Intrarenal resistance index for the assessment of early renal function impairment in patients with liver cirrhosis.

BACKGROUND: Renovascular vasoconstriction in patients with hepatorenal syndrome can be quantified by the renal arterial resistance index (RI). We investigated the value of RI measurement in detection of renal function impairment in patients with different stages of chronic liver disease. METHODS: Subjects were divided into 4 groups containing 21 patients with liver cirrhosis and ascites, 25 patients with liver cirrhosis without ascites, 35 patients with fatty liver disease and 78 control subjects. All patients underwent abdominal ultrasound examination with renal RI measurement and correlation with laboratory results for renal function. RESULTS: RI was significantly higher in ascitic patients compared to non-ascitic patients (0.74 vs. 0.67, p<0.01) and in non-ascitic patients with liver cirrhosis than in control subjects (0.67 vs. 0.62, p<0.01). 48% (19/40) of patients with liver cirrhosis and normal serum creatinine concentration showed elevated RI levels. There were no significant differences in RI levels between patients with fatty liver disease and controls (0.63 vs. 0.62). CONCLUSIONS: Intrarenal RI measurement is a predictor of renal vasoconstriction and serves to detect early renal function impairment in cirrhotic patients. The diagnosis of elevated RI may be taken into account in the clinical management of these patients.

Prevalence of cholecystolithiasis and its management among kidney/pancreas-transplanted type 1 (insulin-dependent) diabetic patients.

BACKGROUND: Simultaneous pancreas/kidney transplantation (SPK) should be the procedure of choice for (pre)uremic patients with type 1 diabetes. All standard immunosuppressive protocols for SPK include a calcineurin-inhibitor. Both calcineurin inhibitors, cyclosporine (CyA) and probably tacrolimus (FK506) too, are associated with the occurrence of cholelithiasis due to their metabolic side effects. PATIENTS AND METHODS: We evaluated the prevalence of cholelithiasis in 83 kidney/pancreas transplanted type I-diabetic patients (46 males, 37 females, mean age 42.8 +/- 7.5 years) by conventional B-mode ultrasound 5 years after transplantation. 56 patients received CyA (group 1) and 27 received tacrolimus (group 2) as first-line-immunosuppressive drug. Additional immunosuppression consisted of steroids, azathioprine or mycophenolate mofetil. Additionally, laboratory analyses of cholestasis parameters (gamma-GT and alcalic phosphatasis) were performed. RESULTS: In total, 23 patients (28%) revealed gallstones and 52 patients (62%) revealed a completely normal gallbladder. In eight patients (10%) a cholecystectomy was performed before or during transplantation because of already known gallstones. No concrements in the biliary ducts (choledocholithiasis) could be detected. In group 2 the number of patients with gallstones was slightly lower (22%) compared with group 1 patients (30%), but without statistical significance. - Cholestasis parameters were not increased and HbA1c values were normal in both groups of patients. CONCLUSION: The prevalence of biliary disease in kidney/pancreas transplanted type I-diabetic patients with 28% is increased in comparison to the general population (10-15%). Lithogenicity under tacrolimus seems to be lower as under cyclosporine based immunosuppressive drug treatment. We recommend regular sonographical examinations to detect an acute or chronic cholecystis as early as possible, which may develop occultly in these patients.

Effect of an oral health training program on knowledge and behavior of state agency long-term-care surveyors.

This study examines the effect of a training program on long-term-care (LTC) surveyors' knowledge of factors affecting oral health and their behavior in citing oral health deficiencies of LTC residents. Twenty surveyors were recruited for the experimental group, along with a non-equivalent comparison group of 31 surveyors. The experimental group participated in a three-hour interactive, case-based training program. The experimental group had a significant increase in total knowledge (p < 0.002) post-test scores with a moderate effect size, eta 2 = 0.115. The training program resulted in a statistically significant increase (p < 0.0001) in oral health citation behavior for the experimental group for six months following training. This study provides evidence that an interactive case-based training program can affect participants' knowledge regarding oral health of LTC residents and participants' oral health citation behavior. As the elderly population experiences an increased life expectancy with increased need for assistance with Activities of Daily Living (ADL), similar training programs will become an important factor in assessing the quality of care provided to LTC residents.

Retained foreign bodies.

OBJECTIVE: To evaluate the frequency of occurrence and outcome of patients having retained foreign bodies after treatment in an urgent-care setting. MATERIALS AND METHODS: Closed case records from the files of the Medical Professional Mutual Insurance Company involving claims of retained foreign body were reviewed for a 7-year period. MAIN RESULTS: Thirty-two patients filed 54 claims against 32 physicians and 22 health care institutions. Defense costs were $298,906, and indemnity payments were $1,279,171. Glass was the most frequent retained foreign body, constituting 53% of claims. Despite the fact that glass is radiopaque, x-ray films were ordered for only 35% of these patients. Retention of glass fragments when no radiologic study was obtained resulted in unsuccessful defense of 60% of the claims and higher indemnity payments. Radiologic studies were ordered for only 31% of all patients. CONCLUSIONS: All wounds should be considered to be at risk for foreign body entry. Documentation in the medical record of wound exploration and patient follow-up, and ordering of plain films and other diagnostic imaging studies should be used more frequently toward this end.

The retained surgical sponge.

OBJECTIVE: A review was performed to investigate the frequency of occurrence and outcome of patients who have retained surgical sponges. METHODS: Closed case records from the files of the Medical Professional Mutual Insurance Company (ProMutual, Boston, MA) involving a claim of retained surgical sponges were reviewed for a 7-year period. RESULTS: Retained sponges occurred in 40 patients, comprising 48% of all closed claims for retained foreign bodies. A falsely correct sponge count after an abdominal procedure was documented in 76% of these claims. Ten percent of claims involved vaginal deliveries and minor non-body cavity procedures, for which no sponge count was performed. Total indemnity payments were $2,072,319, and defense costs were $572,079. In three cases, the surgeon was deemed responsible by the court despite the nursing staff's admitting liability and evidence presented that the surgeon complied completely with the standard of care. A wide range of indemnity payments was made despite a remarkable similarity of outcome in the patients studied. CONCLUSIONS: Despite the rarity of the reporting of a retained surgical sponge, this occurrence appears to be encountered more commonly than generally is appreciated. Operating teams should ensure that sponges be counted for all vaginal and any incisional procedures at risk for retaining a sponge. In addition, the surgeon should not unquestioningly accept correct count reports, but should develop the habit of performing a brief but thorough routine postprocedure wound/body cavity exploration before wound closure. The strikingly similar outcome for most patients would argue for a standardized indemnity payment being made without the need for adversarial legal procedures.

Inter-observer variance in ultrasonographical assessment of Schistosoma mansoni-related morbidity in young schoolchildren.

49 Sudanese schoolchildren aged 6-9 years with Schistosoma mansoni infection were ultrasonographically examined by two independent observers in a double-blind fashion. The first observer recorded normal appearance of the liver in 23 cases, whereas the second observer recorded the appearance as normal in 33 cases. There were 23 concordant observations. For Grade I periportal fibrosis (PF), 13 observations were concordant. PF Grade II was rarely observed (2 versus 3 cases), and Grade III was not recorded at all. In total, 38 out of 49 observations were concordant (77.5%). These preliminary data from two ultrasound observers, from observations on a limited number of patients, can be seen as an indication of a potential inter-observer variation of around 20% for the distinction between the absence of PF and a low level of PF.

Multidimensional assessment of depression.

A brief version of the Multiscore Depression Inventory was evaluated. Good coefficient alpha and test-retest reliabilities were obtained for the total score and the subscales. Two factor analyses were reported which appear to justify the use of a multiscore approach for at least 8 of the 9 subscales: helplessness, energy level, guilt, social introversion, cognitive difficulty, irritability, pessimism, and low self-esteem. Sad mood apparently overlapped with energy level on one analysis (replicating findings with the 118-item Multiscore Depression Inventory), and with self-esteem on the second analysis. Normative data are provided on diverse samples totaling 849 subjects.