The significance of foot process effacement in immunoglobulin a nephropathy: clinicopathologic study of 161 cases with light, immunofluorescence and electron microscopic studies.

IGA nephropathy (IGAN) is the most common glomerular disease worldwide. Patients may present with hematuria and non-nephrotic (NNRP) or uncommonly nephrotic range proteinuria (NRP). To the authors' knowledge, correlation of podocyte foot process effacement (FPE) with subclasses of IGAN and proteinuria (PT) has not been studied. Retrospectively, 161 cases of IGAN with light, immunofluorescence, and electron microscopy (EM) were reviewed and classified according to Haas classification. EM was available in 110 out of 161 (67%) cases. FPE was evaluated as mild, <30%; moderate, 30–70%; and severe, >70% and was correlated with class and the level of PT. Out of 161 cases, 101 were males and 60 were females with M:F ratio of 1.71:1. In 72 cases, race was known as follows: white, 63 (88%); black, 6 (8%); Hispanic, 2 (3%); Asian, 1 (1%). Clinical history was available in 94 cases: PT 39 cases (42%), PT+hematuria 33 cases (35%), hematuria 15 cases (16%), and renal failure in 7 cases (7%). In 88 cases with FPE, PT was nephrotic in 21 and non-nephrotic in 29 cases. FPE is common in IGAN. No correlation between FPE and IGAN subclass (p=.42) or proteinuria group and IGAN subclass (p=.10) is present. Whether FPE is simply a reflection of other pathologic mechanisms and its significance in the pathophysiology of IGAN requires further investigation.

A retrospective study of the association between megestrol acetate administration and mortality among nursing home residents with clinically significant weight loss.

BACKGROUND: Megestrol acetate (MA) is a progestin widely used to treat weight loss and cachexia in patients suffering from AIDS or cancer. Although MA is also frequently prescribed for similarly malnourished elderly individuals, the efficacy and morbidity of MA treatment in this patient population remain unclear. OBJECTIVE: The goal of this study was to examine the effects of MA therapy on weight and overall mortality in elderly nursing home residents. METHODS: This was a case-control cohort study of 17,328 nursing home residents admitted to Beverly Healthcare nursing home between January 1, 2000, and December 31, 2003, who had lost either 5% of total body weight within 3 months or 10% of total body weight within 6 months. Residents within this weight loss group who received MA therapy--within 30 days of their weight loss documentation--were matched (1:2) with non-MA-treated residents with respect to age, sex, race, weight, and first notation of weight loss. Residents were further matched by propensity score for activities of daily living, cognitive functioning, number of medications taken during the 7 days before data entry, clinical condition (unstable, acute episode of a recurrent problem, end-stage disease), cancer diagnosis, and human immunodeficiency virus diagnosis. RESULTS: A total of 709 patients (mean [SD]age, 84.1 [9.7]years; 70.9% female) who received MA therapy were matched with 1418 non-MA-treated patients (mean [SD] age, 84.2 [9.0] years; 70.9% female). Of the 709 MA patients, 281 (39.6%) were alive and in the nursing home at last follow-up, 149 (21.0%) were alive and discharged to another facility or to home, and 279 (39.4%) died in the nursing home. For the controls, 651 (45.9%) were alive and in the nursing home, 308 (21.7%) were discharged to another facility or to home, and 459 (32.4%) died in the nursing home. The median survival of MA-treated residents (23.9 months; 95% CI, 20.2-27.5) was significantly less than untreated residents (31.2 months; 95% CI, 27.8-35.9) (P < 0.001). Median weight and median of weight differences were unchanged after 6 months of treatment with MA compared with matched controls. CONCLUSIONS: MA treatment of elderly nursing home residents with significant weight loss was associated with a significant increase in all-cause mortality without a significant increase in weight. Randomized, prospective studies of the use of MA in elderly nursing home residents are necessary to more fully evaluate morbidity and mortality associated with this therapy.

Vitamin D deficiency in residents of academic long-term care facilities despite having been prescribed vitamin D.

OBJECTIVES: Vitamin D is vitally important in maintaining skeletal health. A low plasma vitamin D concentration is associated with increased parathyroid hormone secretion, increased bone turnover, osteomalacia, and osteoporosis. As a result, vitamin D deficiency is associated with a higher incidence of hip and other fractures. Although Vitamin D deficiency has been reported in long-term care facilities, optimal methods of replenishment have not been defined. The objective of the present study was to identify the pattern of calcium and vitamin D supplementation in nursing home residents and to identify vitamin D deficiency in residents already on supplement therapy. DESIGN: Retrospective chart review. SETTING: Five academic nursing homes staffed by faculty from the University of Arkansas for Medical Sciences. PARTICIPANTS: Elderly residents aged 65 and older receiving calcium and vitamin D supplements. MEASUREMENTS: Data on dose, frequency, and levels of calcium and vitamin D were collected. The medication list and creatinine levels were also recorded. RESULTS: Forty-four (40%) residents were receiving 1000 mg, 48 (44%) were receiving 1200 mg, and 9 (8.2%) were receiving 1500 mg of calcium carbonate. Similarly, 79 (72%) residents were on 400 IU, 13 (12%) were on 600 IU, and only 8 (7%) were on 800 IU of vitamin D3 (cholecalciferol). Low levels of Vitamin D 25 (OH) D (values <30 ng/mL) were identified in 49.4% of residents; 16% were found to have deficiency (<20 ng/mL). CONCLUSION: Despite clear benefit, nursing home residents were not supplemented adequately with calcium and vitamin D.

Changes in ultrasonographic echogenicity and visibility of needles with changes in angles of insonation.

PURPOSE: To objectively compare the echogenicity of several types of needles at clinically important angles of insonation. MATERIALS AND METHODS: Four commercial needles (Echotip, Mini-Stick, Echo-Coat, Surflo) and a prototype dimpled needle were tested in a liver phantom at angles of insonation ranging from 90 degrees to 15 degrees. Photodensity measurement determined echogenicity levels in arbitrary echogenicity units (EU). RESULTS: At 90 degrees angles of insonation all needles were easily seen (60-76 EU) and echogenic levels were similar (P =.264). All values decreased with angulation. From the 35 degrees to 15 degrees angles, the prototype and Echotip needles were superior (P <.05). At 15 degrees the values were 43 EU for the prototype needle, 40 EU for the Echotip needle, 9.0 EU for the Echo-Coat needle, and 5.0 EU for the Surflo needle. CONCLUSION: With angulation, all needles drop in echogenicity, with prototype dimpled and Echotip best maintaining visibility at clinically important angles.

Cytotoxic chemotherapy following tandem autotransplants in multiple myeloma patients.

High-dose treatment (HDT) with autologous stem cell transplant (ASCT) is superior to conventional chemotherapy in multiple myeloma. However, relapses eventually occur, especially in the presence of unfavourable cytogenetic abnormalities, high beta-2 microglobulin levels prior to transplant and extensive prior treatment. Cytotoxic consolidation chemotherapy, following tandem transplants (TT), was given to 75 myeloma patients with at least one poor prognostic factor. When their outcome was compared with that of 75 matched controls who received dexamethasone +/- interferon post TT, no event-free or overall survival advantage was observed. Other approaches may be required to improve survival in multiple myeloma.

Ocular outcomes in low birth weight premature infants with intraventricular hemorrhage.

PURPOSE: To study ocular outcomes in very low birth weight premature infants with intraventricular hemorrhage. METHODS: Parents of 490 consecutive very low birth weight (less than 1500 g) premature infants who were discharged from the neonatal intensive care unit of our hospital between 1994 and 1996 were asked to enroll their child/children in this cross-sectional study. Sixty infants (12%) were recruited and had complete masked ophthalmologic examinations at 12 months corrected gestational age. The medical records of each infant were reviewed after the eye examination was complete. The occurrence of intraventricular hemorrhage and other perinatal comorbidities was documented. Ocular outcomes of infants with no or low-grade (grades I-II) hemorrhages were compared with those of infants with high-grade (grades III-IV) intraventricular hemorrhage. RESULTS: Of the 60 infants examined, 17 (28%) had neonatal intraventricular hemorrhage. Eleven (18%) had high-grade intraventricular hemorrhage, and 49 (82%) had no or low-grade hemorrhage. Of the 11 infants with high-grade intraventricular hemorrhage, 8 (73%) had strabismus compared with 7 (14%) of 49 infants with no or low-grade hemorrhages who developed strabismus (P<0.001). The high-grade group also had a larger proportion of infants with ocular motility defects (P=0.008), nystagmus (P<0.001), optic nerve atrophy (P<0.001), and abnormal retinal findings (P=0.039). Additionally, these infants were more likely to have stage 3 or worse retinopathy of prematurity (P=0.003). CONCLUSIONS: These results confirm the findings of our earlier retrospective study, and suggest that the occurrence of high-grade intraventricular hemorrhage in the early postnatal period places these infants at significant risk for adverse ocular outcomes. These infants require close ophthalmologic surveillance.

Predicting long-term (> or = 5 years) event-free survival in multiple myeloma patients following planned tandem autotransplants.

Although outcome in multiple myeloma (MM) patients has improved significantly with the introduction of autotransplants (AT), the curability of this approach remained to be demonstrated. Therefore, we analysed outcome and prognostic factors using a logistic regression model in 515 consecutive newly diagnosed and previously treated patients intended to receive melphalan-based tandem transplants with follow up of > or = 5 years. One quarter of patients had event-free survivals (EFS) > or = 5 years with no further relapses seen after 7 years (46 patients on plateau). On multivariate analysis, factors associated with EFS > or = 5 years were absence of chromosome 11 and 13 abnormalities (odds ratio: 6.1), < or = 12 months of preceding standard-dose therapy (SDT) (OR: 2.6) and beta-2 microglobulin (B2M) level < or = 2.5 mg/l at time of first AT (OR: 1.7). Patients with only favourable variables (25%) had a 7-year EFS in excess of 35%, compared with 15% and 10%, respectively, with one (43%) or two unfavourable variables (27%), and 0% for 5% of patients with three unfavourable variables (P < 0.0001). Using a 1-year landmark analysis to allow for guaranteed time and thereby excluding early treatment failures, attaining a complete remission (CR) had no significant effect on long-term survival. Our data are consistent with cure in MM patients with a CR duration . or = 7 years and re-establishment of a monoclonal gammopathy of undetermined significance (MGUS) phase in those with persistent evidence of disease post transplantation, but without disease progression > or = 7 years.

Pathogenic Aspergillus species recovered from a hospital water system: a 3-year prospective study.

Nosocomial aspergillosis, a life-threatening infection in immunocompromised patients, is thought to be caused primarily by Aspergillus organisms in the air. A 3-year prospective study of the air, environmental surfaces, and water distribution system of a hospital in which there were known cases of aspergillosis was conducted to determine other possible sources of infection. Aspergillus species were found in the hospital water system. Significantly higher concentrations of airborne aspergillus propagules were found in bathrooms, where water use was highest (2.95 colony-forming units [cfu]/m(3)) than in patient rooms (0.78 cfu/m(3); P=.05) and in hallways (0.61 cfu/m(3); P=.03). A correlation was found between the rank orders of Aspergillus species recovered from hospital water and air. Water from tanks yielded higher counts of colony-forming units than did municipal water. An isolate of Aspergillus fumigatus recovered from a patient with aspergillosis was genotypically identical to an isolate recovered from the shower wall in the patient's room. In addition to the air, hospital water systems may be a source of nosocomial aspergillosis.