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.

 

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

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.

 

 

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.

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

Genetic Determinants of CNS Repair Following Chronic Demyelination in Mice

September 11, 2009 – 2:33 pm

This study was presented at the Congress of the European Committee for Treatment and Research in Multiple Sclerosis in Dusseldorf, Germany, on Sept. 11, 2009, and found that two genes in mice were associated with good central nervous system repair in multiple sclerosis (MS). This early research holds promise for new therapies and better prediction of patient outcomes.

Allan Bieber, Ph.D., a Mayo Clinic neuroscientist and author of the study explains: “Most MS genetic studies have looked at disease susceptibility — or why some people get MS and others do not. This study asked, among those who have MS, why do some do well with the disease while others do poorly, and what might be the genetic determinants of this difference in outcome.”

According to Dr. Bieber, the research suggests that there may be a small number of strong genetic determinants for central nervous system repair following demyelinating disease, rather than a larger number of weak determinants.

Abstract
Clinical experience with humans who have multiple sclerosis and work with animal models of demyelinating disease, has demonstrated that significant CNS repair can occur after demyelination even without therapeutic intervention. However, for reasons that are poorly understood, repair often fails or is incomplete. Recently we have investigated the genetic regulation of CNS repair and remyelination in the Theiler’s murine encephalomyelitis virus (TMEV) model of demyelinating disease. We have found marked differences in spontaneous repair in different strains of mice ranging from minimal repair and the progressive accumulation of neurologic deficits in B10.Q mice, to extensive spontaneous myelin repair with axonal and functional preservation in FVB mice. The “reparative phenotype” of the FVB strain is inherited as a dominant trait in outcrosses with the non-repairing B10.Q strain. To better understand the molecular mechanisms of endogenous CNS repair, we have mapped genetic loci that are responsible for the reparative phenotype. Using single nucleotide polymorphisms (SNPs) as genetic markers, we have detected two very strong quantitative trait loci (QTLs) for CNS repair, one on chromosomes 3 (LOD~15) and one on chromosome 9 (LOD~21). The mouse genes for epidermal growth factor (EGF), a key regulator of cell growth and development, and Tyk 2, a janus kinase that plays a central role in controlling the TH1 immune response, present themselves as potential candidate genes for the QTLs on chromosomes 3 and 9 respectively. We have identified polymorphisms between the FVB and B10.Q strains in the protein coding sequences of both EGF and Tyk2 which support their roles as candidate genes. Relatively little is known about the genetics of CNS repair and these studies begin to identify the molecular pathways that are central to this poorly understood process.

Authors
Kanitta Suwansrinon, MD; Allan J. Bieber, PhD; Moses Rodriguez, MD all from Mayo Clinic

Multiple Sclerosis Treatment at Mayo Clinic
Multiple Sclerosis Research at Mayo Clinic

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

Endoscopic and Surgical Treatment of Mucosal (T1a) Esophageal Adenocarcinoma in Barrett’s Esophagus

September 9, 2009 – 7:43 am

A Mayo Clinic study published in the September 2009 issue of Gastroenterology found that early stage cancers of the esophagus can be treated as effectively by less-invasive, organ-sparing endoscopic therapy as compared to surgical removal of the esophagus.

Dr. Ganapathy Prasad, gastroenterologist and lead author explains “In 20 percent of esophageal cancer cases in the United States, the cancer is detected in the early stages. Traditionally, esophageal cancer patients undergo surgery to remove the esophagus. Our team compared surgery to the use of endoscopic therapy.  Our results showed the less-invasive therapy was just as effective as surgery for early-stage cancers.”

Abstract
Background & Aims
Endoscopic therapy is emerging as an alternative to surgical therapy in patients with mucosal (T1a) esophageal adenocarcinoma (EAC) given the low likelihood of lymph node metastases. Long-term outcomes of patients treated endoscopically and surgically for mucosal EAC are unknown. We compared long-term outcomes of patients with mucosal EAC treated endoscopically and surgically.

Methods
Patients treated for mucosal EAC between 1998 and 2007 were included. Patients were divided into an endoscopically treated group (ENDO group) and a surgically treated group (SURG group). Vital status information was queried using an institutionally approved internet research and location service. Statistical analysis was performed using Kaplan–Meier curves and Cox proportional hazard ratios.

Results
A total of 178 patients were included, of whom 132 (74%) were in the ENDO group and 46 (26%) were in the SURG group. The mean follow-up period was 64 months (standard error of the mean, 4.8 mo) in the SURG group and 43 months (standard error of the mean, 2.8 mo) in the ENDO group. Cumulative mortality in the ENDO group (17%) was comparable with the SURG group (20%) (P = .75). Overall survival also was comparable using the Kaplan–Meier method. Treatment modality was not a significant predictor of survival on multivariable analysis. Recurrent carcinoma was detected in 12% of patients in the ENDO group, all successfully re-treated without impact on overall survival.

Conclusions
Overall survival in patients with mucosal EAC when treated endoscopically appears to be comparable with that of patients treated surgically. Recurrent carcinoma occurs in a limited proportion of patients, but can be managed endoscopically.

Authors
G. A. Prasad, T. T. Wu, D. A. Wigle, N. S. Buttar, L.–M. Wongkeesong, K. T. Dunagan, L. S. Lutzke, L. S. Borkenhagen, and K. K. Wang all from Mayo Clinic

Esophagectomy at Mayo Clinic

By Carol Lammers | Posted in Gastroenterology | Tagged , , , , , , , | Comments (2)

New Surgical Technique for Treatment of Apical Hypertrophic Cardiomyopathy

August 26, 2009 – 9:00 am

Dr. Hartzell Schaff discusses apical myectomy, a new surgical treatment for patients with severely symptomatic apical hypertrophic cardiomyopathy. Dr. Schaff and colleagues presented a study on apical myectomy at the 2009 Annual Meeting of the American Association for Thoracic Surgery.

 


 

ABSTRACT
Objective: Apical hypertrophic cardiomyopathy (ApHCM) is a morphologic variant in which the hypertrophy is primarily localized to the apex of the left ventricle (LV). A subset of patients develop progressive drug refractory diastolic heart failure with severely limiting symptoms due to a resultant low cardiac output. Heart transplant has been the only therapeutic option available for such patients. This study analyzes clinical and hemodynamic outcomes of a novel surgical technique to improve diastolic filling by LV cavity enlargement.
 

Methods: From 1993 through May, 2008, 43 symptomatic patients with ApHCM underwent apical myectomy to augment LV end-diastolic volume (EDV). Information from a prospective database was supplemented by survey information, patient contact, and review of medical records.
 

Results: The mean age was 50±17yr and 65% were female. All patients were severely limited with dyspnea, 63% had angina, and 60% had syncope or pre-syncope. Ninety-one percent of patients were in New York Heart Association (NYHA) class III or IV. Myectomy was performed through an apical incision, and the LV cavity was augmented by excision of hypertrophic muscle at the apex and mid ventricle; a mean of 16±7 g of muscle was removed. In 14 patients who underwent pre- and postoperative hemodynamic catheterization, the LV end-diastolic pressure decreased from 28±9 to 24±7 mmHg (P=0.002) and the EDV index increased from 55±17 to 68±18 cc/m2 (P=0.003). Invasive measurements of stroke volume increased from of 56±17 cc to 63±19 cc (p=0.007). Forty of forty-one hospital survivors had improvement in symptoms after operation. The mean peak maximum oxygen consumption on exercise testing (n=5) increased from 13.5±4.4 to 15.8±4.6 mL/kg per minute. Survival at 1, 3, and 5 years was 95%, 81%, and 81%, respectively. At an average follow-up of 2.6±3.1years, 23 patients (74%) were in NYHA class I or II. One patient underwent heart transplant 5 years after apical myectomy.

Conclusion: For patients with ApHCM who have limiting symptoms despite optimal medical treatment, apical myectomy can improve functional status by decreasing LV end-diastolic pressure, thus improving the effective operative compliance of the LV and increasing stroke volume. This procedure may be of value in other patients with HCM who have severe hypertrophy and small LV end-diastolic volumes.

Authors
Hartzell V. Schaff1, Morgan L. Brown1, Steve R. Ommen1, Joseph A. Dearani1, Martin D. Abel1, A. J. Tajik2, Rick A. Nishimura1; 1Mayo Clinic, Rochester, MN; 2Mayo Clinic, Scottsdale, AZ

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

Laparoscopic Colectomy Demonstration

August 13, 2009 – 2:50 pm

Dr. Robert R. Cima provides a surgical demonstration of laparoscopic colectomy and robotically assisted rectal cancer surgery.

A minimally invasive approach is Mayo’s preferred operative approach for both malignant and benign conditions as there are numerous benefits for patients without any compromise in their surgical outcome.

The first laparoscopic colectomy was reported in the literature in 1991. However, it still accounts for less than 12% of the colectomies performed nationally. The reasons for this are many but the most common explanation is that it requires a higher level of technical skill in order for it to be performed safely and efficiently. There also was a concern about performing laparoscopic colectomy for patients with colorectal cancer.

Fortunately, a national randomized clinical trial led by a Mayo Clinic physician demonstrated that in expert hands the cancer outcomes were the same. More importantly, there were a number of short-term benefits for the patients. These benefits include shorter hospitalizations, less pain and fewer complications. This has been demonstrated in multiple studies including a meta-analysis performed at Mayo Clinic. The Division of Colon and Rectal Surgery at Mayo Clinic in Minnesota has performed over 3,000 minimally invasive colorectal procedures ranging from segmental colectomies to total proctocolectomies with ileal pouch construction.

Colon Cancer Clinical trials

By Carol Lammers | Posted in Colon and rectal surgery | Tagged , , , , , | Comments (3)

A Randomized Controlled Trial of Vertebroplasty for Osteoporotic Spine Fractures

August 10, 2009 – 10:35 am

Dr. David Kallmes discusses a new study that found relief of pain from vertebral compression fractures, as well as improvement in pain-related dysfunction, were similar in patients treated with vertebroplasty and those treated with simulated vertebroplasty without cement injections. The article was published in the New England Journal of Medicine.

 

ABSTRACT
Background: Vertebroplasty is used commonly to treat painful, osteoporotic vertebral compression fractures.

Methods: In this multi-center trial, we randomly assigned patients with 1-3 painful, osteoporotic vertebral compression fractures to vertebroplasty or to a simulated vertebroplasty without cement. The primary outcomes were modified Roland-Morris Disability Questionnaire (RDQ) scores (range, 0-23) and patient ratings of average pain intensity in the preceding 24 hours (0-10 numerical rating scale) at one month. Patients were allowed to cross over after one month.

Results: All patients received their assigned interventions (68 vertebroplasty and 63 simulated vertebroplasty). The baseline characteristics were similar in the two groups. At one month, the vertebroplasty and control groups did not differ significantly on either the RDQ (treatment difference: 0.7; 95% CI: -1.3, 2.8; P = 0.49) or the pain rating (treatment difference: 0.7; 95% CI: -0.3, 1.7; P = 0.19). Both groups showed immediate improvement in disability and pain after the intervention. Although the groups did not differ significantly on any secondary outcome at one month, there was a trend toward a higher rate of clinically meaningful improvement in pain (30% decrease from baseline) in the vertebroplasty group (64% versus 48%, P = 0.06). At three months, there was a higher crossover rate in the control group (43% versus 12%, P<0.001)). There was one serious adverse event in each group.

Conclusions: Improvement in osteoporotic compression fracture pain and pain-related disability was similar in patients treated with vertebroplasty and patients treated with simulated vertebroplasty without cement. (ClinicalTrials.gov NCT00068822)

AUTHORS
D.F. Kallmes1, B.A.Comstock2, P.J. Heagerty2, J.A. Turner, Ph.D.2, D.J. Wilson4, T.H. Diamond5, R. Edwards6, L.A. Gray1, L. Stout2, S. Owen4, W. Hollingworth3, B. Ghdoke2, D.J. Annesley-Williams7, S.H. Ralston,8 J.G. Jarvik2

1Mayo Clinic, Rochester, MN/US, 2University of Washington, Seattle, WA/US 3Department of Social Medicine, Bristol/UK, 4Nuffield Orthopaedic Centre NHS Trust, Oxford/UK, 5St George Hospital, University of New South Wales, Sydney/AU, 6Gartnavel General Hospital, Glasgow/UK, 7Nottingham University Hospital NHS Trust, Nottingham/UK, 8Western General Hospital, University of Edinburgh, Edinburgh/UK

By Carol Lammers | Posted in Neurology, Radiology | Tagged , , , | Comments (2)

Disease Associations With Monoclonal Gammopathy of Undetermined Significance: A Population-Based Study of 17,398 Patients

August 5, 2009 – 3:22 pm

Dr. S. Vincent Rajkumar, Mayo Clinic hematologist, discusses the first systematic study to determine association of Monoclonal Gammopathy of Undetermined Significance (MGUS) with all diseases in 17,398 patients, published in Mayo Clinic Proceedings.

Abstract
OBJECTIVE: To systematically study the association of monoclonal gammopathy of undetermined significance (MGUS) with all diseases in a population-based cohort of 17,398 patients, all of whom were uniformly tested for the presence or absence of MGUS.

PATIENTS AND METHODS: Serum samples were obtained from 77% (21,463) of the 28,038 enumerated residents in Olmsted County, Minnesota. Informed consent was obtained from patients to study 17,398 samples. Among 17,398 samples tested, 605 cases of MGUS and 16,793 negative controls were identified. The computerized Mayo Medical Index was used to obtain information on all diagnoses entered between January 1, 1975, and May 31, 2006, for a total of 422,663 person-years of observations. To identify and confirm previously reported associations, these diagnostic codes were analyzed using stratified Poisson regression, adjusting for age, sex, and total person-years of observation.

RESULTS: We confirmed a significant association in 14 (19%) of 75 previously reported disease associations with MGUS, including vertebral and hip fractures and osteoporosis. Systematic analysis of all 16,062 diagnostic disease codes found additional previously unreported associations, including mycobacterium infection and superficial thrombophlebitis.

CONCLUSION: These results have major implications both for confirmed associations and for 61 diseases in which the association with MGUS is likely coincidental.

Footnotes
This study was supported in part by grants CA62242, CA107476, and AR30582 from the National Institutes of Health, US

AUTHORS: John P. Bida, MA, Robert A. Kyle, MD, Terry M. Therneau, PhD, L. Joseph Melton III, MD, Matthew F. Plevak, MS, Dirk R. Larson, MS, Angela Dispenzieri, MD, Jerry A. Katzmann, PhD and S. Vincent Rajkumar, MD all from Mayo Clinic

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