Fistulography of a Patent Hemodialysis Access: When Not to Treat and Implications for Establishing a Nontreatment Rate.

PURPOSE: To establish a rate of nonintervention in patients referred for hemodialysis access fistulography and to report clinical and fistulographic variables associated with nonintervention. MATERIALS AND METHODS: Encounters for fistulography were reviewed from 2001 to 2016 to determine annual rates of nontreatment over 15 years. Next, an access database was used to retrospectively identify patients undergoing fistulography from 2010 to 2016. Patients who underwent fistulography without intervention (angioplasty or stent placement) served as the nontreatment group (NTG; n = 76). Patients who underwent fistulography with intervention served as the control group (CG; n = 77). Patients with thrombosed accesses were excluded. Clinical indications for intervention and physical examination findings were correlated with fistulography. Need for subsequent percutaneous intervention was recorded. RESULTS: Annual nontreatment rates ranged from 3% to 14% (median, 10%). Preprocedure thrill was encountered in 45 patients in the NTG (59%) vs 6 in the CG (7.8%; P < .01). Aneurysm as indication for fistulography was more common in the NTG than the CG (19 [25%] vs 4 [5%]; P < .01). The NTG had a higher proportion of aneurysms noted on fistulography as well (38 [50%] vs 19 [25%]; P < .01). The CG had a higher proportion of patients needing subsequent percutaneous intervention vs the NTG (73 [96%] vs 38 [50%]; P < .001). CONCLUSIONS: A suggested nonintervention rate for hemodialysis access fistulography is 10%. Patients in the NTG were more likely to have a thrill on physical examination or to present with aneurysms as the clinical indicator. NTG patients were less likely to require subsequent percutaneous intervention.

Greater Protein and Energy Intake May Be Associated With Improved Mortality in Higher Risk Critically Ill Patients: A Multicenter, Multinational Observational Study.

OBJECTIVES: Controversy exists about the value of greater nutritional intake in critically ill patients, possibly due to varied patient nutritional risk. The objective of this study was to investigate whether clinical outcomes vary by protein or energy intake in patients with risk evaluated by the NUTrition Risk in the Critically Ill score. DESIGN: Prospective observational cohort. SETTING: A total of 202 ICUs. PATIENTS: A total of 2,853 mechanically ventilated patients in ICU greater than or equal to 4 days and a subset of 1,605 patients in ICU greater than or equal to 12 days. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: In low-risk (NUTrition Risk in the Critically Ill, < 5) and high-risk (NUTrition Risk in the Critically Ill, ≥ 5) patients, mortality and time to discharge alive up to day 60 were assessed relative to nutritional intake over the first 12 days using logistic regression and Cox proportional hazard regression, respectively. In high-risk but not low-risk patients, mortality was lower with greater protein (4-d sample: odds ratio, 0.93; 95% CI, 0.89-0.98; p = 0.003 and 12-d sample: odds ratio, 0.90; 95% CI, 0.84-0.96; p = 0.003) and energy (4-d sample: odds ratio, 0.93; 95% CI, 0.89-0.97; p < 0.001 and 12-d sample: odds ratio, 0.88; 95% CI, 0.83-0.94; p < 0.001) intake. In the 12-day sample, there was significant interaction among NUTrition Risk in the Critically Ill category, mortality, and protein and energy intake, whereas in the 4-day sample, the test for interaction was not significant. In high-risk but not low-risk patients, time to discharge alive was shorter with greater protein (4-d sample: hazard ratio, 1.05; 95% CI, 1.01-1.09; p = 0.01 and 12-d sample: hazard ratio, 1.09; 95% CI, 1.03-1.16; p = 0.002) and energy intake (4-d sample: hazard ratio, 1.05; 95% CI, 1.01-1.09; p = 0.02 and 12-d sample: hazard ratio, 1.09; 95% CI, 1.03-1.16; p = 0.002). In the 12-day sample, there was significant interaction among NUTrition Risk in the Critically Ill category, time to discharge alive, and protein and energy intake, whereas in the 4-day sample, the test for interaction was not significant. CONCLUSIONS: Greater nutritional intake is associated with lower mortality and faster time to discharge alive in high-risk, longer stay patients but not significantly so in nutritionally low-risk patients.

Unmasking of Previously Asymptomatic Central Venous Stenosis following Percutaneous Transluminal Angioplasty of Hemodialysis Access.

PURPOSE: To determine the frequency of new-onset symptoms of central venous stenosis (CVS) after percutaneous transluminal angioplasty (PTA) of a hemodialysis access-related stenosis in patients with previously asymptomatic CVS and to identify risk factors for this phenomenon. MATERIALS AND METHODS: Retrospective review was performed of patients treated with PTA for an access-related stenosis (excluding central vein interventions) between 2001 and 2016 who returned within 3 months with symptoms of CVS (ie, "unmasking"): 39 patients met these criteria. A control group of 122 patients who had untreated asymptomatic CVS and did not experience unmasking was selected. Fistulograms were graded for degree of CVS. A total of 51% of the unmasked group was male, with an average age of 65 years; 57% of the control group was male, with an average age of 63 years. RESULTS: The incidence of unmasking among patients with untreated asymptomatic CVS was 4.9%. A total of 90% of the unmasked group (35 of 39) had upper-arm access, compared with 77% of the control group (94 of 122; P = .017). A total of 28% of unmasked-group patients (11 of 39) underwent thrombectomy, vs 4% of controls (5 of 122; P < .0001). A total of 54% of unmasked-group patients (21 of 39) had significant brachiocephalic vein stenosis, vs 26% of controls (32 of 122; P = .001). A total of 8% of unmasked-group patients (3 of 39) had superior vena cava stenosis, vs none of the 122 controls (P = .01). A total of 64% of unmasked-group patients (25 of 39) had extensive collateral vessels, vs 24% of controls (29 of 122; P < .0001). CONCLUSIONS: The incidence of unmasking of asymptomatic CVS is low. Prophylactic treatment of asymptomatic CVS therefore remains generally inadvisable. However, patients undergoing declotting with extensive collateral vessels might warrant treatment of asymptomatic CVS.

Growth in retail-based clinics after nurse practitioner scope of practice reform.

BACKGROUND: Retail clinics are largely staffed by nurse practitioners (NPs) and are a popular destination for nonemergent care. PURPOSE: We examined if there was a relationship between NP practice regulations and retail clinic growth after the passage of a scope of practice (SOP) reform bill in Pennsylvania. METHODS: General linear regression models were used to compare retail clinic openings in Pennsylvania, New Jersey, and Maryland between 2006 and 2013. DISCUSSION: From 2006 to 2008, Pennsylvania experienced a significant growth rate in net retail clinic openings per capita (p = .046), whereas New Jersey and Maryland experienced no significant increase (p = .109 and .053, respectively). From 2009 to 2013, Pennsylvania opened 0.20 clinics (p = .129), New Jersey opened 0.23 clinics (p = .086), and Maryland opened 0.34 clinics per capita per year (p = .017). CONCLUSIONS: Our study of three states with varying levels of SOP restraint reveals an association between relaxation of practice regulations and retail clinic growth.

Central venous stenosis is more often symptomatic in hemodialysis patients with grafts compared with fistulas.

PURPOSE: To determine whether hemodialysis patients with central venous stenosis (CVS) are more frequently symptomatic if they have grafts versus fistulas. MATERIALS AND METHODS: A retrospective review was performed of 500 consecutive discrete patients, half with fistulas and half with grafts, who had fistulograms performed over a 4-year period. All fistulograms were evaluated for CVS, which was graded into quartiles. The presence of collaterals was noted and graded. Patient records were analyzed for symptoms of CVS, including face, neck, breast, or limb swelling. Statistical analysis was performed to determine the association between access type, degree of stenosis, location of stenosis, and symptoms. RESULTS: Of 500 fistulograms, 31 were excluded because of inadequate or absent central imaging. Of the remaining 469 patients, 235 had fistulas and 234 had grafts. CVS was present in 51% of patients with fistulas (119 of 237) and 51% of patients with grafts (118 of 237). When CVS was present, 29% (35 of 119) of patients with fistulas were symptomatic versus 52% (62 of 118) of patients with grafts (P = .0005). Overall, only 15% of patients with fistulas in the entire cohort were symptomatic compared with 27% of patients with grafts (P = .002). Sex, access side, and transposition did not influence symptoms; however, patients with upper arm access were more likely than patients with forearm access to be symptomatic (P < .0001), independent of access type. CONCLUSIONS: CVS is more likely to be symptomatic in patients with grafts versus fistulas, and patients with upper arm access are more likely than patients with forearm access to be symptomatic.

Greater Nutrient Intake Is Associated With Lower Mortality in Western and Eastern Critically Ill Patients With Low BMI: A Multicenter, Multinational Observational Study.

BACKGROUND: Little is known about the impact of feeding adequacy by NUTrition Risk in the Critically Ill (NUTRIC) groups in critically ill patients with body mass index (BMI) <20. Our purpose was to assess whether adequacy of protein/energy intake impacts mortality in patients with BMI <20 in Western/Eastern intensive care units (ICUs) and high/low NUTRIC groups. METHODS: Data from the International Nutrition Survey 2013-2014 were dichotomized into Western/Eastern ICU settings; BMI <20 or ≥20; and high (≥5)/low (<5) NUTRIC groups. Association of BMI <20 with 60-day mortality was compared in unadjusted and adjusted (Western/Eastern, age, medical/surgical admission, high/low NUTRIC group) logistic regression models. The impact of adequacy of protein/energy on 60-day mortality relationship was tested using general estimating equations in high/low NUTRIC groups, in unadjusted and adjusted models. RESULTS: Western (n = 4274) patients had higher mean BMI (27.9 ± 7.7 versus (vs) 23.4 ± 4.9, P < 0.0001) than Eastern (n = 1375), respectively. BMI <20 was associated with greater mortality (adjusted odds ratio [OR] 1.30, 95% confidence interval [CI] 1.07-1.57), with no interaction between BMI group and Western/Eastern ICU site. Among patients with BMI <20 and high NUTRIC score, 10% greater protein and energy adequacy was associated with 5.7% and 5.5% reduction in 60-day mortality, respectively. Results were not significantly different between Western and Eastern ICUs. CONCLUSIONS: The benefit of greater protein/energy intake in high-NUTRIC patients was observed regardless of geographic origin or low BMI, suggesting a consistent response to nutrition support in this group. Clinical guidelines and research projects focused on improving care in high-risk critically ill patients can be applied across geographic boundaries.

Remote Ischemic Preconditioning Does Not Prevent White Matter Injury in Neonates.

BACKGROUND: Remote ischemic preconditioning (RIPC) is a mechanism to protect tissues from injury during ischemia and reperfusion. We investigated the neuroprotective effects of RIPC in neonates undergoing cardiac surgery. METHODS: The outcome was white matter injury (WMI), assessed by the change in volume of WMI from preoperative to postoperative brain magnetic resonance imaging (MRI). Patients were randomized to RIPC or SHAM. RIPC was induced prior to cardiopulmonary bypass by four 5-minute cycles of blood pressure cuff inflation to produce ischemia of the lower extremity. For patients randomized to SHAM, the cuff was positioned, but not inflated. RESULTS: The study included 67 patients, with 33 randomized to RIPC and 34 randomized to SHAM. Preoperative and postoperative MRIs were available in 50 patients, including 26 of the 33 RIPC patients and 24 of the 34 SHAM patients. There were no differences in baseline and operative characteristics for either the overall study group or the group with evaluable MRIs. WMI was identified in 28% of the patients preoperatively and in 62% postoperatively. There was no difference in the prevalence of WMI by treatment group (p > 0.5). RIPC patients had an average change in WMI of 600 mL3, and SHAM subjects had an average WMI change of 107 mL3. There was no significant difference in the mean value of WMI change between patients who received RIPC and those who received SHAM treatments (p = 0.178). CONCLUSIONS: In this randomized, blinded clinical trial, there was no evidence that use of RIPC provides neuroprotection in neonates undergoing repair of congenital heart defects with cardiopulmonary bypass.

A randomized comparison between an intravenous catheter system with a retractable guidewire and conventional intravenous catheters.

INTRODUCTION: The aim of this study is to compare an intravenous (IV) catheter system which uses a retractable guidewire (RG-IV) designed to facilitate IV placement with a conventional IV (C-IV) catheter control. MATERIALS AND METHODS: A prospective, randomized design was used. Patients referred to interventional radiology for outpatient procedures were offered participation. Enrollment occurred between August and November 2013. Patients were assigned to receive the RG-IV or C-IV in a 1:1 randomization scheme. After assignment, up to three attempts by a registered nurse occurred with the assigned device; if all three attempts failed, crossover to the other device occurred. The primary outcome variable was first-attempt success at IV placement. Secondary outcome variables included patient and clinician satisfaction, number of attempts, and time to successful placement. Two hundred twenty patients were enrolled (139 men, 81 women) in the study. RESULTS: Of the 220 patients, two were withdrawn prior to IV attempt leaving 218 subjects, 109 in each group. First attempt success (77% RG-IV vs. 82% C-IV, p = 0.5), number of attempts to achieve IV access (1.26 RG-IV vs. 1.29 C-IV, p = 0.98), and time to achieve IV success (2.9 minutes RG-IV vs. 2.7 C-IV, p = 0.82) did not differ between groups. Patient satisfaction with insertion was higher in the C-IV group (4.5/5 vs. 3.9/5, p<0.001) although comfort comparison was not (3.3/5 RG-IV vs. 3.5/5 C-IV, p = 0.15). CONCLUSIONS: In an interventional radiology outpatient population, the RG-IV and C-IV were comparable in first-attempt success, number of attempts, and time to achieve IV success. Patient satisfaction was higher with C-IV.

Rates of autism and potential risk factors in children with congenital heart defects.

OBJECTIVE: Atypical development, behavioral difficulties, and academic underachievement are common morbidities in children with a history of congenital heart defects and impact quality of life. Language and social-cognitive deficits have been described, which are associated with autism spectrum disorders. The current study aimed to assess the rates of autism spectrum disorders in a large sample of children with a history of congenital heart defects and to assess medical, behavioral, and individual factors that may be associated with the risk of autism spectrum disorders. DESIGN: Participants included 195 children with a history of congenital heart defects, who are followed in a large-scale longitudinal study. Measures included behavioral data from 4-year-old neurodevelopmental evaluations and parent-report data from a later annual follow-up. RESULTS: Using established cutoffs on an autism spectrum disorder screener, children with congenital heart defects showed higher rates of "possible" autism spectrum disorders than national rates, (Chi-square Test of Equal Proportions), all Ps < .05. A stepwise variable selection method was used to create a "best prediction model" and multivariable logistic regression was used to identify variables predicting diagnostic status. Factors associated with diagnostic risk included medical (delayed sternal closure, prematurity, positive genetic findings), behavioral (cognitive, language, attention issues), and individual (socioeconomic, cultural/racial) variables. ROC analyses identified a cutoff of 7 to maximize sensitivity/specificity based on parent-reported diagnosis. CONCLUSIONS: Risk of autism spectrum disorder screening status in children with congenital heart defects was higher than expected from population rates. Findings highlight the need for referral to a specialist to assess the presence and severity of social-communication issues and congenital heart defects population-specific screening thresholds for children with concern for autism spectrum disorders.

Clinical Outcomes Related to Protein Delivery in a Critically Ill Population: A Multicenter, Multinational Observation Study.

OBJECTIVE: Optimal intake of energy and protein is associated with improved outcomes, although outcomes relative to protein intake are very limited. Our purpose was to evaluate the impact of prescribed protein delivery on mortality and time to discharge alive (TDA) using data from the International Nutrition Survey 2013. We hypothesized that greater protein delivery would be associated with lower mortality and shorter TDA. METHODS: The sample included patients in the intensive care unit (ICU) ≥ 4 days (n = 2828) and a subsample in the ICU ≥ 12 days (n = 1584). Models were adjusted for evaluable nutrition days, age, body mass index, sex, admission type, acuity scores, and geographic region. Percentages of prescribed protein and energy intake were compared with mortality outcomes using logistic regression and with Cox proportional hazards for TDA. RESULTS: Mean intake for the 4-day sample was protein 51 g (60.5% of prescribed) and 1100 kcal (64.1% of prescribed); for the 12-day sample, mean intake was protein 57 g (66.7% of prescribed) and 1200 kcal (70.7% of prescribed). Achieving ≥ 80% of prescribed protein intake was associated with reduced mortality (4-day sample: odds ratio [OR], 0.68; 95% confidence interval [CI], 0.50-0.91; 12-day sample: OR, 0.60; 95% CI, 0.39-0.93), but ≥ 80% of prescribed energy intake was not. TDA was shorter with ≥ 80% prescribed protein (hazard ratio [HR], 1.25; 95% CI, 1.04-1.49) in the 12-day sample but longer with ≥ 80% prescribed energy in the 4-day sample (HR, 0.82; 95% CI, 0.69-0.96). CONCLUSION: Achieving at least 80% of prescribed protein intake may be important to survival and shorter TDA in ICU patients. Efforts to achieve prescribed protein intake should be maximized.