Publications

BACKGROUND

In everyday practice, the use of colonoscopy for the prevention of colorectal cancer (CRC) is less effective in the proximal than the distal colon. A potential explanation for this is that proximal neoplasms have a more subtle endoscopic appearance, making them more likely to be overlooked.

OBJECTIVE

To investigate the differences in endoscopic appearance, ie, diminutive size and nonpolypoid shape, of proximal compared with distal colorectal neoplasms.

DESIGN

Cross-sectional, single-center study.

SETTING

Endoscopists at the Maastricht University Medical Center in the Netherlands who were previously trained in the detection and classification of nonpolypoid colorectal lesions.

PATIENTS

Consecutive patients undergoing elective colonoscopy.

MAIN OUTCOME MEASUREMENTS

Endoscopic appearance, ie, diminutive size (<6 mm) or nonpolypoid shape (height less than half of the diameter) of colorectal adenomas and serrated polyps (SPs), with a focus on adenomas with advanced histology, ie, high-grade dysplasia or early CRC and SPs with dysplasia or large size.

RESULTS

We included 3720 consecutive patients with 2106 adenomas and 941 SPs. We found that in both men and women, proximal adenomas with high-grade dysplasia/early CRC (n = 181) were more likely to be diminutive or nonpolypoid than distal ones (76.3% vs 26.2%; odds ratio [OR] 9.24; 95% CI, 4.45-19.2; P < .001). Of the proximal adenomas, 84.4% were diminutive or nonpolypoid compared with 68.0% of the distal ones (OR 2.66; 95% CI, 2.14-3.29; P < .001). Likewise, large/dysplastic SPs in the proximal colon were more often nonpolypoid than distal ones (66.2% vs 27.8%; OR 5.51; 95% CI, 2.79-10.9; P < .001).

LIMITATIONS

Inclusion of both symptomatic and asymptomatic patients.

CONCLUSIONS

Proximal colorectal neoplasms with advanced histology frequently are small or have a nonpolypoid appearance. These findings support careful inspection of the proximal colon, if quality of cancer prevention with the use of colonoscopy is to be optimized.

Biventricular device implantation with the insertion of a transvenous left ventricular (LV) lead can be challenging. The aim of this study was to identify predictors of procedural difficulty measured by fluoroscopy time and predictors of LV lead implantation failure. A single-center, retrospective study of 272 consecutive patients who underwent biventricular device implantation from 2004 to 2011 was conducted. Multivariate linear regression was used to assess predictors of fluoroscopy time and logistic regression to identify predictors of LV lead implant failure. The median fluoroscopy time was 36.1 minutes (interquartile range 24.2 to 51.6). After multivariate adjustment, independent predictors of longer fluoroscopy time included a right-sided approach (21.8 minutes longer, 95% confidence interval [CI] 6.8 to 36.9, p = 0.005), previous congenital heart disease surgery (64.6 minutes longer, 95% CI 30.2 to 99.0, p <0.001), and previous failed attempt (30.3 minutes longer, 95% CI 6.0 to 54.5, p = 0.015). Predictors of shorter fluoroscopy time included an LV lead upgrade (7.5 minutes shorter, 95% CI 0.6 to 14.4, p = 0.033), electrophysiology fellow experience (5.4 minutes shorter/year, 95% CI 0.1 to 10.7, p = 0.047), and attending physician experience (1.4 minutes shorter/year, 95% CI 0.01 to 2.9, p = 0.049). Failed implantation occurred in 8% of patients (22 of 272); inability to cannulate the coronary sinus and absent or atretic coronary sinus veins were the most common reasons (8 of 22 failed implants each). A previous failed attempt was the only significant predictor of LV lead implantation failure (odds ratio 33.5, 95% CI 3.2 to 352.6, p = 0.003). In conclusion, 6 patient and operator characteristics predicted LV lead implantation difficulty measured by fluoroscopy time. LV lead implantation failed in 8% of cases, predicted only by a previous failed attempt.

BACKGROUND

Cytomegalovirus (CMV) infection has been implicated in immune activation and accelerated progression of immunodeficiency from human immunodeficiency virus (HIV) coinfection. We hypothesized that CMV is associated with vascular disease in HIV-infected adults.

METHODS

In the Women's Interagency HIV Study, we studied 601 HIV-infected and 90 HIV-uninfected participants. We assessed the association of CMV immunoglobulin G (IgG) level with carotid artery intima-media thickness, carotid artery distensibility, Young's elastic modulus, and blood pressures. Multivariable models adjusted for age, race/ethnicity, smoking, diabetes, and body mass index.

RESULTS

Mean CMV IgG levels were higher in HIV-infected women compared with HIV-uninfected women (P < .01). Among HIV-infected women, higher CMV IgG level was associated with decreased carotid artery distensibility (P < .01) and increased Young's modulus (P = .02). Higher CMV IgG antibody level was associated with increased prevalence of carotid artery lesions among HIV-infected women who achieved HIV suppression on antiretroviral therapy, but not among viremic or untreated HIV-infected women. Adjustment for Epstein-Barr virus antibody levels and C-reactive protein levels had no effect on the associations between CMV IgG levels and vascular parameters.

CONCLUSIONS

Cytomegalovirus antibody titers are increased in HIV-infected women and associated with subclinical cardiovascular disease. Host responses to CMV may be abnormal in HIV infection and associated with clinical disease.