Comparison of Respiratory Variations of Subclavian Vein and Inferior Vena Cava in Hospitalized Patients with Kidney Disease.

BACKGROUND: Accurate assessment of relative intravascular volume is critical for appropriate volume management of patients with kidney disease. Respiratory variations of inferior vena cava (IVC) diameter have been used and may correlate with those of subclavian vein (SCV) by bedside ultrasound. The purpose of this study was to assess the relationship between SCV and IVC respiratory variations by bedside ultrasound in a large group of hospitalized patients with acute and/or chronic kidney disease. METHODS: We compared 160 paired SCV and IVC bedside ultrasound studies from 102 semi-recumbent hospitalized adult patients with kidney disease. Patient encounters in which the SCV or IVC could not be clearly visualized were excluded. Collapsibility index=(Dmax-Dmin)/Dmax*100%; D=venous diameter. RESULTS: Relationships between SCV collapsibility index and IVC collapsibility index were not different for longitudinal and transverse views of the SCV. Correlation of SCV collapsibility index with IVC collapsibility index was 0.75 for mechanical ventilation (n=65, P<0.0001) and 0.67 for spontaneous breathing (n=95, P<0.0001). IVC collapsibility index cut-offs <20% for hypervolemia and >50% for hypovolemia corresponded to SCV collapsibility index cut-offs of <22% and >39%, respectively, for both mechanical ventilation and spontaneous breathing encounters. Using these cut-offs for SCV collapsibilities, assessment as hypervolemia versus not-hypervolemia had maximal sensitivity and specificity for predicting respective IVC collapsibility cut-offs of 88% for mechanical ventilation and 74% for spontaneous breathing, and assessment as hypovolemia versus not-hypovolemia had maximal sensitivity and specificity of 91% and 70%, respectively. Concordance, defined as agreement between assessment using SCV CI and assessment using IVC CI, was 85% for mechanical ventilation and 72% for spontaneous breathing when differentiating hypervolemia versus not-hypervolemia and was 89% and 71% respectively when differentiating hypovolemia versus not-hypovolemia. CONCLUSION: Assessment using SCV collapsibility index in the semi-recumbent position has a reasonable concordance with assessment using IVC collapsibility index for both spontaneous breathing and mechanical ventilation, in a wide range of hospitalized patients with concurrent kidney disease, and may be a useful adjunct to assess relative intravascular volume in patients with kidney disease.

Identifying Phenogroups in patients with subclinical diastolic dysfunction using unsupervised statistical learning.

BACKGROUND: Subclinical diastolic dysfunction is a precursor for developing heart failure with preserved ejection fraction (HFpEF); yet not all patients progress to HFpEF. Our objective was to evaluate clinical and echocardiographic variables to identify patients who develop HFpEF. METHODS: Clinical, laboratory, and echocardiographic data were retrospectively collected for 81 patients without HF and 81 matched patients with HFpEF at the time of first documentation of subclinical diastolic dysfunction. Density-based clustering or hierarchical clustering to group patients was based on 65 total variables including 19 categorical and 46 numerical variables. Logistic regression analysis was conducted on the entire study population as well as each individual cluster to identify independent predictors of HFpEF. RESULTS: Unsupervised clustering identified 3 subgroups which differed in gender composition, severity of cardiac hypertrophy and aortic stenosis, NT-proBNP, percentage of patients who progressed to HFpEF, and timing of disease progression from diastolic dysfunction to HFpEF to death. Clusters that had higher percentages of women had progressively milder cardiac hypertrophy, less severe aortic stenosis, lower NT-proBNP, were diagnosed at an older age with HFpEF, and survived to an older age. Independent predictors of HFpEF for the entire cohort included diabetes, chronic kidney disease, atrial fibrillation, and diuretic use, with additional predictive variables found for each cluster. CONCLUSIONS: Cluster analysis can identify phenotypically distinct subgroups of patients with diastolic dysfunction. Clusters differ in HFpEF and mortality outcome. In addition, the variables that correlate with and predict HFpEF outcome differ among clusters.

Changes in cardiac output with hemodialysis relate to net volume balance and to inferior vena cava ultrasound collapsibility in critically ill patients.

Cardiac output may increase after volume administration with relative intravascular volume depletion, or after ultrafiltration (UF) with relative intravascular volume overload. Assessing relative intravascular volume using respiratory/ventilatory changes in inferior vena cava (IVC) diameters may guide volume management to optimize cardiac output in critically ill patients requiring hemodialysis (HD) and/or UF.We retrospectively studied 22 critically ill patients having relative intravascular volume assessed by IVC Collapsibility Index (IVC CI) = (IVCmax-IVCmin)/IVCmax*100%, within 24 h of cardiac output measurement, during 37 intermittent and 21 continuous HD encounters. Cardiac output increase >10% was considered significant. Net volume changes between cardiac outputs were estimated from "isonatremic volume equivalent" (0.9% saline) gains and losses.Cardiac output increased >10% in 15 of 42 encounters with IVC CI <20% after net volume removal, and in 1 of 16 encounters with IVC CI ≥20% after net volume administration (p = 0.0136). All intermittent and continuous HD encounters resulted in intradialytic hypotension. Net volume changes between cardiac output measurements were significantly less (median +1.0 mL/kg) with intractable hypotension or vasopressor initiation, and net volume removal was larger (median -22.9 mL/kg) with less severe intradialytic hypotension (p < 0.001). Cardiac output increased >10% more frequently with least severe intradialytic hypotension and decreased with most severe intradialytic hypotension (p = 0.047).In summary, cardiac output may increase with net volume removal by ultrafiltration in some critically ill patients with relative intravascular volume overload assessed by IVC collapsibility. Severe intradialytic hypotension may limit volume removal with ultrafiltration, rather than larger volume removal causing severe intradialytic hypotension.

Relationship of inferior vena cava collapsibility to ultrafiltration volume achieved in critically ill hemodialysis patients.

BACKGROUND: Ultrasound (US) assessment of intravascular volume may improve volume management of dialysis patients. We investigated the relationship of intravascular volume evaluated by inferior vena cava (IVC) US to net volume changes with intermittent hemodialysis (HD) in critically ill patients. METHODS: A retrospective cohort of 113 intensive care unit patients in 244 encounters had clinical assessment of intravascular volume followed by US of respiratory/ventilatory variation of IVC diameter, and had HD within 24 h. IVC collapsibility index (IVC CI)=(IVCmax-IVCmin)/IVCmax*100%. Volume management was guided by clinical data plus IVC US findings. Intradialytic hypotension (IDH) was categorized by severity from none to inability to tolerate HD. RESULTS: Linear regression correlating n-weighted proportions of encounters achieving net volume removal of ≥0.5 L, ≥1.0 L, ≥1.5 L, and ≥2.0 L strongly correlated across the range of IVC CI (R2=0.87-0.64). Sensitivity and specificity analysis showed IVC CI was a better predictor than IVCmax of achieving net ultrafiltration (UF) volumes. Mean central venous pressure, pulmonary artery occlusion pressure, and cardiac output were poor predictors by logistic regression and receiver operating curve analyses. IVC CI <20% was the approximate optimal cutoff for achieving ≥0.5 L to ≥2.0 L net UF volumes. Net volume change achieved tended to be less than recommended and may have been limited by the development of IDH. Severity of IDH did not correlate with UF rate in mL/kg/h. χ2 analysis showed pre-US clinical intravascular volume assessments had poor concordance with IVC CI categories. CONCLUSION: IVC US may be a useful tool for predicting whether critically ill patients will achieve volume removal with HD.

Differential expression of microRNAs and their possible roles in patients with chronic idiopathic urticaria and active hives.

BACKGROUND: Chronic idiopathic urticaria (CIU) is a complicated skin disease with unknown pathophysiology. MicroRNAs (miRNA) have been shown to be active in cellular regulation. The goal of this pilot study was to examine whether miRNAs may be involved in the regulation of CIU or as biomarkers for CIU. METHODS: Four groups of three patients each were selected: patients with either active hives or no hives and with positive or negative chronic urticaria (CU) index results. MiRNAs were isolated from patient plasma and analyzed by using miRNA microarray technology to determine the amount of each of the 2567 known human miRNAs. RESULTS: A total of 16 miRNAs were found to be differentially expressed in patients with active hives. Among them, five (2355-3p, 4264, 2355-5p, 29c-5p, and 361-3p) were significantly increased in samples with positive CU index results, which could be useful biomarkers for patients with chronic autoimmune urticaria. The miRNA data bases were used to find the targets of these selected miRNA sequences. These potential targets were then compared against a list of 154 urticaria-related genes. Twenty-five genes were found to match. These included eight that were significantly downregulated and eight that were significantly upregulated; however, seven of the eight downregulated genes (FBXL20, OPHN1, YPEL2, STARD9, EZH1, KLHL24, ING4) and five of the eight upregulated genes (BYSL, PNO1, ADAMTS9, STEAP4, SRGN) have no reported roles in signaling. For the 13 genes with reported roles in signaling, the following pathways were found: transforming growth factor beta signaling pathway (NRC31, KITLG, THBS1, CCL2), glucocorticoid receptor signaling pathway (NR3C1, SELE, CCL2), p53 signaling pathway (CCNG2, THBS1, CCL2), p21-activated kinase pathway (PAK1IP1, KITLG, CCL2), phosphoinositide-3 kinase protein kinase B signaling pathway (KITLG, CHRM, THBS1), and neuroactive ligand-receptor interaction (NRC31, HRH1, CHRM), which could play important roles in CIU. CONCLUSION: A better understanding of those genes with undefined function and simultaneous quantitation of both miRNAs and messenger RNAs are needed to fully understand CIU disease.

A systematic literature search and review of sodium concentrations of body fluids
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BACKGROUND: Wide ranges of sodium concentrations for different body fluid losses have been noted with minimal substantiating data and variability among sources, leading to use of "cumulative fluid balance" regardless of composition in hospitalized patients. AIMS: To define the sodium concentrations of fluid losses from the body. METHOD: We performed a systematic search and literature review in adult humans using PubMed database. RESULTS: Inclusion criteria were met for 107 full-text articles. Mean sodium concentrations were significantly lower for acidic (mean ± SD: 44 ± 12 mEq/L) than for alkaline (55 ± 13 mEq/L) gastric fluid, higher for bile (185 ± 24 mEq/L) or pancreatic fluid (156 ± 3 mEq/L) than for all other body fluids, and similar for intact small bowel (119 ± 14 mEq/L) and ileostomy outputs (116 ± 25 mEq/L). Sodium concentrations were significantly greater for cholera-induced diarrhea (128 ± 18 mEq/L) and lower for osmotic-induced diarrhea (28 ± 16 mEq/L) than all other causes of diarrhea. For osmotic diarrheas, sorbitol-induced diarrhea sodium concentration was higher (63 ± 17 mEq/L) than for carbohydrate malabsorption (43 ± 20 mEq/L), lactulose (26 ± 19 mEq/L), Idolax (16 ± 13 mEq/L), or polyethylene glycol (13 ± 7 mEq/L). For secretory diarrheas, sodium concentration for idiopathic causes (53 ± 22 mEq/L) was lower than for neuroendocrine and villous tumors (75 ± 13 mEq/L) or nonosmotic laxatives (88 ± 33 mEq/L). For pleural, peritoneal, and edema fluid, sodium concentrations (137 ± 13 mEq/L) were similar to plasma. No data were found for wound fluid. Sodium concentration for sweat was 44 ± 17 mEq/L. CONCLUSIONS: This is the first in-depth review of verifiable sodium concentrations of body fluids most commonly lost in hospitalized patients. Sodium concentrations are fluid-specific and consistent. Sodium concentrations for diarrhea are associated with specific mechanisms/causes. These data should be useful to more accurately replace sodium and water content for specific body fluid losses.
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Posttreatment FDG-PET-CT response is predictive of tumor progression and survival in anal carcinoma.

PURPOSE: We hypothesize that posttreatment F-18 fluorodeoxyglucose positron emission tomography-computed tomography (FDG PET-CT) metabolic response predicts clinical outcomes in patients with anal cancer treated with chemoradiation. METHODS AND MATERIALS: This was a single-institution retrospective review of 148 patients treated definitively for anal squamous cell carcinoma between 2005 and 2012. All patients were followed with posttreatment PET-CT scans and clinical examinations. Progression-free survival (PFS), cause-specific survival, and overall survival (OS) estimates were calculated using the Kaplan-Meier method. RESULTS: The median follow-up was 34 months (range, 5-89 months). Pretreatment PET was successful in detecting the primary tumor in 140 cases (95%). Computed tomography (CT) alone was able to detect primary tumors in 78 of 122 patients who had pretreatment CT scans (64%). Inguinal or pelvic lymph nodes were FDG avid in 68 patients, with only 41 of these patients having enlarged lymph nodes by CT criteria (60.3%). Initial posttreatment PET-CT was obtained on average 12.7 ± 4.3 weeks after the last day of radiation (range, 5-25 weeks). Overall complete metabolic response (CR) on initial PET-CT was found in 82 patients (58%). Partial metabolic response was noted in 52 (36.9%) and progression in 7 patients (5%). Only 12/82 patients (14.6%) with a FDG-PET CR eventually recurred. The negative predictive value of a PET-CT scan performed between 13 and 25 weeks posttreatment was 92.9%. The 2-year PFS for patients with CR versus non-CR was 89.8% and 69.2%, respectively (P = .004). The 2-year OS for CR versus non-CR patients was 94.8% and 79.3% (P = .036). CONCLUSIONS: Complete metabolic response on posttreatment FDG PET-CT is highly predictive of increased PFS and OS in patients treated with chemoradiation for anal carcinoma. In addition to close clinical surveillance, we recommend obtaining posttreatment PET-CT scans >12 weeks following definitive treatment for anal cancer.

Vertical Localization of the Malar Prominence.

BACKGROUND: During reconstruction or augmentation, it is important to localize the malar complex in a symmetrical and aesthetically pleasing position. Few studies have determined the location of this feature and none related the location to gender, age, or ethnicity. Some of these have attempted to relate the position to the aesthetically pleasing Golden Ratio φ. METHODS: We assessed the vertical location of the malar prominence relative to other facial landmarks, determined consistency among individuals, and compared this with values used in artistry. Study population consisted of a convenience sample of 67 patients taken from an otolaryngology practice at a large urban medical center. Coordinates of the malar prominence were referenced to distinct facial landmarks from which the ratio of chin-to-malar prominence to chin-to-eye canthus was determined. RESULTS: Average chin-to-malar prominence distance was 0.793 ± 0.023 (SD) of the chin-to-eye canthus distance. Variability due to the specific image chosen [coefficient of variation (CV) = 1.19%] and combined inter/intrareader variability (CV = 1.71%) validate the methodology. Variability among individuals (CV = 2.84%) indicates population consistency. No difference was found between gender and age groups or between whites and Hispanics. Individuals of other/unknown ethnicities were within the range common to whites and Hispanics. Our population's value is not different from the value of 0.809 used in artistry, which is based on the Golden Ratio φ. CONCLUSIONS: The vertical position of the malar prominence is consistent among individuals, is clinically well-approximated by the value based on the Golden Ratio, and may be useful as a reference for surgical reconstruction or augmentation.

Serum 25-hydroxyvitamin D deficiency; a risk factor for chronic kidney disease in ambulatory indigent patients.

OBJECTIVE: To assess whether 25-hydroxyvitamin D (25[OH]D) deficiency is a risk factor for chronic kidney disease (CKD) in ambulatory indigent patients. METHODS: Data for all serum 25(OH)D concentrations measured during 2010 in our ambulatory nondialysis-dependent patients were analyzed along with CKD-related parameters. Patients were stratified into groups based on 25(OH)D levels of <10, 10 to 19, 20 to 29, and ≥30 ng/mL. CKD was defined by estimated glomerular filtration rate (eGFR; Chronic Kidney Disease-Epidemiology Collaboration [CKD-EPI] equation) and abnormal urine protein to creatinine ratios. CKD-associated parameters included serum parathyroid hormone (PTH), 1,25-dihydroxyvitamin D (1,25[OH]2D), alkaline phosphatase, albumin, corrected calcium, and total CO2 levels. RESULTS: A total of 2,811 patients had 25(OH)D levels measured. Patients with 25(OH)D levels <10 ng/mL had significantly increased relative risk (RR) of an eGFR <15 mL/min/1.73 m2 (RR, 4.0), an eGFR of 15 to 29 mL/min/1.73 m2 (RR, 2.6), urine protein to creatinine ratio >3.5 g/g (RR, 5.6), and serum PTH >100 pg/mL (RR, 2.8) compared to patients with a 25(OH)D level ≥30 ng/mL. Patients with 25(OH)D levels of 10 to19 ng/mL had significantly increased RR of a urine protein to creatinine ratio >3.5 g/g (RR, 4.8) and serum PTH >100 pg/mL (RR, 1.5) compared to patients with 25(OH)D levels ≥30 ng/mL. CONCLUSION: 25(OH)D deficiency (<10 ng/mL) was associated with reduced eGFR, nephrotic-range proteinuria, and increased PTH levels in our population of ambulatory urban indigent patients.

A comparative study of stereotactic radiosurgery, hypofractionated, and fractionated stereotactic radiotherapy in the treatment of skull base meningioma.

OBJECTIVES: To compare the outcomes of skull base meningiomas treated with stereotactic radiosurgery (SRS), hypofractionated stereotactic radiotherapy (hFSRT), and fractionated stereotactic radiotherapy (FSRT). METHODS: A total of 220 basal meningiomas in 213 patients were treated using SRS (N=55), hFSRT (N=22), and FSRT (N=143). The median age was 59 years (28 to 84 y). Prior surgery was performed in 74 cases; 39 patients received adjuvant radiotherapy after incomplete resection and 35 patients received salvage radiotherapy after tumor progression. In 146 cases, radiation was the primary therapy. Ten patients had World Health Organization II or III meningiomas. RESULTS: The median follow-up was 32 months (7 to 97 mo). Median tumor volume was 2.8 cm (0.10 to 16.94 cm), 4.8 cm (0.88 to 20.38 cm), and 11.1 cm (0.43 to 214.00 cm) and the median dose was 1250 cGy in 1 fraction to the 80% isodose line (IDL), 2500 cGy in 5 fractions to the 90% IDL, and 5040 cGy in 28 fractions to the 90% IDL for the SRS, hFSRT, and FSRT groups, respectively. Radiographic control was achieved in 91%, 94%, and 95% (P=0.25), whereas clinical response was seen in 89%, 100%, and 91% (P=0.16) in the SRS, hFSRT, and FSRT groups, respectively. CONCLUSIONS: There is no significant difference in the radiographic and clinical response in patients with skull base meningioma treated with SRS, hFSRT, or FSRT and thus gives the clinician the impetus to tailor treatment techniques to the location and size of the tumor at presentation.

Vitamin D deficiency in urban indigent patients in Southern California.

OBJECTIVE: To determine the prevalence of 25-hydroxy (OH) vitamin D deficiency in ambulatory and hospitalized patients from a large urban county medical center in Southern California, and assess the effects of season, ethnicity, age, location of care, and comorbidities on prevalence. METHODS: Data for all serum 25(OH)-D2 and -D3 concentrations measured during 2010, along with associated demographic characteristics and comorbidity data, were analyzed. 25(OH) D concentrations were measured using liquid chromatography-tandem mass spectrometry. RESULTS: Of 210,695 patients, serum 25(OH) D concentrations were measured for 3,276 (1.6%), 78% of whom were Hispanic, 69% female, 14% hospitalized, and 86% ambulatory. Median patient age was 54 years. Prevalence of 25(OH) D <10 ng/mL was 6.5% overall, 5.5% in Hispanics, 6.7% in Asians, 15.5% in African Americans, and 8.9% in whites. Prevalence was significantly higher in African Americans than in Hispanics (relative risk (RR): 2.79), males (RR: 2.07), hospitalized patients (RR: 4.96), and winter (RR: 1.34). Prevalence of 25(OH) D <20 ng/mL was 35% overall, 34% in Hispanics, 32% in Asians, 49% in African Americans, and 33% in whites, and was significantly higher in African Americans than Hispanics (RR: 1.45), males (RR: 1.32), hospitalized patients (RR: 2.02), and younger patients (RR: 1.21, age ≤30; 1.16, age 31-50) versus those age 51 to 70 years, and in winter (RR: 1.21). CONCLUSION: Our study estimated the prevalence of 25(OH) D deficiency and identified at-risk patient groups in Southern California; 25(OH) D deficiency should be suspected, diagnosed, and adequately treated to improve the health status in at-risk urban indigent patient populations.

Treatment of T3 and T4 anal carcinoma with combined chemoradiation and interstitial 192Ir implantation: a 10-year experience.

PURPOSE: To report our experience in treating T3 and T4 anal carcinoma with combined external beam (EBRT) and chemotherapy, followed by interstitial (192)Ir implant boost. METHODS AND MATERIALS: From 1990 to 2000, 31 patients with T3 and T4 anal carcinoma were treated with: 30 Gy EBRT (2 Gy fractions, 5 days/week) + 5-fluorouracil + mitomycin-C. Median implant dose was 31.3 Gy at 0.5 cm, delivered at a mean rate of 0.52 Gy/h. RESULTS: Six patients had local persistence and 4 eventually developed local-regional recurrence. Eight underwent abdomino-perineal resection (APR). With the addition of APR in selected cases, the ultimate local-regional control after initial treatment was 84%. Distant metastases occurred in 10. Of the initial cohort, 55% is still alive and NED. Eight had radiation proctitis and 7 developed postimplant ulceration. Only 1 required surgical intervention. CONCLUSIONS: Treatment of T3 and T4 anal cancer with combined chemotherapy and EBRT, followed by interstitial implant results in an ultimate local-regional control of 84%, after the inclusion of selected APR. It is well tolerated, with acceptable toxicity.

Use of fibrin glue in percutaneous nephrolithotomy.

OBJECTIVES: To report our experience with the use of fibrin glue during tubeless percutaneous nephrolithotomy. We addressed the safety of this approach and evaluated its use for any clinical benefit with respect to length of hospital stay, bleeding, analgesic usage, and urinary extravasation. METHODS: This was a retrospective review of 43 patients who underwent tubeless percutaneous nephrolithotomy. In 20 consecutive patients (one bilateral), percutaneous tracts were injected with 2 to 3 mL of Tissel Vapor Heated sealant at the conclusion of the procedure. The fibrin glue was instilled during simultaneous removal of the percutaneous sheath. These 20 patients were compared with a control group (23 consecutive patients) in which fibrin glue was not used. The length of hospitalization, hematocrit drop, analgesic use, stone burden, operative times, postoperative complications, and any noted computed tomography scan findings were compared. RESULTS: Postoperatively, the average length of hospital stay was less in the experimental than in the control group by 0.71 day (P <0.05). Differences in hematocrit drop between the experimental (6.8%) and control (5.6%) groups were not statistically significant. The total analgesic use was less in the experimental group, but the difference was not statistically significant. No statistical difference was found between the operative times for both groups. Postoperative fevers and wound seroma were noted in the experimental group. No abscesses or any significant changes along the percutaneous tracts were seen on postoperative computed tomography scans. In the control group, no procedure-related complications were noted. CONCLUSIONS: The use of fibrin glue is safe in percutaneous nephrolithotomy procedures and additional prospective randomized studies are needed to evaluate for any clinical benefit.