Early hospital readmissions post-kidney transplantation are associated with inferior clinical outcomes.

Unplanned hospital readmissions are common early post-kidney transplantation. We investigated the relationship between early hospital readmissions and clinical outcomes in a single-center retrospective study that included all adult kidney transplant patients between 2004 and 2008 with follow-up to December 2012. The early hospital readmissions within the first 30 d were numbered and the diagnosis ascertained. Patients were grouped as none, once, and twice or more readmissions. Predictors of early readmissions were assessed, and clinical outcomes and patient and death-censored kidney survival were compared. Among 1064 patients, 203 (19.1%) patients had once and 83 (7.8%) patients had twice or more readmissions within 30 d. Surgical complications, infections, and acute kidney injuries/acute rejection were three most common diagnoses. The length of initial hospital stay and African American race were among the variables associated significantly with readmissions. Patients with early readmissions had lower baseline renal function (p < 0.01) and more early acute rejection (p < 0.01). During follow-up, only frequent readmissions, twice or more, within 30 d were associated with increased risk of death (AHR 1.75, p = 0.01) and death-censored kidney failure (AHR 2.20, p < 0.01). Frequent early hospital readmissions post-transplantation identify patients at risk for poor long-term outcomes, and more studies are needed to understand the mechanisms.

Educational achievement and pain disability among women with chronic pelvic pain.

OBJECTIVE: This study examined the relationship of level of educational (LOE) achievement to pain experience, affective disturbance, and perceived disability among women with chronic pelvic pain presenting for pain treatment. METHODS: 187 patients completed a battery of self-report inventories assessing pain, psychological status, and functional ability. Educational attainment was stratified across five levels from "less than high school" to "graduate/professional school." RESULTS: Significant inverse associations were found between lower educational achievement and more severe pain, somatic preoccupation, emotional suffering and guardedness, and functional impairment. No differences were obtained across the groups for age, duration of pain, or symptoms of depression. CONCLUSIONS: These data provide support for the importance of socioeconomic factors, particularly LOE, in furthering our understanding of the morbidity observed among women suffering chronic pelvic pain.

Nomenclature of magnetic, incommensurate, composition-changed morphotropic, polytype, transient-structural and quasicrystalline phases undergoing phase transitions. II. Report of an IUCr Working Group on Phase Transition Nomenclature.

A general nomenclature applicable to the phases that form in any sequence of transitions in the solid state has been recommended by an IUCr Working Group [Acta Cryst. (1998). A54, 1028-1033]. The six-field notation of the first Report, hereafter I, was applied to the case of structural phase transitions, i.e. to transformations resulting from temperature and/or pressure changes between two crystalline (strictly periodic) phases involving modifications to the atomic arrangement. Extensive examples that illustrate the recommendations were provided. This second Report considers, within the framework of a similar six-field notation, the more complex nomenclature of transitions involving magnetic phases, incommensurate phases and transitions that occur as a function of composition change. Extension of the nomenclature to the case of phases with less clearly established relevance to standard schemes of transition in equilibrium systems, namely polytype phases, radiation-induced and other transient phases, quasicrystalline phases and their transitions is recommended more tentatively. A uniform notation for the translational periodicity, propagation vector or wavevector for magnetic and/or incommensurate substances is specified. The notation adopted for incommensurate phases, relying partly on the existence of an average structure, is also consistent with that for commensurate phases in a sequence. The sixth field of the nomenclature is used to emphasize the special features of polytypes and transient phases. As in I, illustrative examples are provided for each category of phase sequence.

Outcomes after surgery for thoracic outlet syndrome.

PURPOSE: This study determined whether there is an association between psychological and socioeconomic characteristics and the long-term outcome of operative treatment for patients with sensory neurogenic thoracic outlet syndrome (N-TOS). METHODS: Clinical records, preoperative psychological testing results, and long-term follow-up questionnaire data were reviewed for consecutive patients who underwent surgery for N-TOS from 1990 to 1999. Multivariate logistic regression models were developed as a means of identifying independent risk factors for postoperative disability. RESULTS: Operative decompression of the brachial plexus via a supraclavicular approach was performed for upper extremity pain and paresthesia with no mortality and minimal morbidity in 170 patients. After an average follow-up period of 47 months, 65% of patients reported improved symptoms, and 64% of patients were satisfied with their operative outcome. However, 35% of patients remained on medication, and 18% of patients were disabled. Preoperative factors associated with persistent disability include major depression (odds ratio [OR], 15.7; P =.02), not being married (OR, 7.9; P =.04), and having less than a high school education (OR, 8.1; P =.09). CONCLUSION: Operative decompression was beneficial for most patients. Psychological and social factors, including depression, marital status, and education, are associated with self-reported disability. The impact of the preoperative treatment of depression on the outcome of TOS decompression should be studied prospectively.

Phase Equilibria and Crystallography of Ceramic Oxides.

Research in phase equilibria and crystallography has been a tradition in the Ceramics Division at National Bureau of Standards/National Institute of Standatrds and Technology (NBS/NIST) since the early thirties. In the early years, effort was concentrated in areas of Portland cement, ceramic glazes and glasses, instrument bearings, and battery materials. In the past 40 years, a large portion of the work was related to electronic materials, including ferroelectrics, piezoelectrics, ionic conductors, dielectrics, microwave dielectrics, and high-temperature superconductors. As a result of the phase equilibria studies, many new compounds have been discovered. Some of these discoveries have had a significant impact on US industry. Structure determinations of these new phases have often been carried out as a joint effort among NBS/NIST colleagues and also with outside collaborators using both single crystal and neutron and x-ray powder diffraction techniques. All phase equilibria diagrams were included in Phase Diagrams for Ceramists, which are collaborative publications between The American Ceramic Society (ACerS) and NBS/NIST. All x-ray powder diffraction patterns have been included in the Powder Diffraction File (PDF). This article gives a brief account of the history of the development of the phase equilibria and crystallographic research on ceramic oxides in the Ceramics Division. Represented systems, particularly electronic materials, are highlighted.

Prospective analysis of psychosocial outcomes in breast reconstruction: one-year postoperative results from the Michigan Breast Reconstruction Outcome Study.

In the past decade, changing attitudes toward breast reconstruction among both patients and providers have led a growing number of women to seek breast reconstruction after mastectomy. Although investigators have documented the psychological, social, emotional, and functional benefits of breast reconstruction, little research has evaluated the effects of procedure choice on these outcomes. The current study prospectively evaluated and compared psychosocial outcomes for three common options for mastectomy reconstruction: tissue expander/implant, pedicle TRAM, and free TRAM techniques. In a prospective cohort design, patients undergoing postmastectomy reconstruction for the first time with expander/implant, pedicle TRAM, or free TRAM procedures were recruited from 12 centers and 23 plastic surgeons in the United States and Canada. Before reconstruction and at 1 year after reconstruction, patients were evaluated by a battery of questionnaires consisting of both generic and condition-specific surveys. Outcomes assessed included emotional well-being, vitality, general mental health, social functioning, functional well-being, social well-being, and body image. Baseline (preoperative) scores and the change in scores (the difference between postoperative and preoperative scores) were compared across procedure types using t tests and analysis of covariance. Preoperative and 1-year postoperative surveys were obtained from 273 patients. Procedure type was reported in 250 patients, of whom 56 received implant reconstructions, 128 pedicle TRAM flaps, and 66 free TRAM flaps. A total of 161 immediate and 89 delayed reconstructions were performed. Among women receiving immediate reconstruction, significant improvements were observed in all psychosocial variables except body image. However, no significant effects of procedure type on these changes over time existed. Similarly, delayed reconstruction patients had significant increases in emotional well-being, vitality, general mental health, functional well-being, and body image. Although the choice of reconstructive technique did not significantly impact most of these outcomes, significant differences existed among procedure types for three psychosocial subscales. Patients undergoing delayed expander/implant reconstructions reported greater improvements in vitality and social well-being relative to women receiving delayed TRAM procedures. By contrast, delayed TRAM patients noted significantly greater gains in body image compared with women choosing delayed expander-implant reconstruction. The authors conclude that both immediate and delayed breast reconstructions provide substantial psychosocial benefits for mastectomy patients. Although the choice of reconstructive procedure does not seem to significantly affect improvements in psychosocial status with immediate reconstruction, our data suggest that procedure type does have a significant effect on gains in vitality and body image for women undergoing delayed reconstruction.

Psychosocial and sexual functioning in women with vulvodynia and chronic pelvic pain. A comparative evaluation.

OBJECTIVE: To determine whether women with vulvodynia differ from women with chronic pelvic pain and normal controls in their psychological functioning, somatic preoccupation, pain experience and sexual functioning. STUDY DESIGN: Cross-sectional, self-report study of women presenting to University of Michigan specialty and general clinics for the treatment of vulvodynia or chronic pelvic pain or seeking a routine gynecologic examination. All subjects completed questionnaires assessing demographic characteristics, pain, depressive symptoms, general affective state, marital adjustment, functional activity, somatic complaints, exposures, and medical and sexual history. Univariate analyses, chi 2 tests, analyses of variance and logistic regression were used to assess associations between these variables and the diagnostic category. RESULTS: Women with vulvodynia (n = 31) were similar to asymptomatic control women (n = 23) in demographic characteristics, sexual relationship variables, sexual behaviors, current and past depression, somatic sensitivity, and history of sexual or physical abuse. Women with chronic pelvic pain (n = 18) were younger and less educated than the other two groups and were more likely to have a history of physical and sexual abuse, to report recent depression and to screen positive for current depression, to have more work absences and to have more somatic complaints. CONCLUSION: Women with vulvodynia are psychologically similar to control women but differ significantly from women with chronic pelvic pain. A primary psychological cause of vulvodynia is not supported.

Negative affect, self-report of depressive symptoms, and clinical depression: relation to the experience of chronic pain.

OBJECTIVE: The goal of this study was to examine the relative importance of global affective distress, self-report of depressive symptoms, and presence or absence of major depression to the experience of chronic pain. SETTING: A multidisciplinary pain program at a university medical center was the setting for this study. PATIENTS: Subjects in this study were 211 consecutive patients with chronic pain. OUTCOME MEASURES: Pain duration, compensation, and litigation status were controlled for in the statistical analyses, as each correlated significantly with at least one of the measures of affect. Global affective distress was assessed using the Global Severity Index (GSI) from the Brief Symptom Inventory. The Beck Depression Inventory and the Center for Epidemiological Studies Depression Scale were used as measures of self-report of depressive symptoms. Presence or absence of major depression was based on DSM-IV criteria. RESULTS AND CONCLUSIONS: The GSI, Beck Depression Inventory, and Center for Epidemiological Studies Depression Scale were significantly correlated with each measure of the experience of pain, although clinical depression was only significantly related to self-reported disability and negative thoughts about pain. The self-report measures of depression maintained their relation to the dependent measures when the somatic items from the scales were removed, suggesting that the relations were not spuriously due to the influence of pain symptoms on the scales. When examining the unique contribution of each variable to the experience of pain (by simultaneously controlling for the other measures of affect), the GSI was uniquely related to the sensory and affective components of pain. Self-report of depressive symptoms was more highly related to a measure of the evaluative component of pain and uniquely related to self-reported disability and negative thoughts about pain. The results are discussed within the context of theoretical models of the relation between pain and affect, and suggestions for future research are presented.

Chronic myofascial pain: knowledge of diagnosis and satisfaction with treatment.

OBJECTIVE: To examine the relation between pain patients' knowledge of pain diagnosis and their satisfaction with pain treatment. It was hypothesized that myofascial pain (MP) patients would be less knowledgeable regarding their diagnosis and less satisfied with the results of pain treatment. DESIGN: Cross-sectional. SETTING: Multidisciplinary pain clinic. PATIENTS: Patients (n=65) were divided into two groups after multidisciplinary assessment: MP patients (n=30) and a mixed group of chronic pain patients (MCP) (n=35) with neurologic or rheumatologic disorders. MAIN OUTCOME MEASURES: Patient self-report of their knowledge of pain diagnosis and scores on standardized measures of pain intensity, depressive symptoms, and functional disability. RESULTS: MP patients were significantly less accurate in identifying their diagnosis and the source of their pain and were more likely to believe they suffered a physiologic disturbance "more serious and different" than their physicians had suggested. MP patients were also significantly more dissatisfied with the treatment for pain by physicians and reported particular dissatisfaction with the informational aspects of physician-patient communication. No group differences were obtained for measures of pain severity, depression, disability, pain duration, or compensation/litigation status. CONCLUSION: MP patients appear to have less accurate beliefs regarding their pain symptoms and express more dissatisfaction with physician efforts to treat their pain. These findings emphasize the importance of patient education as a component of chronic pain intervention, particularly for MP patients.

The effect of aerobic exercise on self-esteem and depressive and anxiety symptoms among breast cancer survivors.

PURPOSE/OBJECTIVES: To evaluate the effects of 10 weeks of aerobic exercise on depressive and anxiety symptoms and self-esteem of breast cancer survivors. DESIGN: Experimental, crossover. SETTING: Midwestern university town. SAMPLE: Twenty-four breast cancer survivors (mean time following surgery 41.8 months; ranging from 1 to 99 months) recruited via mail and cancer support groups. The mean age of the sample was 48.9 years. METHODS: Subjects were assigned randomly into exercise (EX), exercise-plus-behavior modification (EX + BM), and control groups. EX and EX + BM groups exercised aerobically four days/week at > or = 60% of age-predicted maximum heart rate for 10 weeks. Data were collected pretest, post-test, and crossover (12 weeks following post-test). Because pretest or post-test scores showed no statistical differences between EX and EX + BM groups, data were combined to form one group. MAIN RESEARCH VARIABLES: Aerobic exercise (four days/ week; 30-40 minutes/session), depression, (Beck Depression inventory), anxiety (Speilberger State-Trait Anxiety Inventory), and self-esteem (Rosenberg Self-Esteem Inventory). FINDINGS: Pre- to post-test analyses revealed that women who exercised had significantly less depression and state and trait anxiety over time compared to controls. After the crossover, the control group demonstrated comparable improvements in both depressive and state anxiety scores. Self-esteem did not change significantly. Subjects who received exercise recommendations from their physicians exercised significantly more than subjects who received no recommendation. CONCLUSIONS: Mild to moderate aerobic exercise may be of therapeutic value to breast cancer survivors with respect to depressive and anxiety symptoms but not to self-esteem. A physician's recommendation to exercise appears to be an important factor in a patient's exercise adherence. IMPLICATIONS FOR NURSING PRACTICE: To Improve depressive and anxiety symptoms following breast cancer surgery, healthcare professionals should consider recommending mild to moderate exercise.

Giant lymph node hyperplasia (Castleman's disease) presenting with chylous pleural effusion.

A case of giant lymph node hyperplasia (Castleman's disease) with an original presentation of a chylous pleural effusion occurred in a female adolescent. CT scans showed mediastinal lymphadenopathy. Lymph node biopsy was consistent with the plasmacytic variant of Castleman's disease.

Assessing depression among persons with chronic pain using the Center for Epidemiological Studies-Depression Scale and the Beck Depression Inventory: a comparative analysis.

OBJECTIVE: This study examined the ability of two self-report questionnaires, the Beck Depression Inventory (BDI) and the Center for Epidemiological Studies-Depression Scale (CES-D), to discriminate between chronic pain patients with and without major depression. Since previous research has suggested that medical conditions such as chronic pain can influence the endorsement of items that measure neurovegetative symptoms of depression, the accuracy of each of these questionnaires was also assessed eliminating these items. SUBJECTS: These included 132 consecutive patients with chronic pain, 44 of whom were diagnosed as suffering from major depression according to DSM-IV criteria. METHODS: Patients were administered a battery of questionnaires that included the CES-D and BDI. They were also interviewed by a clinical psychologist to determine the presence or absence of major depression. RESULTS: Both questionnaires were able to discriminate significantly between persons with and without major depression. Removal of the somatic items on each questionnaire did not improve their accuracy. Discriminant function analysis revealed an optimal cut-off score of 21 for the BDI, and 27 for the CES-D. Overall hit rates at these cut-offs for the two questionnaires were comparable, while the CES-D had somewhat better sensitivity (81.8% vs. 68.2%). Conversely, the BDI had slightly better specificity (78.4% vs. 72.7%). CONCLUSION: The results suggest that both questionnaires have good predictive validity among chronic pain patients, and decisions regarding the use of one questionnaire rather than the other may depend upon the goals of the user and the setting within which the questionnaire is used.

The relationship between symptoms of post-traumatic stress disorder and pain, affective disturbance and disability among patients with accident and non-accident related pain.

Recent studies have reported a high prevalence of symptoms of post-traumatic stress disorder (PTSD) among individuals with chronic pain. Studies suggest that persons with pain and PTSD also display higher levels of affective disturbance. In the present study we examined self-reports of pain, affective disturbance, and disability among pain patients with and without symptoms of PTSD. Patients without PTSD symptoms were further subdivided into persons whose pain was the result of an accident or insidious in onset. Thus, three groups were examined: (1) persons with accident related pain and high PTSD symptoms (Accident/High PTSD); (2) persons with no or few symptoms of PTSD whose pain was accident related (Accident/Low PTSD); and (3) patients whose pain was not accident related and did not have PTSD symptoms (No Accident). No Accident patients were older than persons with accident related injuries, and both accident related pain groups were more likely than No Accident patients to be involved in litigation or receiving compensation. Thus, these variables were controlled for in the statistical analyses. Self-report of pain was also included as a covariate in the analyses examining group differences in affective disturbance and disability. Accident/High PTSD patients displayed higher levels of self-reported pain compared to the other two groups. The Accident/High PTSD group also had the highest levels of affective disturbance. Both accident groups tended to report greater disability compared to patients whose pain was not accident related. These findings suggest that PTSD symptoms in chronic pain patients are associated with increased pain and affective distress. Accident related pain, even without the presence of PTSD symptoms, appears to be associated with greater disability. The results indicate that the identification and treatment of PTSD symptoms in refractory pain patients may be a critical albeit subtle factor in the effective management of suffering and disability in this population.

Maternal distress and perceptions of infant development following extracorporeal membrane oxygenation and conventional ventilation for persistent pulmonary hypertension.

Neurodevelopmental outcome and concurrent maternal distress were examined for infants who suffered persistent pulmonary hypertension at birth and were treated with either extracorporeal membrane oxygenation (ECMO) (n = 19) or conventional ventilation (CV) (n = 15). Mothers were asked to complete inventories assessing their infant's (mean age 8.74 months) developmental growth as well as their own psychological health. Relevant sociodemographic and treatment parameters were also entered into the analysis. The results indicated that ECMO and CV infants did not differ on developmental indices and impairment rates were 15-23% respectively, similar to previous reports. In addition, ECMO and CV mothers did not differ in their reports of psychological distress. Correlational analyses revealed that length of treatment for ECMO but not CV infants significantly predicted developmental delay and maternal distress. For CV mothers, maternal distress was associated with the perception of delayed language. The results are discussed in terms of the limited morbidity associated with ECMO and CV interventions and the possible role of a 'vulnerable child syndrome' in understanding the maternal-infant relationship following ECMO therapy.

Zygomycosis due to Mucor circinelloides in a neutropenic patient receiving chemotherapy for acute myelogenous leukemia.

Mucor circinelloides form circinelloides has rarely been associated with human disease, even in immunocompromised patients. We report a case of cutaneous zygomycosis caused by M. circinelloides in a 23-year-old neutropenic woman receiving consolidation chemotherapy for acute myelogenous leukemia. The organism was exquisitely susceptible to amphotericin B. Despite the fact that the patient was profoundly neutropenic for an additional 3 weeks, the lesions began to resolve during therapy, and no surgical debridement was required.

Use of induced sputum specimens for microbiologic diagnosis of infections due to organisms other than Pneumocystis carinii.

The optimal diagnostic approach to pneumonia provides a rapid microbiologic identification of pulmonary pathogens by the least invasive means. The technique of sputum induction has been useful in the evaluation of patients with Pneumocystis carinii or mycobacterial pneumonia. It is not known whether induced sputum samples are preferable for the detection of pathogens other than P. carinii or mycobacteria. Microbiologic yields were evaluated from identically processed induced and conventional sputum samples collected from 509 consecutive patients. No statistically significant differences were found between the microbiologic yields of induced and spontaneous sputum samples. Bacterial pathogens were isolated in 19.6% of induced and 23.5% of routine specimens. Mycobacteria were cultured from 13.1% of routine and 9.4% of induced specimens. Non-Candida albicans fungi grew from 24% of routine and 20% of induced specimens. The process of sputum induction with aerosolized hypertonic saline did not alter either the purulence or the bacterial quantitation of Gram-stained sputum specimens. Sputum induction has been useful for the cytologic diagnosis of malignancy, for the diagnosis of pneumocystosis and tuberculosis, and in patients unable to spontaneously produce sputum samples. The use of induced sputum samples for the diagnosis of other infections may not be necessary when routine sputum specimens are available.

Activity of topoisomerase inhibitors against Pneumocystis carinii in vitro and in an inoculated mouse model.

Five topoisomerase II inhibitors (amsacrine [m-AMSA], two epipodophyllotoxins, and two quinolones) and the alkaloid camptothecin (a topoisomerase I inhibitor) were evaluated to assess their activities against Pneumocystis carinii. In vitro, both etoposide (VP-16) and teniposide (VM-26) at 1 microgram/ml suppressed P. carinii growth. Amsacrine was toxic to P. carinii and to the feeder cells in vitro. Camptothecin suppressed the growth of P. carinii in vitro only at 100 micrograms/ml. Studies in immunosuppressed mice demonstrated the efficacy of teniposide against P. carinii pneumonia, but successful administration of teniposide was schedule dependent with significant toxicity at therapeutic dosages.

Phase Equilibria and Crystal Chemistry in Portions of the System SrO-CaO-Bi2O3-CuO, Part IV- The System CaO-Bi2O3-CuO.

New data are presented on the phase equilibria and crystal chemistry of the binary systems CaO-Bi2O3 and CaO-CuO and the ternary CaO-Bi2O3-CuO. Symmetry data and unit cell dimensions based on single crystal and powder x-ray diffraction measurements are reported for several of the binary CaO-Bi2O3 phases, including corrected compositions for Ca4Bi6O13 and Ca2Bi2O5. The ternary system contains no new ternary phases which can be formed in air at ~700-900 °C.