.0%/year and 3.3%/year, respectively. In both groups of patients, median prostate volume increase was 2.2% per year. For patients who developed prostate cancer, the rate of PSA increase was 2.5 (IQR:2.0-3.3) times the rate of prostate volume increase, compared to a rate of 1.5 (IQR:0.8-2.2) for those who did not develop prostate cancer (p<0.001).

Conclusions: In a large population based cohort, men who developed prostate cancer had a similar rate of prostate growth but a disproportionate rise in PSA compared to men who did not develop prostate cancer. These results suggest that the disproportionate rise in PSA in men who develop prostate cancer is not due solely to concomitant prostatic enlargement.

By Carol Lammers | Posted in Urology | Tagged , , | Leave a Comment

Robot-Assisted Laparoscopic Sacrocolpopexy: A Review of the Learning Curve in Fifty Cases

November 11, 2009 – 1:48 pm

Dr. Daniel Elliot discusses Robot-Assisted Laparoscopic Sacrocolpopexy. This information was recently presented at the North Central Section of the American Urological Association in Scottsdale, Ariz.

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ABSTRACT
INTRODUCTION: With the advent of robotic-assisted laparoscopic surgery, application of open surgical principles is increasingly translated to the minimally invasive laparoscopic approach.

OBJECTIVES: We examined the learning curve for the robot-assisted sacrocolpopexy (RALS) as defined by operative times, mesh erosion and prolapse recurrence.

METHODS: From 2002 to 2008, 53 consecutive females with symptomatic high-grade post-hysterectomy vaginal vault prolapse underwent RALS in the Department of Urology by one surgical team. OR times and post-operative complications were collected prospectively along with patient demographics. A linear regression model was used to predict a learning curve in sequential cases.

RESULTS: With an average follow-up of 35.8 months (range 1.4 to 67), 48 females, with an average age of 66 years underwent RALS (5 conversions to open).

CONCLUSIONS: A decrease in OR time and post-operative complications is evident with more cases of RALS, regardless of patient age, when performed by one surgical team.

AUTHORS: M. A. Childs, Mayo Clinic, Rochester, MN; S. McGee, J. Routh, G. Chow, D. Elliot of Mayo Clinic

By Carol Lammers | Posted in Urology | Tagged , , , | Leave a Comment

Safety and efficacy of Ambrisentan for the therapy of Portopulmonary hypertension (POPH)

November 11, 2009 – 1:26 pm

Dr. Krowka discusses a recent presentation on Portopulmonary hypertension.

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ABSTRACT
Background: Ambrisentan is a newer endothelin receptor antagonist (ERA) with potential advantages over Bosentan for the therapy of POPH: selective ERA antagonism, once-daily dosing and minimizes elevation in liver enzymes. We describe hemodynamic responses and clinical outcomes of patients with POPH treated with Ambrisentan at Mayo Clinic, Rochester, MN.

Methods: We prospectively identified consecutive adult POPH patients evaluated at Mayo Clinic from January 2007 until May 2009 deemed candidates for oral pulmonary hypertension therapy. In this open label study, patients received 5 mg of Ambrisentan daily for 4 weeks with dose increase to 10 mg daily thereafter. Liver enzymes were assessed monthly. Baseline and follow-up echocardiograms and right heart catheterizations were accomplished.

Results: We identified 12 patients with POPH started on single therapy with Ambrisentan. The median age (IQR, interquartile range) was 55(52-60). Seven patients were male and 11 were Caucasian. Patients were followed for a median of 613 days (334-1011). The main etiology of portal hypertension was cirrhosis (10 cases).The most common etiology of cirrhosis was alcohol (5 cases), followed by hepatitis C (3 cases). Cirrhotic patients had a median MELD score of 10(7-12), and the majority of patients were in Child’s A classification (8 cases). Median time on Ambrisentan therapy was 390 days (206-611). Two patients died, one of advanced hepatocellular carcinoma, and one of septic shock following pneumonia. Mean pulmonary artery pressure and pulmonary vascular resistance significantly decreased after therapy with Ambrisentan, with associated improvement in functional class. Transaminases and total bilirubin levels remained stable after initiation of Ambrisentan.

Conclusion: In this prospective cohort of patients with POPH, Ambrisentan proved to be efficacious with significant improvement in hemodynamics and functional class. In addition, Ambrisentan was safe with no significant elevation in transaminases or total bilirubin.

AUTHORS
Rodrigo Cartin-Ceba, Karen Swanson, Michael J. Krowka from Mayo Clinic.

By Carol Lammers | Posted in Uncategorized | Tagged , , , | Leave a Comment

Diagnosis and Treatment of Viral Myocarditis

November 4, 2009 – 10:32 am

Dr. Leslie Cooper Jr., discussed several new diagnostic methods, such as cardiac magnetic resonance imaging (MRI), that are useful for diagnosing myocarditis. These findings were published in the November 2009 issue of Mayo Clinic Proceedings.

 

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Abstract
Myocarditis, an inflammatory disease of heart muscle, is an important cause of dilated cardiomyopathy worldwide. Viral infection is also an important cause of myocarditis, and the spectrum of viruses known to cause myocarditis has changed in the past 2 decades. Several new diagnostic methods, such as cardiac magnetic resonance imaging, are useful for diagnosing myocarditis. Endomyocardial biopsy may be used for patients with acute dilated cardiomyopathy associated with hemodynamic compromise, those with life-threatening arrhythmia, and those whose condition does not respond to conventional supportive therapy. Important prognostic variables include the degree of left and right ventricular dysfunction, heart block, and specific histopathological forms of myocarditis. We review diagnostic and therapeutic strategies for the treatment of viral myocarditis. English-language publications in PubMed and references from relevant articles published between January 1, 1985, and August 5, 2008, were analyzed. Main keywords searched were myocarditis, dilated cardiomyopathy, endomyocardial biopsy, cardiac magnetic resonance imaging, and immunotherapy.

Authors
Jason C. Schultz, MD, Anthony A. Hilliard, MD, Leslie T. Cooper, Jr, MD and Charanjit S. Rihal, MD from Mayo Clinic

By Carol Lammers | Posted in Cardiovascular | Tagged , , , , , , | Leave a Comment

Diabetic Retinopathy

October 22, 2009 – 4:23 pm

Dr. John M. Pach, M.D., of the Department of Ophthalmology and Dr. Steven A. Smith, of the Division of Endocrinology, Diabetes, Metabolism, and Nutrition at Mayo Clinic discuss the discuss major risk factors for diabetic retinopathy including diabetes mellitus.

Dr. Pach

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Dr. Smith

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By Carol Lammers | Posted in Endocrinology | Tagged , , , | Leave a Comment

Colectomy Rate Comparison After Treatment of Ulcerative Colitis With Placebo or Infliximab

October 1, 2009 – 1:54 pm

Dr. William Sandborn discusses a new study led by Mayo Clinic that found ulcerative colitis patients had a 41 percent reduction in colectomy after a year when treated with infliximab. This study is published in the October 2009 issue of Gastroenterology.

 

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ABSTRACT
Background & Aims
The efficacy of infliximab for treating patients with ulcerative colitis has been established.

Methods
The Active Ulcerative Colitis Trial (ACT)-1 and ACT-2 randomized, double-blind, placebo-controlled studies evaluated infliximab induction and maintenance therapy in moderately to severely active ulcerative colitis. Overall, 728 patients received placebo or infliximab (5 or 10 mg/kg) intravenously at weeks 0, 2, and 6, then every 8 weeks through week 46 (ACT-1) or 22 (ACT-2). Colectomy, hospitalization, and surgery/procedure data through 54 weeks after the first infusion were obtained from ACT-1, ACT-2, and associated data sources. In the prespecified analysis, all data were combined to ascertain time to colectomy. Kaplan–Meier product-limit method was used to estimate the cumulative incidence of colectomy, and log-rank test was used to compare the combined infliximab group and placebo.

Results
Eighty-seven percent (630 of 728) of patients had complete colectomy follow-up; 13% (98 of 728) of patients had a median follow-up of 6.2 months. The cumulative incidence of colectomy through 54 weeks was 10% for infliximab and 17% for placebo (P = .02), yielding an absolute risk reduction of 7%. Compared with placebo, fewer ulcerative colitis-related hospitalizations and surgeries/procedures per 100 patient-years of treatment occurred with infliximab therapy: 40 vs 20 (P = .003) and 34 vs 21 (P = .03), respectively. Serious adverse events occurring in infliximab-treated patients included serious infections, tuberculosis, histoplasmosis, listeriosis, and malignancy.

Conclusions
Patients with moderately to severely active ulcerative colitis treated with infliximab were less likely to undergo colectomy through 54 weeks than those receiving placebo.

Conflicts of Interest The authors disclose the following: William J. Sandborn, Paul Rutgeerts, Brian G. Feagan, Walter Reinisch, Stephen B. Hanauer, Gary R. Lichtenstein, Willem J. S. de Villiers, Bruce E. Sands, and Jean Frédéric Colombel have served as consultants for and received honoraria and research grants from Centocor Ortho Biotech, Inc. Daniel Present has served as a consultant for and received a research grant from Centocor Research and Development, Inc. Jewel Johanns and Jiandong Lu are employees of Centocor Clinical Research and Development, Inc., a subsidiary of Johnson & Johnson, and own stock in Johnson & Johnson. Allan Olson is a former employee of Centocor Clinical Research and Development, Inc., is currently employed at R. W. Johnson Pharmaceutical Research and Development, and owns stock in Johnson & Johnson. Kevin Horgan is a former employee of Centocor Clinical Research and Development, Inc.

Funding Support Supported by a research grant from Centocor Research and Development, Inc, Malvern, Pennsylvania, and Schering Plough, Kenilworth, New Jersey. Supported by a grant (1-UL1-RR024150-01) from the National Center for Research Resources, a component of the National Institutes of Health (NIH) and the NIH Roadmap for Medical Research.

Some of the results presented in this article were published as an abstract and presented at The American College of Gastroenterology 2007 annual meeting in Philadelphia, Pennsylvania (Am J Gastroenterol 2007;102[Suppl 2]:Abs984); United European Gastroenterology Week 2007 annual meeting in Paris, France (Gut 2007;39:A26); and 2007 CCFA National Research and Clinical Conference, 6th Annual Advances in the Inflammatory Bowel Diseases in Aventura, Florida (Inflamm Bowel Dis 2007;14[Suppl 1]:AbsO-006).

By Carol Lammers | Posted in Gastroenterology | Tagged , , , | Leave a Comment

Association of Resident Fatigue and Distress With Perceived Medical Errors

September 23, 2009 – 4:35 pm

Dr. Tait Shanafelt discusses a report that distress and fatigue among medical residents are independent contributors to self-perceived medical errors. The findings appear in the Journal of the American Medical Association.

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ABSTRACT
JAMA. 2009;302(12):1294-1300.

Context Fatigue and distress have been separately shown to be associated with medical errors. The contribution of each factor when assessed simultaneously is unknown.

Objective To determine the association of fatigue and distress with self-perceived major medical errors among resident physicians using validated metrics.

Design, Setting, and Participants Prospective longitudinal cohort study of categorical and preliminary internal medicine residents at Mayo Clinic, Rochester, Minnesota. Data were provided by 380 of 430 eligible residents (88.3%). Participants began training from 2003 to 2008 and completed surveys quarterly through February 2009. Surveys included self-assessment of medical errors, linear analog self-assessment of overall quality of life (QOL) and fatigue, the Maslach Burnout Inventory, the PRIME-MD depression screening instrument, and the Epworth Sleepiness Scale.

Main Outcome Measures Frequency of self-perceived, self-defined major medical errors was recorded. Associations of fatigue, QOL, burnout, and symptoms of depression with a subsequently reported major medical error were determined using generalized estimating equations for repeated measures.

Results The mean response rate to individual surveys was 67.5%. Of the 356 participants providing error data (93.7%), 139 (39%) reported making at least 1 major medical error during the study period. In univariate analyses, there was an association of subsequent self-reported error with the Epworth Sleepiness Scale score (odds ratio [OR], 1.10 per unit increase; 95% confidence interval [CI], 1.03-1.16; P = .002) and fatigue score (OR, 1.14 per unit increase; 95% CI, 1.08-1.21; P < .001). Subsequent error was also associated with burnout (ORs per 1-unit change: depersonalization OR, 1.09; 95% CI, 1.05-1.12; P < .001; emotional exhaustion OR, 1.06; 95% CI, 1.04-1.08; P < .001; lower personal accomplishment OR, 0.94; 95% CI, 0.92-0.97; P < .001), a positive depression screen (OR, 2.56; 95% CI, 1.76-3.72; P < .001), and overall QOL (OR, 0.84 per unit increase; 95% CI, 0.79-0.91; P < .001). Fatigue and distress variables remained statistically significant when modeled together with little change in the point estimates of effect. Sleepiness and distress, when modeled together, showed little change in point estimates of effect, but sleepiness no longer had a statistically significant association with errors when adjusted for burnout or depression.

Conclusion Among internal medicine residents, higher levels of fatigue and distress are independently associated with self-perceived medical errors.

Authors Colin P. West, MD, PhD; Angelina D. Tan, BS, BA; Thomas M. Habermann, MD; Jeff A. Sloan, PhD; Tait D. Shanafelt, MD from Mayo Clinic, Rochester, Minnesota.

By Carol Lammers | Posted in General Medical | Tagged , , , | Leave a Comment