Closing perforations and postperforation management in endoscopy: duodenal, biliary, and colorectal

Early recognition of adverse events arising from endoscopy is essential. In some cases the injury can be viewed clearly during the procedure, and immediate action should be taken to repair the defect endoscopically if feasible. If perforation is unclear, imaging can be used to confirm the diagnosis. Surgical intervention is not always necessary; however, a surgical consultation for backup is essential. Selective cases can be managed conservatively or endoscopically with successful outcomes. Early recognition and intervention, input from specialist colleagues, and communication with the patient and family are keys to successfully managing the event

Predictors of quality of life in patients with end-stage renal disease on hemodialysis

Marc M Saad,1 Youssef El Douaihy,1 Christine Boumitri,1 Chetana Rondla,2 Elias Moussaly,1 Magda Daoud,1 Suzanne E El Sayegh3 1Internal Medicine, Staten Island University Hospital, Staten Island, NY, 2Nephrology, Emory University Hospital, Atlanta, GA, 3Nephrology, Staten Island University Hospital, Staten Island, NY, USA Background: Assessment of quality of life (QOL) of end-stage renal disease (ESRD) patients (physical, mental, and social well-being) has become an essential tool to develop better plans of care. Objective of this study is to determine which demographic and biochemical parameters correlate with the QOL scores in patients with ESRD on hemodialysis (HD) using Kidney Disease QOL-36 surveys (KDQOL). Methods: A retrospective chart review of all ESRD patients who underwent HD at an outpatient center. The five components of the KDQOL were the primary end points of this study (burden of kidney disease, symptoms and problems, effects of kidney disease on daily life, mental component survey, and physical component survey). Scores were grouped into three categories (below average, average, and above average). In addition to demographics (age, sex, and race), the independent variables such as weight gain, number of years on dialysis, urea reduction ratio, calcium, phosphorus, parathyroid hormone, albumin, and hemoglobin in the serum were collected. Chi-square analysis for dependent variables and the nominal independent variables was used, and analysis of variance analysis was used for continuous independent variables. Ordinal regression using PLUM (polytomous universal model) method was used to weigh out possible effects of confounders. Results: The cohort size was 111 patients. Mean age was 61.8 (±15.5) years; there were more males than females (64.9% vs 35.1%), the mean time-on-dialysis at the time of the study was 4.3 (4.8) years. Approximately two-thirds of the responses on all five domains of the questionnaire ranked average when compared to the national numbers. The remainders were split between above average (20.6%) and below average (13.4%). In our cohort, no relationships were statistically significant between the five dependent variables of interest and the independent variables by chi-square- and t-test analyses. This was further confirmed by regression analysis. Of note, sex carried the strongest statistical significance (with a P-value of 0.16) as a predictor of “the burden of kidney disease on daily life” in ordinal regression. Conclusion: Prior studies have shown variables such as serum phosphate level, intradialytic weight gain, and dialysis adequacy are associated with lower KDQOL scores; however, this was not evident in our analysis likely due to smaller sample size. Larger size studies are required to better understand the predictors of QOL in ESRD patients on HD. Keywords: quality of life, end-stage renal disease, hemodialysis, metabolic profil

Is kidney function affecting the management of myocardial infarction? A retrospective cohort study in patients with normal kidney function, chronic kidney disease stage III–V, and ESRD

Marc Saad,1 Boutros Karam,1 Geovani Faddoul,2 Youssef El Douaihy,1 Harout Yacoub,1 Hassan Baydoun,3 Christine Boumitri,1 Iskandar Barakat,1 Chadi Saifan,4 Elie El-Charabaty,4 Suzanne El Sayegh4 1Department of Internal Medicine, Staten Island University Hospital, Staten Island, 2Department of Nephrology, Icahn School of Medicine, New York, NY, 3Department of Cardiology, Tulane University Medical Center, New Orleans, LA, 4Department of Nephrology, Staten Island University Hospital, Staten Island, NY, USA Abstract: Patients with chronic kidney disease (CKD) are three times more likely to have myocardial infarction (MI) and suffer from increased morbidity and higher mortality. Traditional and unique risk factors are prevalent and constitute challenges for the standard of care. However, CKD patients have been largely excluded from clinical trials and little evidence is available to guide evidence-based treatment of coronary artery disease in patients with CKD. Our objective was to assess whether a difference exists in the management of MI (ST-segment elevation myocardial infarction and non-ST-segment elevation myocardial infarction) among patients with normal kidney function, CKD stage III–V, and end-stage renal disease (ESRD) patients. We conducted a retrospective cohort study on patients admitted to Staten Island University Hospital for the diagnosis of MI between January 2005 and December 2012. Patients were assigned to one of three groups according to their kidney function: Data collected on the medical management and the use of statins, platelet inhibitors, beta-blockers, and angiotensin converting enzyme inhibitors/angiotensin receptor blockers were compared among the three cohorts, as well as medical interventions including: catheterization and coronary artery bypass graft (CABG) when indicated. Chi-square test was used to compare the proportions between nominal variables. Binary logistic analysis was used in order to determine associations between treatment modalities and comorbidities, and to account for possible confounding factors. Three hundred and thirty-four patients (mean age 67.2±13.9 years) were included. In terms of management, medical treatment was not different among the three groups. However, cardiac catheterization was performed less in ESRD when compared with no CKD and CKD stage III–V (45.6% vs 74% and 93.9%) (P<0.001). CABG was performed in comparable proportions in the three groups and CABG was not associated with the degree of CKD (P=0.078) in binary logistics regression. Cardiac catheterization on the other hand carried the strongest association among all studied variables (P<0.001). This association was maintained after adjusting for other comorbidities. The length of stay for the three cohorts (non-CKD, CKD stage III–V, and ESRD on hemodialysis) was 16, 17, and 15 days, respectively and was not statistically different. Many observations have reported discrimination of care for patients with CKD considered suboptimal candidates for aggressive management of their cardiac disease. In our study, medical therapy was achieved at high percentage and was comparable among groups of different kidney function. However, kidney disease seems to affect the management of patients with acute MI; percutaneous coronary angiography is not uniformly performed in patients with CKD and ESRD when compared with patients with normal kidney function. Keywords: myocardial infarction, chronic kidney disease, end-stage renal diseas