Modulation, microbiota and inflammation in the adult CF gut: A prospective study.

BACKGROUND: Cystic Fibrosis (CF) has prominent gastrointestinal and pancreatic manifestations. The aim of this study was to determine the effect of Cystic fibrosis transmembrane conductance regulator (CFTR) modulation on, gastrointestinal inflammation, pancreatic function and gut microbiota composition in people with cystic fibrosis (CF) and the G551D-CFTR mutation. METHODS: Fourteen adult patients with the G551D-CFTR mutation were assessed clinically at baseline and for up to 1 year after treatment with ivacaftor. The change in gut inflammatory markers (calprotectin and lactoferrin), exocrine pancreatic status and gut microbiota composition and structure were assessed in stool samples. RESULTS: There was no significant change in faecal calprotectin nor lactoferrin in patients with treatment while all patients remained severely pancreatic insufficient. There was no significant change in gut microbiota diversity and richness following treatment. CONCLUSION: There was no significant change in gut inflammation after partial restoration of CFTR function with ivacaftor, suggesting that excess gut inflammation in CF is multi-factorial in aetiology. In this adult cohort, exocrine pancreatic function was irreversibly lost. Longer term follow-up may reveal more dynamic changes in the gut microbiota and possible restoration of CFTR function.

Irritant contact dermatitis in healthcare workers as a result of the COVID-19 pandemic: a cross-sectional study.

COVID-19 healthcare workers (HCWs) require frequent handwashing and use of personal protective equipment (PPE) to prevent infection. However, evidence is emerging that these practices are causing adverse effects on their skin integrity. A single-centre, cross-sectional study of HCWs from an Irish hospital was undertaken to evaluate the degree of COVID-19-related irritant contact dermatitis (ICD) between April and May 2020. Of 270 participants surveyed, 223 (82.6%) reported symptoms of ICD. The hands were the most commonly affected site (76.47%) and the most frequently reported symptom was dry skin (75.37%). Nearly all (268; 99.26%) HCWs had increased hand-washing frequency, but 122 (45.35%) did not use emollients. In the ICD group, 24.7% cited a history of dermatitis compared with 4.3% of unaffected staff (P < 0.001). The ICD group recorded PPE usage for an average of 3.15 h compared with the non-ICD group at 1.97 h (P = 0.21). Promoting awareness of COVID-19-related ICD is vital to highlight prevention and treatment for frontline staff.

A pilot study demonstrating the altered gut microbiota functionality in stable adults with Cystic Fibrosis.

Cystic Fibrosis (CF) and its treatment result in an altered gut microbiota composition compared to non-CF controls. However, the impact of this on gut microbiota functionality has not been extensively characterised. Our aim was to conduct a proof-of-principle study to investigate if measurable changes in gut microbiota functionality occur in adult CF patients compared to controls. Metagenomic DNA was extracted from faecal samples from six CF patients and six non-CF controls and shotgun metagenomic sequencing was performed on the MiSeq platform. Metabolomic analysis using gas chromatography-mass spectrometry was conducted on faecal water. The gut microbiota of the CF group was significantly different compared to the non-CF controls, with significantly increased Firmicutes and decreased Bacteroidetes. Functionality was altered, with higher pathway abundances and gene families involved in lipid (e.g. PWY 6284 unsaturated fatty acid biosynthesis (p = 0.016)) and xenobiotic metabolism (e.g. PWY-5430 meta-cleavage pathway of aromatic compounds (p = 0.004)) in CF patients compared to the controls. Significant differences in metabolites occurred between the two groups. This proof-of-principle study demonstrates that measurable changes in gut microbiota functionality occur in CF patients compared to controls. Larger studies are thus needed to interrogate this further.

A Study To Assess The Prevalence Of Exercise-Induced Bronchoconstriction In Inter-County Hurling.

Exercise-Induced Bronchoconstriction (EIB) is an acute, transient airway narrowing occurring after exercise which may impact athletic performance. Studies report 10% of the general population and up to 90% of asthmatics experience EIB. Ninety-two players from three elite hurling squads underwent a spirometric field-based provocation test with real-time heart rate monitoring and lactate measurements to ensure adequate exertion. Players with a new diagnosis of EIB and those with a negative field-test but with a previous label of EIB or asthma underwent further reversibility testing and if negative, methacholine challenge. Eight (8.7%) of players had EIB, with one further athlete having asthma with a negative field test. Interestingly, only three out of 12 players who had previously been physician-labelled with EIB or asthma had their diagnosis objectively confirmed. Our study highlights the role of objective testing in EIB.

Trial of a novel plasma gas disinfection system (Radica) to reduce mattress residual bacterial contamination in the acute hospital setting: a preliminary study.

BACKGROUND: In routine clinical practice, mattresses are manually cleaned using specialised cleaning and high-level disinfecting fluids. While effective against a wide range of organisms, the success of this approach is dependent on a thorough and complete application and is likely to be susceptible to human error and thus variable. The efficacy of available infection control measures to reduce such mattress contamination is unknown as it is not subject to quality control measures. There is a pressing need to identify more effective methods to prevent cross contamination within the medical environment, given the lack of available treatment strategies. AIM: The purpose of this study is to investigate the ability of a new technology, gaseous technology, to reduce colonization levels, compared to standard cleaning, and so attenuate superficial nosocomial infections. METHODS: We conducted a prospective, single-centre, open-label, non-randomized trial with blinded outcome assessments, comparing the standard cleaning of hospital mattresses with a novel plasma based disinfection system Radica™, followed by a standard post-cleaning culturing protocol (five swabs/mattress). RESULTS: The median (interquartile range) maximal colony count per mattress for the 20 Radica versus 7 routinely cleaned mattresses was 1 (1-2.7) versus Too-Numerous-to-Count (TNTC) (32-TNTC), respectively, p = 0.002. Of the 20 Radica™ treated mattresses, 12 (60 %) had no positive culture result while all of the standard cleaned mattresses had at least two positive cultures. CONCLUSION: The plasma based Radica disinfection system reduces mattress bacterial colonization levels as compared to routine cleaning. This is a potentially important technology in the health care system to reduce surface colonisation and hence nosocomial infections.

Clostridium difficile carriage in adult cystic fibrosis (CF); implications for patients with CF and the potential for transmission of nosocomial infection.

Clostridium difficile is an anaerobic Gram-positive, spore-forming, toxin-producing bacillus transmitted among humans through the faecal-oral route. Despite increasing carriage rates and the presence of C. difficile toxin in stool, patients with CF rarely appear to develop typical manifestations of C. difficile infection (CDI). In this study, we examined the carriage, toxin production, ribotype distribution and antibiotic susceptibility of C. difficile in a cohort of 60 adult patients with CF who were pre-lung transplant. C. difficile was detected in 50% (30/60) of patients with CF by culturing for the bacteria. C. difficile toxin was detected in 63% (19/30) of C. difficile-positive stool samples. All toxin-positive stool samples contained toxigenic C. difficile strains harbouring toxin genes, tcdA and tcdB. Despite the presence of C. difficile and its toxin in patient stool, no acute gastrointestinal symptoms were reported. Ribotyping of C. difficile strains revealed 16 distinct ribotypes (RT), 11 of which are known to be disease-causing including the hyper-virulent RT078. Additionally, strains RT002, RT014, and RT015, which are common in non-CF nosocomial infection were described. All strains were susceptible to vancomycin, metronidazole, fusidic acid and rifampicin. No correlation was observed between carriage of C. difficile or any characteristics of isolated strains and any recorded clinical parameters or treatment received. We demonstrate a high prevalence of hypervirulent, toxigenic strains of C. difficile in asymptomatic patients with CF. This highlights the potential role of asymptomatic patients with CF in nosocomial transmission of C. difficile.

Ionizing radiation exposure as a result of diagnostic imaging in patients with lymphoma.

PURPOSE: Survival rates among patients with lymphoma continue to improve. Strategies aimed at reducing potential treatment-related toxicity are increasingly prioritized. While radiological procedures play an important role, ionizing radiation exposure has been linked to an increased risk of malignancy, particularly among individuals whose cumulative radiation exposure exceeds a specific threshold (75 millisieverts). METHODS: Within this retrospective study, the cumulative radiation exposure dose was quantified for 486 consecutive patients with lymphoma. RESULTS: The median estimated total cumulative effective dose (CED) of ionizing radiation per subject was 69 mSv (42-118). However, younger patients (under 40 years) had a median CED of 89 mSv (55-124). CONCLUSION: This study highlights the considerable radiation exposure occurring among patients with lymphoma as a result of diagnostic imaging. To limit the risk of secondary carcinogenesis, consideration should be given to monitoring cumulative radiation exposure in individual patients as well as considering imaging modalities, which do not impart an ionizing radiation dose.

Thromboprophylaxis in myeloma: what is happening outside of clinical trials?

Patients with myeloma are at high risk of venous thromboembolism (VTE). There is no consensus about what agent to use or what haematologists are doing in clinical practice. A survey was sent to haematologists treating patients with myeloma in Ireland. 32/45 (71%) responded. 13/28 (46%) felt that VTE affected < 5% of patients. However, 8/28 (29%) felt it affected 10-19%. Thromboprophylaxis was most commonly used in patients on lenalidomide; 25/28 (89%) and thalidomide; 23/28 (82%). 23/28 (82%) used LMWH and 20/28 (71%) used aspirin either very frequently or frequently. 3/28 (11%) had used dabigatran/rivaroxaban despite there being little evidence to support their use. Efficacy was the most important factor in choosing an agent for 25/28 (89%). Bleeding was not felt to be an issue 15/29 (52%) were not using thromboprophylaxis guidelines. This survey demonstrated wide variation in the beliefs and practices regarding the burden of VTE in patients with myeloma and the need for thromboprophylaxis.

Inhaled versus nebulised tobramycin: a real world comparison in adult cystic fibrosis (CF).

BACKGROUND: There are no published data on real-life clinical experience comparing inhaled antibiotic therapy via new rapid delivery systems with nebulised antibiotic therapy in CF. This real world study compares safety, effectiveness and tolerability using tobramycin inhaled powder (TIP) versus tobramycin inhaled solution (TIS). METHODS: Adult patients with CF commencing TIP (n=78) completed a questionnaire assessing safety, efficacy, tolerability, patient-satisfaction and self-reported adherence to TIS at baseline and during 12 months of TIP therapy. FEV1% predicted and exacerbation rate were recorded at each visit. RESULTS: There was a significant improvement in adherence scores, with a significant decrease in the number of intravenous antibiotic courses received during 12 months of TIP compared with the preceding 12 months using TIS. 94% of patients who had previously used TIS preferred TIP therapy over TIS. CONCLUSIONS: Inhaled powder tobramycin in CF is associated with improved adherence, tolerability and decreased exacerbation rates compared to nebulised treatment in real-life practice.

A study to assess inhaler technique and its potential impact on asthma control in patients attending an asthma clinic.

OBJECTIVES: The aim of this study was to evaluate inhaler technique and symptom control in patients with poorly controlled asthma at baseline and at follow-up in a dedicated asthma clinic in a tertiary hospital. We also investigated the impact of asthma on these patients' quality of life. METHODS: Patients referred to a newly established asthma clinic in Cork University Hospital were prospectively recruited over a 6-month period. Their inhaler technique was assessed by a pulmonary nurse specialist using a validated scoring system. They received instruction on inhaler usage when scores were suboptimal. Patients completed a validated asthma control questionnaire (ACQ) and asthma quality of life questionnaire (AQLQ). At follow-up 3-4 months later, the inhaler technique was reassessed and the ACQ questionnaire repeated. RESULTS: Forty-six patients were recruited (female = 74%), and 40/46 were followed up. Mean [SD] FEV1 % predicted at baseline = 76.5% [21.5]. About 63% of the patients were classified as incorrectly using their inhaler at their initial assessment. This decreased to 20% at follow-up, indicating an overall significant improvement in inhaler usage post-training (p = 0.003). ACQ scores improved significantly from median [interquartile range] 2.70 [1.66] to 2.00 [1.90] (p = 0.002). Baseline measurement indicated that patients' quality of life was moderately affected by asthma, with a median AQLQ score of 4.75 [1.97]. CONCLUSION: This study demonstrates the importance of educating and formally assessing inhaler technique in patients with asthma as a part of their ongoing clinical review.

Serum D-dimer concentrations in nephrotic syndrome track with albuminuria, not estimated glomerular filtration rate.

BACKGROUND: The nephrotic syndrome is associated with an increased risk of venous and arterial thrombosis. There are little published data on the distribution, interpretation or determinants of serum D-dimer levels in patients with the nephrotic syndrome. We aimed to describe this relationship. METHODS: This was a cross-sectional study of 100 patients with the nephrotic syndrome. Multivariate linear regression was used to evaluate for independent predictors of elevated D-dimer levels. Patients were observed for a period of 2 years after the baseline measurement of D-dimer level to assess for subsequent clinically evident thrombosis. RESULTS: On univariate linear regression, D-dimer elevation was associated with age in years ß (95% CI) 0.02 (0.016, 0.03), log-transformed urinary protein:creatinine ratio in g/g 0.439 (0.32, 0.558) and inversely with serum albumin in g/l -0.05 (-0.073, -0.035) and estimated glomerular filtration rate (eGFR) in ml/min/1.73 m(2) -0.01 (-0.016, -0.003). On multivariate linear regression, age in years ß (95% CI) 0.019 (0.012, 0.026), serum albumin in g/l -0.023 (-0.043, -0.003), and log-transformed urinary protein:creatinine ratio in g/g 0.266 (0.124, 0.408) were independently associated with elevated D-dimer levels. CONCLUSION: D-dimer levels are commonly raised in the nephrotic syndrome in the absence of clinically evident thrombosis, and are independently associated with age, degree of proteinuria and serum albumin, but not with eGFR. Baseline levels of D-dimer did not predict subsequent episodes of clinically evident thrombosis after 2 years of follow-up.

Perinephric haematoma causing refractory hypertension in a 17-year-old male.

New-onset arterial hypertension is a well-recognised complication of kidney trauma. Cases have been described in young healthy athletes with hypertension arising years after sports-related trauma. The pathophysiology of this disease is thought to arise from intrarenal arterial stenosis resulting from rapid deceleration during the initial injury. This leads to arterial obstruction and ischaemia with increased secretion of renin, eventually leading to elevated blood pressure. Though hypertension in these cases is generally gradual in onset and long-standing, it can also rise acutely, leading to malignant hypertension. We present the case of a 17-year-old male who presented with refractory hypertension following blunt trauma to his left kidney during a recent sporting injury. This is followed by a discussion of the relevant literature in this area to date, highlighting the key challenges involved in the management of these patients.

Association of cigarette smoking with drug use and risk taking behaviour in Irish teenagers.

BACKGROUND: Cigarette smoking has been shown to act as a 'gateway' to cannabis use and further risk taking behaviours. This study aims to (1) establish the prevalence of cigarette smoking and cannabis use in Irish teenagers, (2) to quantify the strength and significance of the association of cigarette smoking and cannabis use and other high risk behaviours and (3) examine whether the above associations are independent of the extent of social networking. METHODS: Adolescent students across five urban, non-fee paying schools completed an abridged European schools survey project on alcohol and other drugs (ESPAD) questionnaire. RESULTS: 370/417 (88.7%) students completed the questionnaire. 228 (61.6%) were female, 349 (94.3%) were aged 15-16 years. 48.4% of those surveyed had smoked tobacco at some stage in their lifetime, 18.1% in the last 30 days. 15.1% have used cannabis with 5.7% using it in the last 30 days. 29.6% of cigarette smokers have used cannabis in comparison to 1.6% of non-smokers. On multivariate analysis lifetime cigarette smoking status was independently associated with hard drug use, adjusted OR=6.0, p<0.01; soft drug use, adjusted OR=4.6, p<0.01 and high risk sex practises, adjusted OR=10.6, p<0.05. CONCLUSIONS: Cigarette smoking prevalence remains high in Irish teenagers and is significantly associated with drug use and other risk taking behaviours. Specific teenage smoking cessation strategies need to be developed targeting these combined high risk health behaviours.

Changes in serum calcium, phosphate, and PTH and the risk of death in incident dialysis patients: a longitudinal study.

Elevated bone mineral parameters have been associated with mortality in dialysis patients. There are conflicting data about calcium, parathyroid hormone (PTH), and mortality and few data about changes in bone mineral parameters over time. We conducted a prospective cohort study of 1007 incident hemodialysis and peritoneal dialysis patients. We examined longitudinal changes in bone mineral parameters and whether their associations with mortality were independent of time on dialysis, inflammation, and comorbidity. Serum calcium, phosphate, and calcium-phosphate product (CaP) increased in these patients between baseline and 6 months (P<0.001) and then remained stable. Serum PTH decreased over the first year (P<0.001). In Cox proportional hazards models adjusting for inflammation, comorbidity, and other confounders, the highest quartile of phosphate was associated with a hazard ratio (HR) of 1.57 (1.07-2.30) using both baseline and time-dependent values. The highest quartiles of calcium, CaP, and PTH were associated with mortality in time-dependent models but not in those using baseline values. The lowest quartile of PTH was associated with an HR of 0.65 (0.44-0.98) in the time-dependent model with 6-month lag analysis. We conclude that high levels of phosphate both at baseline and over follow-up are associated with mortality in incident dialysis patients. High levels of calcium, CaP, and PTH are associated with mortality immediately preceding an event. Promising new interventions need to be rigorously tested in clinical trials for their ability to achieve normalization of bone mineral parameters and reduce deaths of dialysis patients.

Successful treatment of hypoalbuminemic hemodialysis patients with a modified regimen of oral essential amino acids.

OBJECTIVE: To evaluate compliance and the change in serum albumin associated with essential amino acid (EAA) therapy in hypoalbuminemic hemodialysis subjects. DESIGN AND SETTING: Open label, single intervention, pilot study conducted at 2 outpatient hemodialysis centers located in Baltimore, Maryland. SUBJECTS: Eighteen patients with a mean 3-month prestudy serum albumin of <3.8 g/dL and a mean Kt/V of > or =1.0, without any recent hospitalizations or infections, who provided informed consent, and who demonstrated > or =90% compliance rate during a 2 week run-in period, were enrolled in the study. The mean age was 61.3 years, 44% were male, 78% were black, and 50% were diabetic. INTERVENTION: Subjects were instructed to take 3 Aminess N tablets (Recip AB, Stockholm, Sweden) 3 times each day with meals (total of 6.8 g of EAA per day) for 4 months. MAIN OUTCOME MEASURE: Median 4-month compliance and the change in mean follow-up serum albumin levels (mean of the serum albumin levels at day 30, day 60, day 90, and day 120 after the start of therapy) compared with mean baseline serum albumin levels (mean of the serum albumin levels at day -90, day -60, day -30, and day 0 before therapy). Secondary outcomes included changes in grip strength and body weight. Data was also collected on C-reactive protein levels, dialysis adequacy (Kt/V), and serum bicarbonate. A 2-day dietary recall was obtained at both the start and finish of the study. RESULTS: Monthly compliance with EAA tablets remained relatively stable over the study period, with median compliance rates of 86%, 88%, 82%, and 82% at months 1 through 4, and an overall median compliance of 82%. Seventy-eight percent of patients had an overall compliance rate of 70% or greater. Serum albumin improved from baseline to follow-up by a mean (95% confidence interval) of 0.20 g/dL (95% confidence interval, 0.04 to 0.30; P =.001). Lowest postdialysis weight increased from a mean of 74.5 kg to 77.1 kg (P =.05), and there was a nonsignificant increase in grip strength. C-reactive protein levels increased in 33%, remained constant in 11%, and decreased in 56% of subjects, and there was no significant correlation between change in C-reactive protein levels and improvement in serum albumin. Dietary recalls did not show any significant change in the spontaneous protein or caloric intakes in association with the use of the EAA tablets. CONCLUSION: Although uncontrolled, these results support the feasibility and benefits of moderate dose oral EAA supplementation in hypoalbuminemic hemodialysis subjects.

Timing of nephrologist referral and arteriovenous access use: the CHOICE Study.

Recent clinical practice guidelines recommend the creation of an arteriovenous (AV) vascular access (ie, native fistula or synthetic graft) before the start of chronic hemodialysis therapy to prevent the need for complication-prone dialysis catheters. We report on the association of referral to a nephrologist with duration of dialysis-catheter use and type of vascular access used in the first 6 months of hemodialysis therapy. The study population is a representative cohort of 356 patients with questionnaire, laboratory, and medical record data collected as part of the Choices for Healthy Outcomes in Caring for End-Stage Renal Disease Center Study. Patients who reported being seen by a nephrologist at least 1 month before starting hemodialysis therapy (75%) were more likely than those referred later to use an AV access at initiation (39% versus 10%; P < 0.001) and 6 months after starting hemodialysis therapy (74% versus 56%; P < 0.01). Patients referred within 1 month of initiating hemodialysis therapy used a dialysis catheter for a median of 202 days compared with 64, 67, and 19 days for patients referred 1 to 4, 4 to 12, and greater than 12 months before initiating hemodialysis therapy, respectively (P trend < 0.001). Patients referred at least 4 months before initiating hemodialysis therapy were more likely than patients referred later to use an AV fistula, rather than a synthetic graft, as their first AV access (45% versus 31%; P < 0.01). These associations remained after adjustment for age, sex, race, marital status, education, insurance coverage, comorbid disease status, albumin level, body mass index, and underlying renal diagnosis. These data show that late referral to a nephrologist substantially increases the likelihood of dialysis-catheter use at the initiation of hemodialysis therapy and is associated with prolonged catheter use. Regardless of the time of referral, only a minority of patients used an AV access at the initiation of treatment, and greater than 25% had not used an AV access 6 months after initiation. Thus, further efforts to improve both referral patterns and preparation for dialysis after referral are needed.

Cohort study of the prognostic significance of acute transplant glomerulitis in acutely rejecting renal allografts.

BACKGROUND: Acute transplant glomerulitis is a unique lesion in renal allografts, the prognostic significance of which is controversial. We conducted this retrospective cohort study to examine the independent prognostic significance of moderate-to-severe transplant glomerulitis in acute rejection. METHODS: Renal allograft survival for patients with acute rejection were studied, comparing one group with significant glomerulitis (G, n=28) with those with no glomerulitis (NG, n=35). Clinical, biopsy, and demographic data and renal graft survival were compared, and the association of G with graft failure was examined. RESULTS: In the G versus NG group, a greater percentage of patients were highly sensitized (peak panel reactive antibody value >80%; P=0.009), had had a previous renal transplant (40% vs. 11%; P=0.02), or had suffered from delayed graft function (P=0.03). The G group had a trend toward earlier rejection episodes (P=0.07), a significantly higher serum creatinine at the time of index biopsy (P=0.01), a higher prevalence of vascular rejection (P=0.02), and less improvement in mean reciprocal serum creatinine at 1-2 weeks after biopsy (P=0.02). Although there was a trend toward shorter allograft survival in the G group (P=0.09), the level of significance of which increased with adjustment for transplantation time period and the duration of the transplant-biopsy interval (P=0.06), the relative risk for graft loss was no longer significant when additionally adjusted for index biopsy Banff score (relative risk, 0.97; P=0.97). CONCLUSION: In this study, G was significantly more common in highly sensitized patients and was strongly associated with vascular rejection biopsies but was not an independent predictor of graft survival.

Treatment of HIV-associated nephropathy.

HIV-associated nephropathy (HIVAN) is the most common cause of renal failure in patients infected with type 1 human immunodeficiency virus (HIV-1). The renal prognosis for HIVAN is poor and is typically associated with rapid progression to renal death. We report a patient with biopsy-proven HIVAN who was successfully treated with corticosteroids and review the currently available evidence supporting the specific treatments of this condition. A 34-year-old African-American male with a 2-year history of uncomplicated HIV disease developed progressive azotemia despite treatment with highly active antiretroviral therapy (HAART). He was treated with an uncomplicated 4-month course of prednisone, which improved his serum creatinine from 2.9 to 1.9 mg/dl and decreased his degree of proteinuria from 8 to 2.1 g/day. Two years post-steroid treatment his renal function remains stable. Increasing evidence supports that both ACE inhibitors and HAART are effective in preventing and in some cases of reversing HIVAN induced renal failure. In selected patients who progress despite these measures, a limited course of corticosteroid may achieve long-standing disease remissions. In general, with adequate supervision, corticosteroid therapy appears to be well tolerated and has an acceptable side effect profile. Although persuasive in view of the abysmal natural history of HIVAN, the currently available studies are subject to major methodological limitations. Appropriate randomized controlled trials are urgently required in order to further examine the efficacy, optimal timing, and potential side effects of these treatments.

Outpatient vancomycin use and vancomycin-resistant enterococcal colonization in maintenance dialysis patients.

BACKGROUND: Although outpatient vancomycin is widely used as empiric therapy for dialysis-associated infections, its relationship with vancomycin-resistant enterococcal (VRE) colonization is not established. METHODS: During a two-year prospective cohort study, rectal swabs obtained from patients at the start and finish of the study period and during interim hospitalizations were cultured for VRE. RESULTS: Ten of 124 patients initially grew VRE. Twenty-four of the remaining patients had no follow-up cultures because of patient death (62%), transfer to another dialysis facility (17%), patient's refusal (7%), and transplantation (4%), and were thus excluded. The remaining patients (N = 90) had a median age of 54.3 years and were 92% African American and 50% male. Fifty-eight percent were treated by hemodialysis. They received 403 g of intravenous vancomycin over 157.2 patient-years of follow-up, 73% as outpatients. Sixteen of 90 patients (17.8%) became colonized with VRE, an incidence rate of one case per 9.8 patient-years of follow-up. None of the 29 patients who did not receive vancomycin developed VRE compared with 26% of those treated with vancomycin (P = 0.001). The odds ratio (95% CI) for the association of outpatient vancomycin (g per year) with VRE colonization was 1.23 (1.05, 1.44, P = 0.008). The association remained significant following adjustment in separate logistic regression analyses for relevant demographic, clinical, antimicrobial (inpatient vancomycin, oral or intravenous cephalosprins, aminoglycosides, quinalones, or antianaerobics), and hospitalization exposures. The unadjusted relative risk of death in patients growing VRE was significantly higher than in those not colonized with VRE (P = 0.005). CONCLUSIONS: VRE colonization is a relatively common and under recognized problem among chronic dialysis patients. It is strongly and independently associated with the outpatient use of vancomycin, which should be avoided whenever possible.

Relation between gender and vascular access complications in hemodialysis patients.

Native arteriovenous (AV) fistulae for hemodialysis vascular access are believed to be associated with fewer complications than synthetic polytetrafluoroethylene (PTFE) grafts. We conducted a study among patients in the Dialysis Morbidity and Mortality Study to compare risk factors for complications of AV fistulae and PTFE grafts in men and women and to examine the effect of age on vascular access complications. We analyzed data from 833 incident patients with end-stage renal disease who had a PTFE graft (n = 621) or AV fistula (n = 212) in use 1 month after starting hemodialysis therapy. Follow-up using inpatient and outpatient Medicare administrative data identified a 1.8-times greater risk for a subsequent vascular access procedure for PTFE grafts (0.71 procedures/access-year) than for AV fistulae (0.39 procedures/access-year). Men with grafts and women with grafts or fistulae had a greater risk for a first subsequent access procedure than did men with fistulae (0.79, 0.65, and 0.59 versus 0.33 procedures/access-year, respectively). After adjustment for age, race, presence of diabetes mellitus, and history of smoking, peripheral vascular disease, and cardiovascular disease, use of a PTFE graft compared with an AV fistula was associated with a greater risk for a first subsequent procedure in men (relative hazard, 2.2; 95% confidence interval [CI], 1.6 to 2.9), but not in women (relative hazard, 1.0; 95% CI, 0.7 to 1.4). The excess risk associated with a PTFE graft compared with an AV fistula was limited to men in the lower three quartiles of age (ie,