Computerized decision support for EPO dosing in hemodialysis patients.

BACKGROUND: Anemia management in hemodialysis patients poses significant challenges. The present study explored the hypothesis that computerized dosing of intravenous erythropoietin (EPO) would increase the percentage of hemoglobin (Hb) values within the target range and reduce staff time spent on anemia management. STUDY DESIGN: Retrospective cohort. SETTING & PARTICIPANTS: In-center hemodialysis patients who received EPO at Dialysis Clinic Inc dialysis units for at least 3 months between October 1, 2005, and April 30, 2006. QUALITY IMPROVEMENT PLAN: Computerized decision support (CDS) for EPO dosing is compared with manual physician-directed dosing. OUTCOMES: Achieved monthly Hb values, quantity of EPO administered, and time spent by dialysis unit personnel. MEASUREMENTS: Monthly Hb and quantity of EPO administered to 1,118 patients from 18 dialysis units treated using CDS and 7,823 patients from 125 dialysis units treated using manual dosing. RESULTS: There was no difference in the likelihood of a monthly Hb level of 11-12 or 10-12 g/dL using CDS compared with manual dosing. The likelihood of an Hb level > 12 g/dL decreased and the likelihood of an Hb level < 10 g/dL increased using CDS. EPO use was 4% lower using CDS, although the difference was not statistically significant. CDS was associated with a nearly 50% decrease (P < 0.001) in the time spent by dialysis unit staff on anemia management. LIMITATIONS: Retrospective and nonrandomized. CONCLUSION: The number of monthly Hb values in an 11- (and 10-) to 12-g/dL target range and EPO use did not differ with EPO dosing using CDS compared with manual dosing. Staff resources devoted to anemia management decreased significantly using CDS.

Retail cutting characteristics for US Choice and US Select beef subprimals.

US Choice (Ch) and US Select (Se) beef subprimals from the rib, chuck, plate, loin, and round were obtained to conduct retail cutting tests. Subprimals were merchandised into bone-in or boneless retail cuts and associated components by experienced retail meat merchandisers. These Se subprimals had less (P<0.05) trimmable fat than their Ch counterparts: ball tip, top sirloin, outside round, inside round, and ribeye. Se inside rounds, outside rounds, eye of rounds, boneless striploins, and ball tips had greater (P<0.05) purge losses than the same cuts from Ch. The only subprimals where grade impacted total saleable yield were the top (inside) rounds (Ch=80.13%, Se=87.34%; P=0.004) and outside rounds cut into roasts, steaks, and cubed steaks (Ch=87.61%, Se=90.28%; P=0.05). Methods to increase retail yields from beef subprimals should consider minimizing purge and increasing cutting efficiencies in addition to reducing fat trim.

Presymptomatic testing for adult onset polycystic kidney disease in at-risk kidney transplant donors.

Autosomal dominant adult-onset polycystic kidney disease (ADPKD) is estimated to have an incidence of 1/1,000 and accounts for approximately 10% of all end-stage renal disease in the United States. While relatives are attractive as renal donors due to their availability and the improved transplant success associated with living-related donors, they may coincidentally be at risk for ADPKD. Accurate presymptomatic testing for at-risk potential donors is critical for both the donor and the recipient. We report here 2 families in which presymptomatic testing for ADPKD was accomplished by DNA linkage analysis on several potential renal donors prior to transplant. This resulted in the protection of both donors and recipients by preventing the transplantation of a kidney affected by ADPKD. Thorough counseling prior to DNA analysis (including discussion of accuracy and possible testing outcomes of presymptomatic diagnosis of ADPKD, diagnosis of noncarrier status, false paternity, and non-informative study) was essential to provide informed consent and preserve confidentiality within the family. Confidentiality for potential donors found presymptomatically to be affected (with a 94% or greater probability) was especially difficult to maintain.

Long-term renal function in heart transplant recipients receiving cyclosporine therapy.

BACKGROUND: Immunosuppression with cyclosporine has improved allograft function and reduced both morbidity and mortality in organ transplantation. However, cyclosporine-induced nephrotoxicity still is a concern. The purpose of our study was to evaluate the effects of cyclosporine on renal function in orthotopic heart transplant recipients. METHODS: Thirty-nine patients who received transplants from 1985 to 1991 and had at least three yearly glomerular filtration rate measurements posttransplantation by 125I-iothalamate clearance method were included in the study. In addition, serum creatinine (before and after transplantation) and cyclosporine doses were analyzed. RESULTS: Maintenance immunosuppression at 1 year consisted of prednisone (0.1 mg/kg/day), azathioprine (2 mg/kg/day), and cyclosporine (12-hour trough level 100 to 150 ng/ml by fluorescence polarization immunoassay). The mean serum creatinine at 1 year was significantly higher than the mean pretransplantation serum creatinine (1.51 +/- 0.32 versus 1.28 +/- 0.38, p < 0.05) and stabilized after the first year. The mean glomerular filtration rate by 125I-iothalamate clearance method was 70.6 +/- 20.3 ml/min/1.73 m2 (range 32 to 105) at 1 year and remained relatively stable during the follow-up period of up to 7 years. Creatinine clearance calculated by the Cockcroft and Gault formula overestimated the true glomerular filtration rate after the third year. The mean cyclosporine dosage was significantly lower after the first-year dose of 3.9 +/- 1.8 mg/kg/day (p < 0.05). Three patients in 39 started hemodialysis at 5, 7, and 10 years after transplantation. CONCLUSION: Our data indicate that the adequacy of renal function is preserved with long-term cyclosporine therapy in heart transplant recipients.

Renal transplantation. A 20-year experience in a Veterans Administration Medical Center.

Between March 1963 and December 1983, 324 renal transplants were performed in 273 veteran patients at the Veterans Administration Medical Center, Nashville, Tenn. Cadaver donors were used in 273 transplants, with an overall one-year patient survival of 72.5% and one-year functional graft survival of 50%. Twenty-four living-related transplants were performed, with an overall one-year patient survival of 89% and one-year functional graft survival of 75%. For analytical purposes the 20-year transplant experience was divided into five eras. One-year patient survival increased from 45% in era 1 to 84% in era 5, while functional graft survival increased from 45% to 70%. Death has occurred in 139 patients, with sepsis being responsible for the largest number of early deaths. Cardiovascular disease was responsible for most late deaths.

Urinary tract calculous disease after renal transplantation.

We report 3 cases of a series of 372 (0.8 per cent) renal transplant recipients in whom urinary tract calculi developed as a complication of the procedure. In each patient symptoms were minimal and not classic of calculous disease. We disagree with the contention that all such patients have either hypercalcemia, infection, or tubular acidosis, although thorough evaluation is indicated. We believe this entity should be considered in problematic renal transplantation patients. Conservative therapy is advocated when the situation permits.

Hemodialysis and renal transplantation in progressive systemic sclerosis: report of 2 cases.

Renal failure is a common cause of death in patients with progressive systemic sclerosis (PSS). The present paper describes two patients with chronic renal failure secondary to PSS whom we have treated by a combination of chronic hemodialysis and renal transplantation. Also reviewed are reports of six additional patients who have undergone renal transplantation. We conclude that chronic hemodialysis and renal transplantation are successful life-sustaining treatment modalities in some patients with end-stage renal disease due to PSS.

Renal autograft survival after perfusion and hypothermic storage in a hyperosmolar high potassium-containing solution.

A hyperosmolar high postassium-containing kidney perfusate and storage solution with demonstrated in vitro advantages over extracellular-like solutions was tested for renal preservation superiority in vivo. A model allowing simultaneous evaluation of creatinine clearance of both kidneys from the same animal, each having been perfused and stored for 24 hours in different preservation solutions, offered certain advantages over conventional models. Immediate function, greater ultimate creatinine clearance and preservation of cellular architecture during 24 hours of hypothermic storage was demonstrated convincingly in kidneys preserved in the hyperosmolar high potassium containing solution. Simplicity of preparation and absence of precipitates were additional desirable features of this solution. The use of Ringer's lactated solution for perfusion and cold storage of kidneys should be avoided.

The use of bactericidal concentrations of antibiotics in hypothermic pulsatile perfusion and the effects on canine renal autograft function.

Although cadaver allograft contamination occurs frequently, the potential danger to the transplant recipient varies. Usually the results of culture from the donor and kidney perfusates are not available at the time of transplantation. A positive culture result often necessitates the use of prophylactic antibiotics. The antibiotic may be potentially nephrotoxic, and in the setting of minimal or changing renal function this effect may be potentiated. If significant contamination with virulent organisms is found prior to transplantation, clinical judgment often dictates that the graft be discarded. Perfusion and storage with solutions containing broad-spectrum antibiotics would substantially reduce the incidence of contamination in perfused kidneys. This would in turn reduce the requirement for potentially nephrotoxic antimicrobial therapy in the transplant recipient. Since the antibiotics tested are effective against a wide range of contaminants and apparently cause no detrimental effects, it would seem reasonable to add them routinely to the perfusate solution.

Long-term hemodialysis for patients over 50.

Hemodialysis can hodl end-state renal failure at bay and enable patients to lead a relatively normal life-regardless of their age. In a 10 year retrospective study of 574 patients, the 154 patients over 50 had about the same survival rates as younger persons for the first three years of dialysis. After that, the older patients had higher mortality. Patients who dialyzed themselves at home-with a relative or friend to help-had much better results than those who were dialyzed at the center. This in part reflects the selection process, since patients with severe medical problems usually weren't allowed to try self-dialysis. Older patients did particularly well on home dialysis, which was attributed to their maturity and dependability. Older patients with cardiac instability may require carefully monitored dialysis at the center and frequent blood transfusions. In general, though, patients over 50 needed fewer transfusions and fewer days in the hospital than younger patients.

Yield grade and carcass weight effects on the cutability of lamb carcasses fabricated into innovative style subprimals.

Lamb carcass (n = 100) were selected from USDA yield grades (YG) 2, 3, and 4 and carcass weight (CW) groups 20.4 to 24.9, 25.0 to 29.5, and 29.6 to 34.0 kg. Lamb carcass were fabricated into semiboneless and boneless subprimals and trimmed to three s.c. fat trim levels: .64, .25, and .00 cm of fat remaining. Innovative subprimals were fabricated and yields were calculated for the subprimals and dissectible components (lean, bone, connective tissue, external fat, and seam fat) from each of the various subprimals. Carcass weight as a main effect in a two-way analysis of variance did not account for a significant amount of the variation in yield among trimmed subprimals or the percentage of the dissectible components, but USDA YG was a significant main effect in determining variation in yield for many of the subprimals or dissectible components. Muscle seaming of shoulders and legs and removal of excessive tails on the loin and rack resulted in a majority of the seam fat being removed from these cuts. Dissection data clearly showed that seam fat is a major component of rack and shoulder cuts and with increasing fatness or higher numerical yield grade there are clearly increased amounts of this depot. Increased trimming of external fat magnifies and draws more attention to the amount of seam fat remaining. Production of heavy, lean lambs would be more useful in an innovative type of program because of the larger-sized muscles. Heavy, fat lambs would not be as useful because of their decreased yields and excess seam fat located in cuts that cannot be muscled-seamed because of the loss of retail cut integrity. Seam fat was highly correlated to percentage of kidney and pelvic fat and to external fat thickness and with USDA yield grade but was not strongly correlated to carcass weight.

Retail yields from beef chuck and round subprimals from two grade groups when merchandised as single muscle cuts.

Beef subprimals from two different grade groups were obtained from two beef processors to assist in updating the Beef Computer Assisted Retail Decision Support (CARDS) program with new fabrication styles. The grade groups consisted of Top Choice (containing subprimals from carcasses with a Modest or Moderate degree of marbling) and Select (containing subprimals from carcasses with a Slight degree of marbling). Subprimals (shoulder clod; top blade, roast; arm roast; knuckle, peeled; outside round, flat) were separated into individual muscles and fabricated into retail cuts by professional retail meat cutters. Mean retail cutting yields and labor requirements were calculated from observed weights (kilograms) and processing times (seconds). Data were analyzed to determine means and standard errors of percentage yield and processing times for subprimals in each grade group, and comparisons were made between grade groups. Generally, there were few differences in processing times between Top Choice and Select subprimals, and the trimming phase required the most time to complete for each subprimal. Differences (P < 0.05) were observed in saleable yield between Top Choice and Select subprimals for the shoulder clod (Top Choice = 73.89%; Select = 78.49%), top blade, roast (Top Choice = 84.36%; Select = 86.70%), and outside round, flat (Top Choice = 85.99%; Select = 91.34%). Trimmable fat differed (P < 0.05) between Top Choice and Select subprimals: shoulder clod (Top Choice = 25.30%; Select = 20.85%), top blade, roast (Top Choice = 14.88%; Select = 12.59%), arm roast (Top Choice = 8.35%; Select = 7.47%), knuckle (Top Choice = 5.72%; Select = 2.73%), and outside round, flat (Top Choice = 13.82%; Select = 7.26%). Most of the differences in saleable yields were related to less trimmable fat for Select subprimals, which also required less trimming time than Top Choice subprimals. These data will serve to update the Beef CARDS program and will provide retailers and foodservice operators with third-party cutting yield and time allocation information.

Subprimal purchasing and merchandising decisions for pork: relationship to retail yield and fabrication time.

Boxed pork was obtained to represent four different purchase specifications (different anatomical separation locations and[or] external fat trim levels) common in the pork industry to conduct a study of retail yields and labor requirements. Bone-in loins (n = 180), boneless loins (n = 94), and Boston butts (n = 148) were assigned randomly to fabrication styles within subprimals. When comparing cutting styles within subprimals, it was evident that cutting style affected percentage of retail yield and cutting time. When more bone-in cuts were prepared from bone-in loin subprimals, retail yields ranged from 92.80 +/- .61 to 95.28 +/- .45%, and processing times ranged from 222.57 +/- 10.13 to 318.99 +/- 7.85 s, from the four suppliers. When more boneless cuts were prepared from bone-in loin subprimals, retail yields ranged from 71.12 +/- 1.10 to 77.92 +/- .77% and processing times ranged from 453.49 +/- 8.95 to 631.09 +/- 15.04 s from the different loins. Comparing boneless to bone-in cuts from bone-in loins resulted in lower yields and required greater processing times. Significant variations in yields and times were found within cutting styles. These differences seemed to have been the result of variation in supplier fat trim level and anatomical separation (primarily scribe length).

Subprimal purchasing and merchandising decisions for pork: relationship to retail value.

To assess retail value and profitability, cutting test data were obtained in a simulated retail cutting room for boxed pork subprimals, bone-in loins (n = 180), boneless loins (n = 94), Boston butts (n = 148), fresh hams (n = 28), and boneless hams (n = 23). Processing times (seconds) and retail weights (kilograms) were used to determine relative value. Cutting style affected (P < .05) value differential (US$/subprimal) for bone-in and boneless loins. When cutting styles within subprimals were pooled, value differential was affected (P < .05) by purchasing specification for bone-in loins, boneless loins, Boston butts, and inside fresh hams. Processing bone-in loins to a boneless end point produced a greater (P < .05) value differential and percentage of gross margin than a bone-in retail end point. Bone-in loins fabricated to a boneless retail end point produced a greater (P < .05) value differential and percentage of gross margin than boneless loins fabricated to the same end point. The increase in retail value can be attributed to the increased number and weight of retail cuts produced from bone-in loins. The thick, boneless loin cutting style produced a greater (P < .05) value differential and percentage of gross margin as a result of a lower (P < .05) cost of fabrication and increased value of retail cuts than the thin, boneless cutting style. In general, boneless pork cutting methods were more profitable than bone-in cutting methods regardless of subprimal.

Influence of wholesale lamb marketing options and merchandising styles on retail yield and fabrication time.

Lamb carcasses (n = 94) from five packing plants, selected to vary in weight class and fat thickness, were used to determine retail yield and labor requirements of wholesale lamb fabrication. Carcasses were allotted randomly according to weight class to be fabricated as whole carcasses (n = 20), three-piece boxes (n = 22), or subprimals (n = 52). Processing times (seconds) were recorded and wholesale and retail weights (kilograms) were obtained to calculate retail yield. Subprimals were fabricated into bone-in retail cuts or boneless or semi-boneless retail cuts. Retail yield for subprimal lamb legs decreased from 85.3 +/- .6% for bone-in to 68.0 +/- .7% for a completely boneless retail product. Correspondingly, processing times increased from 126.1 +/- 5.4 s to 542.0 +/- 19.2 s for bone-in and boneless legs, respectively. For all subprimals, retail yield percentage tended to decrease and total processing time increase as cuts were fabricated to boneless or semi-boneless end points compared with a bone-in end point. Percentage retail yield did not differ (P > .05) among whole carcass, three-piece box, and subprimal marketing methods. Total processing time was shorter for subprimals (P < .05) than for the other two marketing methods.

Retail yield and fabrication times for veal as influenced by purchasing options and merchandising styles.

Twenty-nine selected styles of subprimals or sections of veal were obtained from a commercial facility to assist in the development of a support program for retailers. They were fabricated into bone-in or boneless retail cuts and associated components by trained meat cutters. Each style selected (n = 6) was used to generate mean retail yields and labor requirements, which were calculated from wholesale and retail weights and processing times. Means and standard errors for veal ribs consisting of five different styles (n = 30) concluded that style #2, 7-rib 4 (10 cm) x 4 (10 cm), had the lowest percentage of total retail yield (P < .05) owing to the greatest percentage of bone. Furthermore, rib style #2 required the longest total processing time (P < .05). Rib styles #3, 7-rib chop-ready, and #5, 6-rib chop ready, yielded the greatest percentage of total retail yield and also had the shortest total processing time (P < .05). Within veal loins, style #2, 4 (10 cm) x 4 (10 cm) loin kidney fat in, had the greatest percentage fat (P < .05). Loin styles #2 and #3, 4 (10 cm) x 4 (10 cm) loin special trimmed, generated more lean and fat trimmings and bone, resulting in lower percentage of total retail yields than loin style #1, 0 (0 cm) x 1 (2.5 cm) loin special trimmed (P < .05). Results indicated that bone-in subprimals and sections required more processing time if fabricated into a boneless end point. In addition, as the number of different retail cuts increased, processing times also increased.

Foodservice yield and fabrication times for beef as influenced by purchasing options and merchandising styles.

Selected beef subprimals were obtained from fabrication lines of three foodservice purveyors to assist in the development of a software support program for the beef foodservice industry. Subprimals were fabricated into bone-in or boneless foodservice ready-to-cook portion-sized cuts and associated components by professional meat cutters. Each subprimal was cut to generate mean foodservice cutting yields and labor requirements, which were calculated from observed weights (kilograms) and processing times (seconds). Once fabrication was completed, data were analyzed to determine means and standard errors of percentage yields and processing times for each subprimal. Subprimals cut to only one end point were evaluated for mean foodservice yields and processing times, but no comparisons were made within subprimal. However, those traditionally cut into various end points were additionally compared by cutting style. Subprimals cut by a single cutting style included rib, roast-ready; ribeye roll, lip-on, bone-in; brisket, deckle-off, boneless; top (inside) round; and bottom sirloin butt, flap, boneless. Subprimals cut into multiple end points or styles included ribeye, lip-on; top sirloin, cap; tenderloin butt, defatted; shortloin, short-cut; strip loin, boneless; top sirloin butt, boneless; and tenderloin, full, side muscle on, defatted. Mean yields of portion cuts, and mean fabrication times required to manufacture these cuts differed (P < 0.05) by cutting specification of the final product. In general, as the target portion size of fabricated steaks decreased, the mean number of steaks derived from any given subprimal cut increased, causing total foodservice yield to decrease and total processing time to increase. Therefore, an inverse relationship tended to exist between processing times and foodservice yields. With a method of accurately evaluating various beef purchase options, such as traditional commodity subprimals, closely trimmed subprimals, and pre-cut portion steaks in terms of yield and labor cost, foodservice operators will be better equipped to decide what option is more viable for their operation.

Mineral composition of lamb carcasses from the United States and New Zealand.

The mineral composition-iron (Fe), zinc (Zn), copper (Cu), calcium (Ca), magnesium (Mg), sodium (Na), potassium (K), fluoride (F), and phosphorus (P) (New Zealand lamb only)-of lean tissue from lamb retail cuts was studied. Twenty-four US lamb carcasses of different ages (5 to 11 months), geographical regions (Texas, Colorado and Montana) and USDA quality grades (Prime and Choice) and 27 New Zealand lamb carcasses from three weight groups (11 to 12·5 kg, 13 to 14·5 kg, and 16·5 to 18 kg), age rangining from 7 to 8 months, were selected for use in this study. Mineral concentrations were influenced more by retail cut and age than by quality grade or weigth group. Foreshank and shoulder cuts from both the US and New Zealand group consistently had the highest (P < 0·05) Zn content among the cuts. The K content of the muscle in US lambs increased as age increased, while the level of Ca and Zn in New Zealand lambs decreased as carcass weight increased. Except for Ca, the mineral concentrations of the lean tissue from US lambs were higher than the New Zealand lambs, although the differences were not always significant. US lambs had approximately 20%, 30% and 37% more Fe, Zn and Mg, respectively, but 27% less Ca than lean tissue from the New Zealand lambs.