Surgical Management of Benign and Malignant Colorectal Disease in the Immunocompromised Patient

Patients who are immunosuppressed either due to an underlying disease process or medications to treat a disease require important perioperative considerations. Preoperative evaluation mandates a higher index of suspicion for pathology given that peritoneal and systemic markers of illness may be masked. Intraoperatively, consideration should be given for diversion more frequently than in a nonimmunosuppressed patient. Postoperatively, patients should be managed in a multidisciplinary fashion. This review largely focuses on the immunosuppressive mediations used for the treatment of inflammatory bowel disease, benign colorectal disease in an immunosuppressed patient, and colorectal malignancies in immunosuppressed patients to highlight important considerations for this patient population. This review contains 4 figures, 5 tables, and 78 references. Key words: anal squamous cell carcinoma, appendicitis versus typhlitis, biologic therapy, corticosteroids, human papillomavirus, immunosuppression, neutropenic enterocolitis

Surgical Management of Benign and Malignant Colorectal Disease in the Immunocompromised Patient

DeckerMed Surgery ◽

10.2310/surg.2059 ◽

2017 ◽

Author(s):

Cindy Kin ◽

Amy Lightner ◽

Mark Welton

Keyword(s):

Preoperative Evaluation ◽

Disease Process ◽

Underlying Disease ◽

Colorectal Disease ◽

Immunosuppressed Patient ◽

Neutropenic Enterocolitis ◽

Anal Squamous Cell Carcinoma ◽

Benign Colorectal Disease ◽

Pulmonary Hypertension

Cardiac Anesthesia: A Problem-Based Learning Approach ◽

10.1093/med/9780190884512.003.0025 ◽

2019 ◽

pp. 238-243

Author(s):

Renata G. Ferreira ◽

Andreas Schuler

Keyword(s):

Pulmonary Hypertension ◽

Pulmonary Artery ◽

Pulmonary Artery Pressure ◽

Preoperative Evaluation ◽

Disease Process ◽

Underlying Disease ◽

Noncardiac Surgery ◽

Heart Catheterization ◽

Perioperative Morbidity ◽

Artery Pressure

Pulmonary hypertension (PHTN) is a rare yet devastating disease. PHTN is defined as a mean pulmonary artery pressure of 25 mm Hg or greater at rest, measured during right heart catheterization. The survival without therapy is only 2.8 years. Its estimated prevalence ranges from 0.001 to 0.01. In noncardiac surgery, PHTN is considered to be an important predictor of complications, with perioperative morbidity ranging from 14% to 24%. Given this potential morbidity, careful preoperative evaluation and understanding of risks and management of these patients is strongly encouraged as it may improve outcomes after surgery. The perioperative risk and management among patients with PHTN undergoing noncardiac surgery may differ. Therefore, it is important for the anesthesiologist to understand the underlying disease process causing elevation of the pulmonary artery pressure when evaluating the risks and benefits of the proposed procedure.

Drug-Induced Movement Disorders

Perspectives on Neurophysiology and Neurogenic Speech and Language Disorders ◽

10.1044/nnsld25.2.70 ◽

2015 ◽

Vol 25 (2) ◽

pp. 70-77

Author(s):

Amy Lustig ◽

Cesar Ruiz

Keyword(s):

Movement Disorders ◽

Medical Management ◽

Disease Process ◽

Underlying Disease ◽

Extrapyramidal Symptoms ◽

Drug Induced ◽

General Overview ◽

Management Approaches ◽

Broad Understanding ◽

Underlying Disease Process

The purpose of this article is to present a general overview of the features of drug-induced movement disorders (DIMDs) comprised by Parkinsonism and extrapyramidal symptoms. Speech-language pathologists (SLPs) who work with patients presenting with these issues must have a broad understanding of the underlying disease process. This article will provide a brief introduction to the neuropathophysiology of DIMDs, a discussion of the associated symptomatology, the pharmacology implicated in causing DIMDs, and the medical management approaches currently in use.

Telemedicine for Patients with Inflammatory Bowel Disease (TELE-IBD) Clinical Trial: Qualitative Assessment of Participants’ Perceptions of the TELE-IBD Intervention (Preprint)

10.2196/preprints.14165 ◽

2019 ◽

Author(s):

Charlene C Quinn ◽

Sarah Chard ◽

Erin G Roth ◽

J. Kevin Eckert ◽

Katharine M Russman ◽

...

Keyword(s):

Clinical Trial ◽

Disease Activity ◽

Remote Monitoring ◽

Standard Care ◽

Disease Process ◽

The United States ◽

Qualitative Assessment ◽

Structured Interviews ◽

Treatment Groups ◽

BACKGROUND Inflammatory bowel diseases (IBD), comprising Crohn’s disease and ulcerative colitis, affects 1 to 3 million people in the United States. Telemedicine has shown promise in IBD. The objective of the parent study, TELE-IBD, was to compare disease activity and quality of life (QoL) in a one-year randomized clinical trial of IBD patients receiving telemedicine versus standard care. Treatment groups experienced improvements in disease activity and QoL but there was not significant differences between groups. Study adherence to the text-based intervention was less than the 80% of the targeted goal. OBJECTIVE To understand adherence to remote monitoring, the goal of this qualitative assessment was to obtain TELE-IBD trial participants’ perceptions of the TELE-IBD system, including their recommendations for future TELE-IBD monitoring. METHODS In the parent study, patients attending three tertiary referral centers with worsening IBD symptoms in the previous two years were eligible for randomization to remote monitoring via texts every other week (EOW), weekly (W) or standard care. Participants (n=348) were evenly enrolled in the treatment groups and 259 (74.4%) completed the study. For this study, a purposive sample of adherent (N=15) and non-adherent (N=14) patients was drawn from the TELE-IBD trial population. Adherence was defined as the completion of 80% or more of the W or EOW self-assessments. Semi-structured interviews conducted by phone surveyed 1) the strengths and benefits of TELE-IBD; 2) challenges associated with using TELE-IBD; and 3) how to improve the TELE-IBD intervention. Interviews were recorded, professionally transcribed, and coded based on a priori concepts and emergent themes with the aid of ATLAS.ti qualitative data analysis software. RESULTS Participants' discussions centered on three elements of the intervention: 1) self-assessment questions, 2) action plans, and 3) educational messages. Participants also commented on: text-based platform, depression and adherence, TELE-IBD system in place of office visit, and their recommendations for future TELE-IBD systems. Adherent and non-adherent participants prefer a flexible system that is personalized, including targeted education messages, and they perceive TELE-IBD as effective in facilitating IBD self-management. CONCLUSIONS Participants identified clear benefits to the TELE-IBD system, including obtaining a better understanding of the disease process, monitoring their symptoms, and feeling connected to their health care provider. Participants' perceptions obtained in this qualitative study will assist in improving the TELE-IBD system to be more responsive to patients with IBD. CLINICALTRIAL NCT01692743

Prevalence and distribution of peripheral musculoskeletal manifestations in spondyloarthritis including psoriatic arthritis: results of the worldwide, cross-sectional ASAS-PerSpA study

RMD Open ◽

10.1136/rmdopen-2020-001450 ◽

2021 ◽

Vol 7 (1) ◽

pp. e001450

Author(s):

Clementina López-Medina ◽

Anna Molto ◽

Joachim Sieper ◽

Tuncay Duruöz ◽

Uta Kiltz ◽

...

Keyword(s):

Psoriatic Arthritis ◽

Latin American ◽

Underlying Disease ◽

Cross Sectional Study ◽

Joint Disease ◽

Joint Involvement ◽

Cross Sectional ◽

Small Joint ◽

Musculoskeletal Manifestations ◽

ObjectivesTo characterise peripheral musculoskeletal involvement in patients with spondyloarthritis (SpA) including psoriatic arthritis (PsA), across the world.MethodsCross-sectional study with 24 participating countries. Patients with a diagnosis of axial SpA (axSpA), peripheral SpA (pSpA) or PsA according to their rheumatologist were included. The investigators were asked which diagnosis out of a list of six (axSpA, PsA, pSpA, inflammatory bowel disease-associated SpA, reactive arthritis or juvenile SpA (Juv-SpA)) fitted the patient best. Peripheral manifestations (ie, peripheral joint disease, enthesitis, dactylitis and root joint disease), their localisation and treatments were evaluated.ResultsA total of 4465 patients were included (61% men, mean age 44.5 years) from four geographic areas: Latin America (n=538), Europe plus North America (n=1677), Asia (n=975) and the Middle East plus North Africa (n=1275). Of those, 78% had ever suffered from at least one peripheral musculoskeletal manifestation; 57% had peripheral joint disease, 44% had enthesitis and 15% had dactylitis. Latin American had far more often peripheral joint disease (80%) than patients from other areas. Patients with PsA had predominantly upper limb and small joint involvement (52%).Hip and shoulder involvement was found in 34% of patients. The prevalence of enthesitis ranged between 41% in patients with axSpA and 65% in patients with Juv-SpA. Dactylitis was most frequent among patients with PsA (37%).ConclusionThese results suggest that all peripheral features can be found in all subtypes of SpA, and that differences are quantitative rather than qualitative. In a high proportion of patients, axial and peripheral manifestations coincided. These findings reconfirm SpA clinical subtypes are descendants of the same underlying disease, called SpA.

Effective use of monoclonal antibodies for treatment of persistent COVID-19 infection in a patient on rituximab

BMJ Case Reports ◽

10.1136/bcr-2021-243469 ◽

2021 ◽

Vol 14 (8) ◽

pp. e243469

Author(s):

Carlos X Rabascall ◽

Becky X Lou ◽

Brianne Navetta-Modrov ◽

Stella S Hahn

Keyword(s):

Monoclonal Antibodies ◽

Symptom Onset ◽

Severe Disease ◽

Therapeutic Window ◽

Immunosuppressed Patient ◽

Unique Case ◽

Risk Of Progression ◽

Effective Use ◽

Potential Use

As we are over a year into the COVID-19 pandemic, we have made many forward strides in therapeutics. These treatments, such as monoclonal antibodies, have help mitigate the detrimental and often fatal consequences of COVID-19. The current indication for the use of monoclonal antibodies is mild to moderate COVID-19 infection within 10 days of symptom onset in those who are at high risk of progression to severe disease. However, their role in patients with prolonged symptoms is not clear. We present a unique case of monoclonal antibodies use after 54 days of symptom onset in an immunosuppressed patient with persistent COVID-19 infection despite standard treatment. This case illustrates the potential use of monoclonal antibodies outside of the current recommended therapeutic window in immunosuppressed patients, who may have difficulty with viral clearance.

Measuring Disease Modification in Alzheimer's Disease

CNS Spectrums ◽

10.1017/s109285290002589x ◽

2007 ◽

Vol 12 (S1) ◽

pp. 11-14

Author(s):

Jeffrey L. Cummings

Keyword(s):

Alzheimer’S Disease ◽

Alzheimer's Disease ◽

Immunoglobulin A ◽

Disease Process ◽

Underlying Disease ◽

Therapeutic Interventions ◽

Disease Modification ◽

Amyloid Disease ◽

Therapeutic Modalities ◽

Disease Modifying

AbstractWe appear to be on the brink of a new epoch of treatment for Alzheimer's disease. Compelling evidence suggests that Aβ42 secretion is the triggering event in the pathogenesis of Alzheimer's disease, and that tau aggregation may be an important secondary event linked to neurodegeneration. Prophylactic administration of anti-amyloid agents designed to prevent Aβ accumulation in persons with subclinical disease is likely to be more effective than therapeutic interventions in established Alzheimer's disease. Drug development programs in Alzheimer's disease focus primarily on agents with anti-amyloid disease-modifying properties, and many different pharmacologic approaches to reducing amyloid pathology and tauopathy are being studied. Classes of therapeutic modalities currently in advanced-stage clinical trial testing include forms of immunotherapy (active β -amyloid immunoconjugate and human intravenous immunoglobulin), a γ-secretase inhibitor, the selective Aβ42-lowering agent R-flurbiprofen, and the anti-aggregation agent tramiprosate. Non-traditional dementia therapies such as the HMG-CoA reductase inhibitors (statins), valproate, and lithium are now being assessed for clinical benefit as anti-amyloid disease-modifying treatments. Positive findings of efficacy and safety from clinical studies are necessary but not sufficient to demonstrate that a drug has disease-modifying properties. Definitive proof of disease-modification requires evidence from validated animal models of Alzheimer's disease; rigorously controlled clinical trials showing a significantly improved, stabilized, or slowed rate of decline in cognitive and global function compared to placebo; and prospectively obtained evidence from surrogate biomarkers that the treatment resulted in measurable biological changes associated with the underlying disease process.

Clinical Features and Outcomes of a Racially Diverse Population with Fibrillary Glomerulonephritis

American Journal of Nephrology ◽

10.1159/000455390 ◽

2017 ◽

Vol 45 (3) ◽

pp. 248-256 ◽

Cited By ~ 13

Author(s):

Fernanda Payan Schober ◽

Meghan A. Jobson ◽

Caroline J. Poulton ◽

Harsharan K. Singh ◽

Volker Nickeleit ◽

...

Keyword(s):

Clinical Characteristics ◽

Disease Process ◽

Signs And Symptoms ◽

Patient Characteristics ◽

Underlying Disease ◽

Fibrillary Glomerulonephritis ◽

Black Patients ◽

End Stage ◽

20 Nm ◽

The University

Background: Fibrillary glomerulonephritis is characterized by randomly arranged fibrils, approximately 20 nm in diameter by electron microscopy. Patients present with proteinuria, hematuria and kidney insufficiency, and about half of the reported patients progress to end-stage kidney disease within 4 years. The dependence of patient characteristics and outcomes on race has not been explored. In this study, we describe a cohort of patients with fibrillary glomerulonephritis and compare their clinical characteristics and outcomes with those of patients previously described. Methods: The University of North Carolina (UNC) Nephropathology Database was used to retrospectively identify patients diagnosed with fibrillary glomerulonephritis between 1985 and 2015. Of these patients, those treated at UNC were selected. Their demographic and clinical characteristics - including signs and symptoms, comorbidities, laboratory values, treatments and outcomes - were compared with those of patients described earlier. Results: Among the 287 patients identified, 42 were treated at the UNC Kidney Center. When compared to earlier cohorts, a higher frequency of black race, hepatitis C virus (HCV) infection and use of hemodialysis were noted in both black and HCV-positive patients. Autoimmune diseases, infections and malignancies were frequently observed, present in over half of all cases. Conclusion: According to this study, fibrillary glomerulonephritis represents a secondary glomerular disease process (associated with autoimmune disease, infection or malignancy) in many cases and hence screening is essential. As the screening for comorbidities increased over time, more underlying causes were identified. We noted a high frequency of HCV among black patients, suggesting a possible causative association. Treatment of underlying disease is essential for patients for the best outcome.

Chronic Nonspecific Inflammatory Bowel Disease of the Cecum and Proximal Colon in Children With Grossly Normal-Appearing Colonic Mucosa: Diagnosis by Colonoscopic Biopsies

PEDIATRICS ◽

10.1542/peds.80.2.255 ◽

1987 ◽

Vol 80 (2) ◽

pp. 255-261

Author(s):

Melvin B. Heyman ◽

Jay A. Perman ◽

Linda D. Ferrell ◽

M. Michael Thaler

Keyword(s):

Inflammatory Bowel Disease ◽

Abdominal Pain ◽

Bowel Disease ◽

Colonic Mucosa ◽

Disease Process ◽

Proximal Colon ◽

Chronic Abdominal Pain ◽

Medical Attention ◽

Inflammatory Bowel ◽

Inflammatory Changes

The diagnosis of inflammatory bowel disease rests on radiologic, endoscopic, and histologic creteria. Five patients, 2 to 17 years of age, sought medical attention because of chronic abdominal pain, diarrhea, and heme-positive stools. Rectal biopsies, visual inspection of colonic mucosa through the colonoscope, and contrast radiographs of the large and small intestine yielded nonspecific results. Serial endoscopic biopsies demonstrated a gradient of inflammatory changes diminishing in severity distally from the ileocecal valve and cecum. The disease process was most evident in specimens from the cecum, whereas biopsies distal to the transverse colon had a normal histologic appearance in all five patients. Biopsies from the proximal colon may provide evidence of inflammatory bowel disease not detectable using standard techniques. The combination of chronic abdominal pain, diarrhea, and heme-positive stools associated with inflammatory changes in biopsy specimens obtained from the proximal colon, but normal findings on radiologic, colonoscopic, and rectal biopsy examinations, may represent an early stage in the evolution of chronic nonspecific inflammatory bowel disease, including ulcerative colitis or regional enteritis (Crohn disease).

Cytomegalovirus-Associated Hemophagocytic Syndrome

PEDIATRICS ◽

10.1542/peds.75.2.280 ◽

1985 ◽

Vol 75 (2) ◽

pp. 280-283

Author(s):

ELIZABETH H. DANISH ◽

BEVERLY B. DAHMS ◽

MARY L. KUMAR

Keyword(s):

Viral Infection ◽

Epstein Barr Virus ◽

Hemophagocytic Syndrome ◽

Clinical Course ◽

Underlying Disease ◽

Barr Virus ◽

Pathologic Findings ◽

Epstein Barr ◽

Herpes Group

Virus-associated hemophagocytic syndrome, first described by Risdall and co-workers in 1979,1 is a rare histiocytic proliferative syndrome characterzed by fever, hepatosplenomegaly, pancytopenia, and erythrophagocytosis by histiocytes that appear benign by histologic criteria. The clinical course and pathologic findings may be identical with another histiocytic disorder, familial erythrophagocytic lymphohistiocytosis, which occurs predominantly in infants. Diagnosis of virus-associated hemophagocytic syndrome depends entirely on evidence of concurrent viral infection, usually of the herpes group. Epstein-Barr virus has been associated with this syndrome in the few cases reported in children without underlying disease, whereas cytomegalovirus (CMV) has been implicated in immunosuppressed patients. We report a case of fatal CMV-associated hemophagocytic syndrome which occurred in a previously healthy infant.