BUN as an Independent Predictor of Post-Hospital-Discharge Mortality among Older Veterans.

BACKGROUND/OBJECTIVES: An elevated blood urea nitrogen (BUN) in known to be an important prognostic indicator in patients with end-stage heart or kidney disease or certain other life-threatening illnesses. However, it is less certain as to whether an elevated BUN is an independent predictor of long-term mortality risk in less seriously ill patients. To address this issue, we examined the relationship between BUN and long-term mortality after adjusting for potential confounders and other indicators of health status/disease severity, in a select population of older medically stable Veterans. DESIGN: Long-term prospective cohort study. SETTING: Outpatient follow-up of patients discharged from a recuperative care and rehabilitation unit (RCRU) of a Department of Veterans Affairs Community Living Center. PARTICIPANTS: 383 older Veterans (mean age = 78.6±7.6 years, 98% male, and 87% white) discharged alive and in stable medical condition. MEASUREMENTS: At discharge, each subject completed a comprehensive assessment and was then monitored as an outpatient for up to 9.3 years. Associations between blood urea nitrogen at RCRU discharge and mortality were identified utilizing Cox proportional hazards (PH) regression analyses adjusting for conditions known to confound this relationship. RESULTS: Within the follow-up period, 255 subjects (67%) died. In the unadjusted Cox PH model, a BUN ≥ 30 mg/dL was associated with a nearly 2-fold increased risk of mortality (hazard ratio 1.90, 95%CI 1.41 - 2.56). The association between BUN and long-term mortality remained highly significant after adjusting for potential confounders (hazard ratio 1.78, 95%CI 1.29 - 2.44). CONCLUSION: Our findings support BUN levels as an independent predictor of long-term mortality in older, medically stable Veterans. An elevated BUN may be reflective of global health status rather than solely an indicator of the severity of acute illness or unstable chronic disease.

Toward a level playing field: predictive factors for the outcomes of mental health treatment for adolescents.

OBJECTIVE: To understand better the effectiveness of routine treatment for emotional and behavioral problems experienced by adolescents, methods are needed to control for between-provider differences in the distribution of factors that adversely affect treatment success. Such methods are necessary to fairly compare providers' outcomes and to aid clinicians in identifying adolescents for whom routine care may need to be altered. As a preliminary step toward developing a model to adjust treatment outcomes to account for predictive factors, findings from studies of treated samples of adolescents were reviewed to identify the factors that influence the likelihood of treatment success for this population. METHOD: Medline and PSYCInfo databases were searched for studies of treated adolescents that reported the association between expert-nominated predictive factors and outcomes. Thirty-four studies met inclusion criteria. RESULTS: Significant predictors identified in these studies include diagnosis, baseline severity of symptoms and functional impairment, family dysfunction, and previous treatment. Several expert-nominated factors have not been adequately studied in treated samples. CONCLUSIONS: Much basic work is needed before a convincing body of empirical evidence can explain predictive factors for adolescent mental health treatment outcomes. Future efforts should determine a reduced set of predictive factors that can be measured with minimal burden to providers.

High fever after flexible bronchoscopy and bronchoalveolar lavage in noncritically ill immunocompetent children.

Flexible bronchoscopy (FB) and bronchoalveolar lavage (BAL) have been applied increasingly to the evaluation of pulmonary disease in children. Although several complications have been reported following FB and BAL, high fever after BAL in immunocompetent children has not previously been reported. To determine the frequency, clinical characteristics, and outcome of these complications in children who developed high fever post-BAL, we retrospectively reviewed all bronchoscopic procedures done on an outpatient basis between August 1995 and July 1997. We identified 78 immunocompetent noncritically ill children who had undergone FB and BAL as an outpatient procedure for evaluation of underlying pulmonary disease, of whom 13 (17%) developed temperature (T) higher than or equal to 39 degrees C (fever group). The 13 patients in the fever group had a median age of 10 (range, 4-48) months and a reported T of 39.4 degrees C (39.1-40.6 degrees C) occurring 7.5 (4-12) hr after BAL. To determine if there were differences in clinical or BAL fluid (BALF) characteristics, we compared each child in the fever group to two children in the nonfever group, based upon primary indications and age. There were no differences in demographic or clinical characteristics between the two groups. Lymphocyte concentrations in BALF were significantly reduced in the fever group (P = 0.03). An abnormal BALF cell differential (defined as one or more of the following: neutrophils >10%, lymphocytes >30%, or eosinophils >1%) was significantly more common in the fever group (P = 0.008, odds ratio 3.6). We conclude that high fever is a frequent adverse event following BAL in noncritically ill immunocompetent children with underlying pulmonary disease. Pre-BAL clinical characteristics are not associated with development of high fever. However, the finding of an abnormal BALF cell differential is strongly associated with development of high fever post-BAL.

The use of telephone interview methodology to obtain 24-hour dietary recalls.

OBJECTIVE: To compare 24-hour dietary recalls collected over the telephone to in-person recalls collected in the 1994-1996 Continuing Survey of Food Intakes by Individuals (CSFII). DESIGN: Trained interviewers collected 24-hour dietary recalls over the telephone using the multiple-pass approach. These results were compared to in-person interviews from a pooled subsample of CSFII respondents. SUBJECTS/SETTING: List-assisted random-digit dialing was used to identify 700 women between the ages of 20 and 49 years. One eligible woman per household was selected to participate. STATISTICAL ANALYSES: Approximate t tests to examine differences in average nutrient and energy intakes were conducted on weighted data. RESULTS: The reported intakes of most nutrients in the current 24-hour dietary recalls collected over the telephone were significantly higher than those reported in the 1994 and 1995 CSFII, but there were no significant differences between the telephone survey and 1996 CSFII results. The 24-hour dietary recalls collected over the telephone yielded consistently greater mean nutrient intake per respondent compared with a comparable pooled subsample from the 1994, 1995, and 1996 CSFII. Generally, no significant differences were found in the food group data between the telephone survey and the CSFII survey. Mean dietary intakes reported by the comparable CSFII subsample increased from 1994 to 1996. APPLICATIONS: Collecting 24-hour dietary recalls over the telephone is a practical and valid data collection tool for use in national food consumption surveys.

Encouraging physicians to respond to surveys through the use of fax technology.

High response rates in surveys of physicians are difficult to achieve. One possible strategy to improve physicians' survey participation is to offer the option of receiving and returning the survey by fax. This study describes the success of the option of fax communication in a survey of general practitioners, family physicians, and pediatricians in Arkansas with regard to pediatric asthma. Eligible physicians were given the choice of receiving the survey by telephone, mail, or fax. In this observational study, physicians' preferences, response rates, and biases for surveys administered by fax were compared with mail and telephone surveys. The overall survey response rate was 59%. For the 96 physicians completing an eligibility screener survey, the largest percentage requested to be surveyed by fax (47%) rather than by telephone (28%) or mail (25%). Faxing may be one strategy to add to the arsenal of tools to increase response rates in surveying physicians.

Non-insulin dependent diabetes mellitus in African-American youths of Arkansas.

Non-insulin dependent diabetes mellitus (NIDDM) occurs more frequently in certain adult populations, including African-Americans. Recently an increase in the incidence of NIDDM has been observed among African-American youths in Arkansas. Clinical presentations among these youths vary from asymptomatic to severe diabetic ketoacidosis. From a chart review, data were examined to determine which physical, biochemical, and autoimmune characteristics were most helpful in appropriate classification of NIDDM vs insulin dependent diabetes mellitus (IDDM). It is apparent that several diagnostic and treatment issues need to be addressed to improve the management of African-American youths with NIDDM.

Fitting the two-stage clonal expansion model based on exact hazard to the ED01 data using SAS NLIN.

The two-stage clonal expansion model is a popular model for carcinogenesis data. One common form of this model is based on the approximate hazard function. In certain situations, this formulation is not appropriate, and the exact hazard should be applied. However, the difficulty of implementing the model based on the exact hazard has deterred many from using it. This paper presents a program implementing the exact hazard model for piecewise constant dosing using SAS, a package that is readily available to most that are interested in this type of analysis. Also, an analysis of the ED01 data is presented using this program, and comparisons are made to an earlier analysis based on the approximate hazard. By allowing for an independent background tumor mechanism, an excellent fit to the bladder tumor incidence data was obtained.

Clinical utility of flexible bronchoscopy and bronchoalveolar lavage in young children with recurrent wheezing.

OBJECTIVE: The objective of this study was to determine in young children with recurrent wheezing poorly responsive to bronchodilator therapy whether flexible bronchoscopy (FB) and bronchoalveolar lavage (BAL) provide clinically useful information, whether age-specific differences are present in bronchoscopic and BAL fluid (BALF) findings, and whether differential cellular analysis of BALF is useful in suggesting an infectious or inflammatory process. DESIGN: This was a retrospective case series with descriptive and analytical components. The study population included children referred to a large tertiary care children's hospital subspecialty service for further evaluation of recurrent wheezing. Clinical and demographic data and findings of FB and BALF studies were collected from chart review. For purposes of data analysis patients were divided into 0- to 6-, 7- to 12-, and 13- to 18-month age groups. RESULTS: Thirty otherwise healthy children, 0 to 18 months of age with recurrent wheezing, who had undergone FB were identified; and 28 were found to have positive diagnostic findings. Airway abnormalities were found in 17 (57%) and tended to be more common in the 0- to 6-month age group. In the 27 who also had BAL performed, 3 (11%) had a positive bacterial culture, 9 (33%) a positive viral culture, and 5 (19%) an elevated lipid-laden macrophage index suggesting aspiration. Differential cellular analysis was abnormal in 11 (41%), a finding that was significantly associated with a positive bacterial culture, a positive viral culture, or an elevated lipid-laden macrophage index. CONCLUSIONS: In this population of young children with recurrent wheezing poorly responsive to bronchodilator therapy, FB and BAL yielded useful diagnostic findings in most children studied. In addition, in the presence of an infectious or inflammatory process, differential cellular analysis of BALF revealed an increased percentage of neutrophils.

Dual-energy x-ray absorptiometry in osteopetrosis.

We have used dual-energy x-ray absorptiometry (DXA) in evaluation and follow-up of a patient with osteopetrosis, before and after cord blood transplantation. Other methods of follow-up in such cases have been described, but the use of DXA has not previously been reported. We have shown that DXA offers a safe means of assessing disease progression, the timing of treatment, and response after therapy for osteopetrosis.