Excess risk of renal allograft loss and early mortality among elderly recipients is associated with poor exercise capacity.

BACKGROUND: Successful renal transplantation in the elderly offers substantial benefits in quality and life expectancy. However, in this group of patients there is an early increased risk of death compared with those remaining on dialysis. MATERIALS AND METHODS: Graft and patient outcomes in 64 older transplant recipients were compared with 338 patients aged 18 - 59 years. We identified potential risk factors that may predict clinical outcomes in older transplant recipients. A log-rank test and Cox regression analyses were performed to assess the impact of various patient characteristics on graft and patient survival. RESULTS: Among older patients, graft survival was 76.6% and 67% at 1 and 3 years, respectively. When graft survival was censored for death with functioning graft, the 1- and 3-year graft survival was 83% and 82%, respectively. Patient survival was 78% and 71% at 1 and 3 years, respectively. These survival rates were significantly lower than those of younger recipients. Pretransplant inactivity, delayed graft function, smoking history and longer waiting time predicted poor graft and patient survival. A history of chronic obstructive pulmonary disease, and peripheral vascular disease also predicted a higher mortality among older recipients. CONCLUSION: Older kidney transplant recipients are at high risk for allograft failure and early death. Poor functional capacity predicts a poor outcome for older patients undergoing renal transplantation. Therefore, careful patient selection is paramount, and every effort should be made to initiate timely interventions aimed at increasing physical activity in those with low fitness level.

Prisoners favour hepatitis C testing and treatment.

More people with hepatitis C virus pass through incarcerated settings each year than any other venue. The goal of this study was to assess inmates' attitudes towards hepatitis C testing and treatment while incarcerated. We interviewed 153 male and female inmates at the Rhode Island Department of Corrections (RIDOC). Ninety-one per cent of inmates said they would agree to be tested for hepatitis C and 95% said that they would be willing to be treated for hepatitis C while incarcerated. Thirty-three per cent perceived themselves to be at risk for hepatitis C. Inmates were very interested in hepatitis C testing and, if indicated treatment. Inmates' attitudes towards hepatitis C testing and treatment do not pose a major obstacle to implementing comprehensive hepatitis C screening and treatment programme in correctional settings.

Prevalence of hydrocephalus in 157 patients with vestibular schwannoma.

The purpose of this study was to determine the prevalence of hydrocephalus in patients with vestibular schwannoma. A second objective was to investigate possible etiologies for hydrocephalus in this population by attempting to correlate the incidence and severity of hydrocephalus with tumor volume and extent of fourth ventricular compression. The MRI examinations of 157 adult patients with vestibular schwannoma were retrospectively reviewed. Tumor size was quantified, and the presence of accompanying hydrocephalus was assessed, categorized as communicating type or non-communicating type and then rated as mild, moderate or severe (grades 1-3). Next, the degree of fourth ventricular distortion caused by tumor mass effect was evaluated and categorized as mild, moderate or severe (grades 1-3). Spearman's rank correlation coefficient was used to test the relationships between tumor volume and (1) the extent of fourth ventricular effacement and (2) severity of hydrocephalus. Hydrocephalus was present in 28/157 (18%) cases and was categorized as mild in 11/28 (39%), moderate in 15/28 (54%) and severe in 2/28 (7%). Communicating-type hydrocephalus was present in 17/28 (61%) and non-communicating type in 11/28 (39%). There was a positive correlation between the grade of non-communicating hydrocephalus and tumor volume (r=0.38; P<0.001) and between the severity of fourth ventricular compression and extent of hydrocephalus in this group(r=0.43; P<0.001). In patients who were classified as having communicating hydrocephalus, the correlation between tumor volume and the severity of hydrocephalus was poor (r=0.19; P=0.02) as was the correlation between the extent of fourth ventricular distortion and the severity of hydrocephalus (r=0.21; P<0.01). There is a high prevalence of hydrocephalus in patients with vestibular schwannoma. In a minority of cases non-communicating type hydrocephalus is present and the severity of hydrocephalus can be attributed to the affect of tumor volume on fourth ventricular compression. More commonly, however, communicating-type hydrocephalus exists and the correlation between the severity of fourth ventricular compression and extent of hydrocephalus is poor. Therefore, other etiologies for hydrocephalus, such as tumor protein sloughing, are likely relevant.

Growth hormone administration and exercise effects on muscle fiber type and diameter in moderately frail older people.

OBJECTIVE: Reduced muscle mass and strength are characteristic findings of growth hormone deficiency (GHD) and aging. We evaluated measures of muscle strength, muscle fiber type, and cross sectional area in response to treatment with recombinant human growth hormone (rhGH) with or without a structured resistance exercise program in frail older subjects. DESIGN: Placebo-controlled, randomized, double blind trial. SETTING: Outpatient clinical research center at an urban university-affiliated teaching hospital. PARTICIPANTS: Thirty-one consenting older subjects (mean age 71.3 +/- 4.5 years) recruited as a subset of a larger project evaluating rhGH and exercise in older people, who underwent 62 quadricep-muscle biopsies. INTERVENTION: Random assignment to a 6-month course of one of four protocols: rhGH administered subcutaneously daily at bedtime, rhGH and a structured resistance exercise program, structured resistance exercise with placebo injections, or placebo injections only. MEASUREMENTS: Muscle biopsy specimens were obtained from the vastus lateralis muscle. Isokinetic dynamometry strength tests were used to monitor individual progress and to adjust the weights used in the exercise program. Serum insulin-like growth factor-I (IGF-I) was measured and body composition was measured using a Hologic QDR 1000W dual X-ray densitometer. RESULTS: The administration of rhGH resulted in significant increase in circulating IGF-I levels in the individuals receiving rhGH treatment. Muscle strength increased significantly in both the rhGH/exercise (+55.6%, P =.0004) as well as the exercise alone (+47.8%, P =.0005) groups. There was a significant increase in the proportion of type 2 fibers between baseline and six months in the combined rhGH treated subjects versus those not receiving rhGH (P =.027). CONCLUSIONS: Our results are encouraging in that they suggest an effect of growth hormone on a specific aging-correlated deficit. IGF-I was increased by administrating rhGH and muscle strength was increased by exercise. The administration of rhGH to frail older individuals in this study resulted in significant changes in the proportions of fiber types. Whether changes in fiber cross-sectional area or absolute number occur with long-term growth hormone administration requires further study.

HIV testing among young adults and older adolescents in the setting of acute substance abuse treatment.

OBJECTIVES: To examine the feasibility and acceptance of HIV testing among youth in acute substance abuse treatment. METHODS: Youth, aged 18 to 25 years old, in state-funded inpatient detoxification completed a confidential demographic/risk behavior questionnaire, and were offered a choice of no testing, serum-based testing, or oral fluid (Orasure, Epitope, Inc., Beaverton, OR, U.S.A.) HIV testing. RESULTS: In all, 74% of 204 participants accepted HIV testing. In a multivariate model, female gender (odds ratio [OR], 0.32; 95% confidence interval [CI] 0.14-0.74) and having been recently tested (OR, 0.11; 95% CI, 0.05-0.26) were independently associated with refusing testing. Recent sexual activity (OR, 5.4; 95% CI, 1.5-20.4), recent use of methamphetamines (speed) or a combination of cocaine and heroin (speedball) (OR, 3.8; 95% CI, 1.6-9.0), and a recent perceived risk for HIV (OR, 4.6; 95% CI, 1.9-10.9) were independently associated with test acceptance. Thus, 150 of 150 (100%) chose the Orasure test. Overall, 64.6% (97 of 150) of those tested received their results, but among participants requiring a follow-up appointment to learn test results, only 9.2% (8 of 87) returned. CONCLUSIONS: HIV testing is feasible and acceptable in this population. All patients preferred Orasure testing to a serum enzyme-linked immunosorbent assay (ELISA). Most youth tested in detoxification will only learn their results if they are provided during treatment. Rapid HIV testing with same-day results could improve follow-up rates.

A beta-blocker, not magnesium, is effective prophylaxis for atrial tachyarrhythmias after coronary artery bypass graft surgery.

OBJECTIVE: To evaluate magnesium as a sole or adjuvant agent with currently used prophylactic drugs in suppressing postoperative atrial tachyarrhythmias (POAT) after coronary artery bypass graft (CABG) surgery. DESIGN: Single-center prospective, randomized clinical trial. SETTING: University hospital. PARTICIPANTS: Patients (n = 400) undergoing CABG surgery. INTERVENTIONS: Patients were randomized among 6 prophylaxis regimens: (1) control (no antiarrhythmics), (2) magnesium only, (3) digoxin only, (4) magnesium and digoxin, (5) propranolol only, and (6) magnesium and propranolol. Patients randomized to a regimen including magnesium received 12 g given during 96 hours postoperatively. Patients in a digoxin regimen received 1 mg after cardiopulmonary bypass and 0.25 mg daily. Patients in a propranolol regimen received 1 mg intravenously every 6 hours until able to take 10 mg orally 4 times a day. Prophylaxis regimens were discontinued after 4 days postoperatively. MEASUREMENTS AND MAIN RESULTS: The primary outcome was a sustained POAT or discharge from the hospital. Control patients had an incidence of POAT (38%) not significantly different from patients in magnesium-only (38%), digoxin-only (31%), and magnesium with digoxin (37%) regimens. Patients treated with propranolol had a significant reduction in POAT. Nearly identical POAT rates in the propranolol-only (18%) and propranolol with magnesium (19%) groups support the lack of efficacy of magnesium in this trial. Study design allowed analysis of and showed a beta-blocker withdrawal effect in addition to suppressive benefit of postoperative beta-blockers. CONCLUSION: beta-Blocker prophylaxis is indicated to reduce the incidence of POAT in CABG surgery patients and to prevent a beta-blocker withdrawal effect in patients receiving these medications preoperatively. Digoxin and magnesium as sole or adjuvant agents do not offer suppressive or ventricular rate reduction benefits in POAT.

A 9-year, single-institution, retrospective review of death rate and prognostic factors in adult respiratory distress syndrome.

OBJECTIVE: To evaluate, at a single institution, the adult respiratory distress syndrome (ARDS) death rate in critically ill ventilated surgical/trauma patients and to identify the factors predicting death in these patients. SUMMARY BACKGROUND DATA: The prognostic features affecting mortality at the onset of ARDS have not been clearly defined. Defining rare characteristics would be valuable because it would allow for better stratification of patients in clinical trials and more appropriate utilization of constrained resources in ICU environments. METHODS: A retrospective analysis of 980 ventilated surgical and trauma intensive care unit patients from January 1990 to December 1998 was performed at Rhode Island Hospital. One hundred eleven adult intensive care unit patients with ARDS were identified using the criteria of Lung Injury Score more than 2.50 and the definition from the American-European Consensus Conference. Slightly more than half were trauma patients, 57% were men, and the median age was 59 years. The overall death rate was 52%. Patients were segregated by admission date to the intensive care unit (before or after January 1, 1995). Severity of illness was measured by the Revised Trauma Score for trauma patients and the Acute Physiology and Chronic Health Evaluation III for surgical patients. The Multiple Organ Dysfunction Score was determined on the day of onset of ARDS for all patients. Other recorded variables were age, sex, intensive care unit length of stay, length and mode of ventilation, presence or absence of tracheostomy, ventilation variables of peak and mean airway pressures, lung injury scores, elective versus emergency surgery, and presence or absence of pneumonia. RESULTS: There was a significant decrease in the ARDS death rate from the period 1990 to 1994 to the period 1995 to 1998. The major reason for the decline was a reduction in the posttraumatic ARDS death rate. Lung-protective ventilation strategies were used more frequently in the second period than in the first, and the death rate was significantly decreased in trauma patients in the second period when lung-protective ventilation modes were used. Predictors of death at the onset of ARDS were advanced age, Multiple Organ Dysfunction Score of 8 or more, and Lung Injury Score of 2.76 or more. CONCLUSION: In this single-institution series, the death rate from ARDS declined from 1990 to 1998, primarily in posttraumatic patients, and the decrease is related to the use of lung-protective ventilation strategies. Based on this patient population, the authors developed a statistical model to evaluate important prognostic indicators (advanced age, organ system and pulmonary dysfunction measurements) at the onset of ARDS.

Prognostic value of stress-gated Tc-99m sestamibi SPECT after acute myocardial infarction.

Stress-gated technetium-99m (Tc-99 m) sestamibi single-photon emission computed tomography (SPECT) is used to risk stratify patients after acute myocardial infarction (AMI). In clinical practice, results of this test are used primarily to identify patients with myocardial ischemia for intervention. The value of this test to risk stratify patients with AMI not at high ischemic risk has not been addressed. More than 1-year follow-up was undertaken in 124 patients who underwent predischarge gated Tc-99m sestamibi SPECT studies and who did not undergo subsequent revascularization. Clinical variables and test-derived variables were evaluated to predict cardiac death, recurrent AMI, and hospitalization for unstable angina, congestive heart failure, or coronary revascularization. Independent predictors by multivariate analysis for cardiac death or recurrent AMI were a history of prior AMI (relative risk [RR] = 5.32, confidence interval [CI] 2.17 to 12.96), a low exercise capacity (RR = 6.84, CI 1.99 to 23.48), and left ventricular (LV) ejection fraction (EF) <40% (RR = 2.63, CI 1.04 to 6.38). The incidence of cardiac death or recurrent AMI was 29.8% in patients with a low exercise capacity versus 4.5% in those with good exercise capacity, and 38.1% in patients with LVEF <40% versus 9.4% in those with LVEF >40%. Independent predictors of cardiac death, AMI, or hospitalization for unstable angina, congestive heart failure, or revascularization were a history of prior AMI (RR = 2.24, CI 1.11 to 4.50) and LVEF <40% (RR = 3.13, CI 1.64 to 5.95). Among patients followed after AMI without revascularization Tc-99m sestamibi SPECT can identify a high-risk subset. The strongest independent predictors are poor exercise capacity and LVEF < 40%.

Effects of fluconazole administration in critically ill patients: analysis of bacterial and fungal resistance.

HYPOTHESIS: The administration of fluconazole in intensive care unit (ICU) patients leads to the emergence of bacterial and fungal resistance. DESIGN: Retrospective analysis of 2 patient cohorts: (1) critically ill patients treated in surgical, trauma, and medical ICUs between June 1997 and January 1999 who did and did not receive fluconazole; and (2) ICU patients with fungal infections and sensitivity testing results from June 1994 to December 1998. SETTING: University-affiliated tertiary care hospital. PATIENTS: The first cohort included 99 ICU patients with documented microorganism culture(s) who were treated with (n = 50) or without (n = 49) fluconazole; the second cohort included 38 patients with Candida species infection, identification, and antifungal susceptibility testing. RESULTS: Mortality (40% vs 20%; P = .03) and hospital length of stay (33.8 vs 25.6 days; P = .04) were higher in the patients treated with fluconazole compared with patients not treated with fluconazole. The ICU length of stay was also higher in patients treated with fluconazole (23.7 vs 15.1 days; P = .009). An increase in bacterial resistance occurred in patients after fluconazole treatment as opposed to bacterial resistance of patients who were treated for bacterial microorganism(s) without fluconazole (16% vs 4%; P = .049). Comparison of patient populations with Candida species identification before and after December 1997 showed an increase in Candida species resistance to fluconazole (11% vs 36%; P = .16), respectively. Fungal strains were dominated by a combination of Candida albicans and Candida glabrata in both populations (60% [before 1998] vs 82% [after 1998]), with an emergence of Candida non-albicans species tolerant to fluconazole. The amount of fluconazole administered and the number of patients receiving fluconazole treatment in the ICUs has also increased when comparing both periods. CONCLUSIONS: Comparison of critically ill patient populations with and without fluconazole treatment found increased mortality and longer hospital and ICU lengths of stay in the fluconazole-treated group. This group also had higher bacterial pathogen resistance to antibiotics after fluconazole administration compared with bacterial resistance of patients without fluconazole treatment. Our results warrant concern regarding worsening bacterial infections, increased mortality, and an increase in Candida resistance to fluconazole from increased use in ICU patients, with a shift in yeast infection that is more difficult to treat.

Analysis of the effect of conversion from open to closed surgical intensive care unit.

OBJECTIVE: To compare the effect on clinical outcome of changing a surgical intensive care unit from an open to a closed unit. DESIGN: The study was carried out at a surgical intensive care unit in a large tertiary care hospital, which was changed on January 1, 1996, from an open unit, where private attending physicians contributed and controlled the care of their patients, to a closed unit, where patients' medical care was provided only by the surgical critical care team (ABS or ABA board-certified intensivists). A retrospective review was undertaken over 6 consecutive months in each system, encompassing 274 patients (125 in the open-unit period, 149 in the closed-unit period). Morbidity and mortality were compared between the two periods, along with length-of-stay (LOS) and number of consults obtained. A set of independent variables was also evaluated, including age, gender, APACHE III scores, the presence of preexisting medical conditions, the use of invasive monitoring (Swan-Ganz catheters, central and arterial lines), and the use of antibiotics, low-dose dopamine (LDD) for renal protection, vasopressors, TPN, and enteral feeding. RESULTS: Mortality (14.4% vs. 6.04%, p = 0.012) and the overall complication rate (55.84% vs. 44.14%, p = 0.002) were higher in the open-unit group versus the closed-unit group, respectively. The number of consults obtained was decreased (0.6 vs. 0.4 per patient, p = 0.036), and the rate of occurrence of renal failure was higher in the open-unit group (12.8% vs. 2.67%, p = 0.001). The mean age of the patients was similar in both groups (66.48 years vs. 66.40, p = 0.96). APACHE III scores were slightly higher in the open-unit group but did not reach statistical significance (39.02 vs. 36.16, p = 0.222). There were more men in the first group (63.2% vs. 51.3%). The use of Swan-Ganz catheters or central and arterial lines were identical, as was the use of antibiotics, TPN, and enteral feedings. The use of LDD was higher in the first group, but the LOS was identical. CONCLUSIONS: Conversion of a tertiary care surgical intensive care unit from an open to closed environment reduced dopamine usage and overall complication and mortality rates. These results support the concept that, when possible, patients in surgical intensive care units should be managed by board-certified intensivists in a closed environment.

Analysis of missed cases of abusive head trauma.

CONTEXT: Abusive head trauma (AHT) is a dangerous form of child abuse that can be difficult to diagnose in young children. OBJECTIVES: To determine how frequently AHT was previously missed by physicians in a group of abused children with head injuries and to determine factors associated with the unrecognized diagnosis. DESIGN: Retrospective chart review of cases of head trauma presenting between January 1, 1990, and December 31, 1995. SETTING: Academic children's hospital. PATIENTS: One hundred seventy-three children younger than 3 years with head injuries caused by abuse. MAIN OUTCOME MEASURES: Characteristics of head-injured children in whom diagnosis of AHT was unrecognized and the consequences of the missed diagnoses. RESULTS: Fifty-four (31.2%) of 173 abused children with head injuries had been seen by physicians after AHT and the diagnosis was not recognized. The mean time to correct diagnosis among these children was 7 days (range, 0-189 days). Abusive head trauma was more likely to be unrecognized in very young white children from intact families and in children without respiratory compromise or seizures. In 7 of the children with unrecognized AHT, misinterpretation of radiological studies contributed to the delay in diagnosis. Fifteen children (27.8%) were reinjured after the missed diagnosis. Twenty-two (40.7%) experienced medical complications related to the missed diagnosis. Four of 5 deaths in the group with unrecognized AHT might have been prevented by earlier recognition of abuse. CONCLUSION: Although diagnosing head trauma can be difficult in the absence of a history, it is important to consider inflicted head trauma in infants and young children presenting with nonspecific clinical signs.

Windsurfing injuries: results of a paper- and Internet-based survey.

OBJECTIVE: To describe the frequency, pattern, and mechanism of windsurfing injuries. METHODS: A 24-question multiple-choice paper-based survey was distributed to windsurfers at beaches in the United States and the Dominican Republic, and an identical survey was placed on the Internet. RESULTS: Two hundred ninety-four surveys in all were completed describing 339 acute and 150 chronic injuries. The foot, knee, chest wall, and ankle were the most commonly injured body parts. Sprains (26.3%) were most common, followed by lacerations (21.2%), contusions (16.2%), and fractures (14.2%). Direct injury from the windsurfing apparatus resulted in 64.5% of the acute injuries, and 12% were caused by contact with the ocean floor. The maneuvers most likely to result in injury were jumping, high-speed falls, and catapult falls. There was no statistically significant difference between the Internet- and paper-based surveys regarding anatomic distribution of injuries or type of injury. The incidence of injuries requiring medical care in study participants was estimated to be one injury per 1000 days sailed. CONCLUSIONS: Sprains, lacerations, and contusions to the lower extremity are the most common windsurfing injuries. Equipment modifications are suggested that may decrease the risk of injury.

Correlation of thallium uptake with left ventricular wall thickness by cine magnetic resonance imaging in patients with acute and healed myocardial infarcts.

Myocardial infarction (MI) is characterized by cellular necrosis which undergoes fibrotic transformation over time. Cine magnetic resonance imaging (MRI) offers high-resolution 3-dimensional images of the left ventricular myocardium, allowing sampling of the myocardial wall thickness over the entire left ventricle. Tomographic (single-photon emission computed tomography [SPECT]) thallium images also provide 3-dimensional information on the location and level of thallium uptake, which has been shown to correlate with myocardial viability. The purposes of this study were: (1) to examine the relation between both end-diastolic and end-systolic wall thickness and normalized thallium-201 uptake over the left ventricle in a group of patients with MI, (2) to examine the relation between regional wall thickening and normalized thallium uptake, and (3) to examine the relation between thallium uptake and wall thickness both early and late after infarction. Twenty-four patients with MI underwent stress, redistribution, and reinjection thallium SPECT imaging and cine MRI within several days. Seventeen patients underwent imaging late after infarction and 7 underwent imaging early after infarction. Normalized thallium activity was correlated with MRI wall thicknesses at both end-diastole and end-systole for 18 segments for each ventricle. In addition, end-diastolic and end-systolic wall thicknesses were grouped by their corresponding thallium activity levels into percentiles. End-systolic wall thickness correlated significantly with normalized thallium uptake in 14 of 18 segments, end-diastolic wall thickness in only 4 of 18 segments, and wall thickening in only 3 of 18 segments. Mean values for end-diastolic and end-systolic wall thicknesses corresponding to severely reduced (<50%) normalized thallium activity were 9.9 +/- 1.1 and 8.5 +/- 0.6, respectively. Using receiver-operating curve analysis, end-systolic wall performed as a better diagnostic parameter than end-diastolic wall for identifying severely reduced thallium activity levels. For all levels of thallium activity, end-diastolic wall thicknesses were all thinner late versus early after MI, whereas end-systolic wall thickness was thinner only in the segments corresponding to severely reduced thallium activity. Based on these results, end-systolic wall thickness is the best noninvasive anatomic parameter of myocardial scar.

Incidence of seizures after surgery for supratentorial meningiomas: a modern analysis.

The authors have assessed the incidence of postoperative seizures in 158 patients with supratentorial meningiomas diagnosed by computerized tomography (CT) and/or magnetic resonance (MR) imaging, which theoretically should lead to early diagnosis and treatment and the potential for improved seizure outcome. Univariate chi-square and logistic regression analyses were performed 24 independent variables against the outcome variable of occurrence of a postoperative seizure. The median duration of preoperative seizures was 1 month, considerably shorter than that found in studies conducted prior to the advent of CT and MR imaging. Of 63 patients with a history of preoperative seizures, 40 (63.5%) had complete cessation of seizures after surgery. Twelve (92.3%) of 13 patients with one to three postoperative seizures eventually achieved complete seizure control, whereas only four (40%) of 10 patients with more than three postoperative seizures achieved this result. Overall 88.9% of patients with preoperative seizures achieved complete seizure control postoperatively. Multivariate analysis was used to identify six variables that were predictive of the occurrence of postoperative seizures: preoperative seizure history preoperative language disturbance, extent of tumor removal, parietal location of tumor, postoperative anticonvulsant medication status, and postoperative hydrocephalus. These variables were incorporated into a diagnostic model designed to predict the risk of a postoperative seizure following meningioma surgery. On the basis of their findings, the authors conclude that earlier detection and treatment of supratentorial meningiomas improve seizure outcome in patients with preoperative epilepsy. Furthermore an assessment of the risk of postoperative seizures may help guide decisions concerning weaning patients from anticonvulsant medications postoperatively.