Primary patency rates of AV fistulas and the effect of patient variables

BACKGROUND

DOQI (The Dialysis Outcomes Quality Initiative) recommend 40% of prevalent renal failure patients should be undergoing hemodialysis (HD) using autogenous arteriovenous fistulae (AVF). The aim of this study is to assess the primary patency rates of wrist and elbow fistulae, and to examine how patient variables influence the success of a fistula. In addition, an attempt has been made to address the main issue of survival rates in this high risk patient population.

METHODS

A retrospective study was performed on all patients in the University Hospital of North Staffordshire who underwent creation of a wrist or elbow fistula for HD. During the study period 289 primary AVFs were created. In all, 210 AVF were sited at the wrist and 79 at the elbow. Follow-up ranged from 3 months to 4 yrs. Primary patency and patient death, transplant and transfer were taken as end points. Patient survival was defined as time of fistula creation to patient death. Actuarial survival was calculated using Kaplan-Meier survival analyses, with differences between groups determined using log rank analysis, and statistical significance obtained using X2 tests.

RESULTS

Primary patency for wrist fistulae was 49, 41 and 32% at 6, 12 and 24 months, respectively, and 57, 51 and 38% for elbow fistulae. Regression analysis showed fistula survival to be significantly greater in males than in females (p=0.023). Fistula survival rates in non-diabetics patients were higher than in patients with diabetes however, this was not significant (p=0.11); (54, 48 and 34% in diabetics compared to 45, 35 and 26% in non-diabetics at 6, 12 and 24 months, respectively). Age did not influence fistula survival; however, it did affect patient survival. Patient survival was 90, 74 and 56% at 1, 2 and 3 yrs, respectively, and in >60s fell to 86, 71 and 50%. Overall 74/245 (30%) patients died.

CONCLUSION

These results suggest that overall primary patency rates for wrist and elbow fistulae are comparable to similar studies at 6, 12 and 24 months. Fistula survival after this period is dictated by poor patient survival. Our findings suggest that creation of primary vascular access at the elbow in older females and diabetics may be associated with better results.

Kimberlite ascent and eruption

Wilson and Head model kimberlite ascent and eruption by considering the propagation of a volatile-rich dyke. Wilson and Head's model has features in common with Sparks et al., but it is inconsistent with geological observations and constraints on volatile solubility. Here we show that this may be due to erroneous physical assumptions.

Mutations in the RSK2(RPS6KA3) gene cause Coffin-Lowry syndrome and nonsyndromic X-linked mental retardation

We describe three families with X-linked mental retardation, two with a deletion of a single amino acid and one with a missense mutation in the proximal domain of the RSK2(RPS6KA3) (ribosomal protein S6 kinase, 90 kDa, polypeptide 3) protein similar to mutations found in Coffin-Lowry syndrome (CLS). In two families, the clinical diagnosis had been nonsyndromic X-linked mental retardation. In the third family, although CLS had been suspected, the clinical features were atypical and the degree of intellectual disability much less than expected. These families show that strict reliance on classical clinical criteria for mutation testing may result in a missed diagnosis. A less targeted screening approach to mutation testing is advocated.

Management of septic arthritis: a systematic review

OBJECTIVE

To evaluate the existing evidence on the diagnosis and management of septic arthritis in native joints.

DESIGN

Systematic review.

DATA SOURCES

Cochrane Library, Medline, Embase, National Electronic Library for Health, reference lists, national experts.

REVIEW METHODS

Systematic review of the literature with evaluation of the methodological quality of the selected papers using defined criteria set out by the Clinical Effectiveness and Evaluation Unit of the Royal College of Physicians.

RESULTS

3291 citations were initially identified. Of these, 189 full text articles were identified for potential selection. Following review of these full text articles, 80 articles were found to fulfil the inclusion criteria and were included in the final list.

CONCLUSIONS

were drawn on the diagnosis, investigation and management of septic arthritis.

DISCUSSION

Little good quality evidence exists to guide the diagnosis and management of septic arthritis. Overall, no investigation is more reliable in the diagnosis of septic arthritis than the opinion of an experienced doctor. Aspiration and culture of synovial fluid is crucial to the diagnosis, but measurement of cell count is unhelpful. Antibiotics are clearly required for a prolonged period, but there are no data to indicate by which route or for how long. Key unanswered questions remain surrounding the medical and surgical management of the infected joint.

Cannabis 'dependence' and attentional bias for cannabis-related words

Drug users have attentional biases for drug-related stimuli, and the frequency of drug use and craving are associated with attentional bias. However, research to date has not investigated the relationship between the severity of cannabis dependence, and attentional bias for cannabis-related stimuli. In the present study, 28 recreational cannabis users completed a modified Stroop task with cannabis-related and control words, plus questionnaire measures of cannabis dependence and craving. Participants were split into those who met diagnostic criteria for cannabis dependence based on scores on the Cannabis Severity of Dependence Scale (C-SDS), and those who did not. The cannabis-dependent group had a significant attentional bias for the cannabis-related words, but the non-dependent group did not. Correlations indicated that attentional bias was also associated with the frequency of cannabis use, and with subjective craving.

Posttraumatic migraine characteristics in athletes following sports-related concussion

OBJECT

The object of this study was to compare symptom status and neurocognitive functioning in athletes with no headache (non-HA group), athletes complaining of headache (HA group), and athletes with characteristics of posttraumatic migraine (PTM group).

METHODS

Neurocognitive tests were undertaken by 261 high-school and collegiate athletes with a mean age of 16.36 +/- 2.6 years. Athletes were separated into three groups: the PTM group (74 athletes with a mean age of 16.39 +/- 3.06 years), the HA group (124 athletes with a mean age of 16.44 +/- 2.51 years), and the non-HA group (63 patients with a mean age of 16.14 +/- 2.18 years). Neurocognitive summary scores (outcome measures) for verbal and visual memory, visual motor speed, reaction time, and total symptom scores were collected using ImPACT, a computer software program designed to assess sports-related concussion. Significant differences existed among the three groups for all outcome measures. The PTM group demonstrated significantly greater neurocognitive deficits when compared with the HA and non-HA groups. The PTM group also exhibited the greatest amount of departure from baseline scores.

CONCLUSIONS

The differences among these groups can be used as a basis to argue that PTM characteristics triggered by sports-related concussion are related to increased neurocognitive dysfunction following mild traumatic brain injury. Thus, athletes suffering a concussion accompanied by PTM should be examined in a setting that includes symptom status and neurocognitive testing to address their recovery more fully. Given the increased impairments observed in the PTM group, in this population clinicians should exercise increased caution in decisions about treatment and when the athlete should be allowed to return to play.

Disease association of two distinct interleukin-18 promoter polymorphisms in Caucasian rheumatoid arthritis patients

Interleukin (IL)-18 is an important mediator of innate and adaptive immunity. We searched for an association of IL-18 promoter single-nucleotide polymorphisms (SNP) with rheumatoid arthritis (RA) in Caucasians. The entire study population was composed of two independent cohorts from Germany (n=200) and Scotland (n=410). Presence of IL-18 SNP at positions -607 and -137 was determined by allele-specific PCR in 327 RA patients and 283 healthy donors (HD). Diplotype distributions of both loci were in Hardy-Weinberg equilibrium (HWE) in the German and Scottish HD cohorts. In contrast, locus -607 was in HW disequilibrium in German, and locus -137 in Scottish RA patients. Diplotypic exact chi(2) tests suggested that -607CC was overrepresented in German, and -137CC in Scottish RA patients, but conservative chi(2) trend analyses could not prove any significant disease association of these single loci. SNP -607 and -137 were in strong linkage disequilibrium. The -607C(*)-137C haplotype was more prevalent in German RA (3.2 vs 1.2%) and in Scottish RA patients (4.1 vs 0.9%) than in the respective HD cohorts. These observations suggest that SNP of both positions contribute to the genetic background of RA pathogenesis.

Evidence of systematic expressed sequence tag IMAGE clone cross-hybridization on cDNA microarrays

We present evidence of a potentially serious source of error intrinsic to all spotted cDNA microarrays that use IMAGE clones of expressed sequence tags (ESTs). We found that a high proportion of these EST sequences contain 5'-end poly(dT) sequences that are remnants from the oligo(dT)-primed reverse transcription of polyadenylated mRNA templates used to generate EST cDNA for sequence clone libraries. Analysis of expression data from two single-dye cDNA microarray experiments showed that ESTs whose sequences contain repeats of consecutive 5'-end dT residues appeared to be strongly coexpressed, while expression data of all other sequences exhibited no such pattern. Our analysis suggests that expression data from sequences containing 5' poly(dT) tracts are more likely to be due to systematic cross-hybridization of these poly(dT) tracts than to true mRNA coexpression. This indicates that existing data generated by cDNA microarrays containing IMAGE clone ESTs should be filtered to remove expression data containing significant 5' poly(dT) tracts.

Attentional and evaluative biases for smoking cues in nicotine dependence: component processes of biases in visual orienting

The present study investigated attentional and evaluative biases for smoking-related cues in cigarette smokers and non-smokers. Using a visual probe task, we manipulated the presentation conditions of the stimuli to examine: (1). whether smokers have a bias to allocate attention towards smoking-related pictures that appear below the threshold of conscious awareness; and (2). whether attentional biases for smoking-related pictures that appear above the threshold of awareness operate both in initial orienting and in the maintenance of attention. We also obtained explicit and implicit measures of the valence of the smoking-related pictures from pleasantness ratings and from behavioural responses on a stimulus-response compatibility (SRC) task. Results showed that smokers, but not non-smokers, had an attentional bias for smoking-related pictures which had been presented at two exposure durations (200 and 2000 ms). The bias was not found in a brief (17 ms) masked exposure condition, so there was no evidence that it operated preconsciously. Smokers also showed greater preferences for smoking-related than control cues, compared with non-smokers, on both the explicit and implicit indices of stimulus valence. Results are discussed with reference to incentive and cognitive models of addiction.

A randomised placebo controlled 12 week trial of budesonide and prednisolone in rheumatoid arthritis

OBJECTIVES

To compare budesonide, a locally acting glucocorticoid with minimal systemic exposure, with conventional glucocorticoid treatment and placebo in rheumatoid arthritis.

METHODS

A double blind, randomised, controlled trial over 12 weeks in 143 patients with active rheumatoid arthritis, comparing budesonide 3 mg daily, budesonide 9 mg daily, prednisolone 7.5 mg daily, and placebo. Particular attention was paid to the pattern of clinical response and to changes in the four week period following discontinuation of treatment.

RESULTS

There were improvements in tender joint count and swollen joint count on budesonide 9 mg compared with placebo (28% for tender and 34% for swollen joint counts, p<0.05). Prednisolone 7.5 mg gave similar results, while budesonide 3 mg was less effective. ACR20 response criteria were met by 25% of patients on placebo, 22% on budesonide 3 mg, 42% on budesonide 9 mg, and 56% on prednisolone 7.5 mg. A rapid and significant reduction in symptoms and signs in response to budesonide 9 mg and prednisolone 7.5 mg was evident by two weeks and maximal at eight weeks. There was no evidence that budesonide provided a different pattern of symptom control from prednisolone, or that symptoms became worse than placebo treatment levels after discontinuation of glucocorticoid treatment. Adverse effects attributable to glucocorticoids were equally common in all groups.

CONCLUSIONS

The symptomatic benefits of budesonide 9 mg and prednisolone 7.5 mg are achieved within a short time of initiating treatment, are maintained for three months, and are not associated with any rebound in symptoms after stopping treatment.

Symptomatic cavernous sinus aneurysms: management and outcome after carotid occlusion and selective cerebral revascularization

BACKGROUND AND PURPOSE

Therapeutic internal carotid artery (ICA) occlusion for symptomatic intracavernous artery aneurysms can result in ischemic infarction despite normal clinical balloon test occlusion (BTO). We evaluated outcomes in patients with symptomatic cavernous sinus aneurysms in whom clinical BTO was normal, who underwent carotid occlusion with selective bypass surgery guided by physiologic BTO using quantitative cerebral blood flow (CBF) analysis by means of stable xenon-enhanced CT.

METHODS

After a normal clinical BTO, 26 consecutive patients with symptomatic cavernous sinus aneurysms underwent a baseline xenon-enhanced CT CBF analysis followed by a second CBF analysis, during which repeat BTO was performed. Patients with a decrease in cortical CBF to below 30 mL/100 g/min were considered moderate risk and those with greater than 30 mL/100 g/min were low risk for developing postocclusion ischemic infarction. Moderate-risk patients underwent cerebral revascularization followed by proximal carotid occlusion. Low-risk patients underwent carotid occlusion alone. Patients were clinically followed up for at least 3 months after carotid occlusion. All patients underwent head CT at least 1 month after carotid occlusion.

RESULTS

Eight patients were moderate risk and 18 low risk. Mean follow-up was 15.3 months. Mean CT follow-up was 10.2 months. No low-risk patient developed a postocclusion ischemic deficit by examination or infarct by CT. One patient in the moderate-risk group developed right hemiparesis and a left posterior middle cerebral artery infarction by CT 2 months after carotid occlusion.

CONCLUSION

In this series, BTO combined with quantitative CBF analysis was a safe and reliable technique for identification of patients at risk for ischemic infarction after carotid occlusion, despite a normal clinical BTO.

Does age play a role in recovery from sports-related concussion? A comparison of high school and collegiate athletes

OBJECTIVE

To evaluate symptoms and neurocognitive recovery patterns after sports-related concussion in high school and college athletes.

STUDY DESIGN

College athletes (n = 371) and high school athletes (n = 183) underwent baseline neuropsychological evaluation between 1997 and 2000. Individuals who received a concussion during athletic competition (n = 54) underwent serial neuropsychologic evaluation after injury and were compared with a noninjured within-sample control group (n = 38). Main outcome measures included structured interview, four memory measures, and Concussion Symptom Scale ratings. Baseline to postinjury change scores and multiple analyses of variance were used to compare recovery curves within and between groups.

RESULTS

High school athletes with concussion had prolonged memory dysfunction compared with college athletes with concussion. High school athletes performed significantly worse than age-matched control subjects at 7 days after injury (F = 2.90; P <.005). College athletes, despite having more severe in-season concussions, displayed commensurate performance with matched control subjects by day 3 after concussion. Self-report of postconcussion symptoms by student athletes was not predictive of poor performance on neuropsychologic testing.

CONCLUSIONS

Caution and systematic evaluation should be undertaken before returning athletes with concussion to competition. Sole reliance on the self-report of the athlete may be inadequate. Preliminary data may suggest a more protracted recovery from concussion in high school athletes.

Prospective comparative study of patients with culture proven and high suspicion of adult onset septic arthritis

OBJECTIVE

To investigate whether patients with acute septic arthritis (SA) diagnosed by positive synovial fluid (SF) culture (Newman grade A) have different clinical and serological features from those with sterile SF in whom there is nonetheless a high suspicion of SA (Newman grades B and C).

PATIENTS AND METHODS

A prospective 12 month multicentre hospital based study of adult patients with SA recruited 47 patients with culture positive SA and 35 patients with clinically suspected SA but sterile SF.

RESULTS

Patient demography, clinical and laboratory features at presentation were similar irrespective of the underlying diagnosis, SF culture, and the presence of prosthetic joints. Medical and surgical treatment and outcome were comparable in the two patient groups. Patients with both suspected and proven SA were more likely to be from the more socially deprived areas of our community (p<0.0001).

CONCLUSION

Patients in whom there is a high clinical suspicion of SA are comparable to those patients with SA with a positive SF culture and have similar morbidity and mortality on follow up. Therefore, if clinical suspicion of SA is high then it is correct to treat as SA in the absence of bacterial proof.

Relationship between postconcussion headache and neuropsychological test performance in high school athletes

BACKGROUND

The relevance of headache to outcome after sports-related concussion is poorly understood.

HYPOTHESES

High school athletes reporting headache approximately 1 week after injury will have significantly more other concussion symptoms and will perform more poorly on neuropsychological tests than athletes not experiencing headache.

STUDY DESIGN

Prospective cohort study.

METHODS

Study participants included 109 high school athletes who had sustained concussion and who were divided into two groups: those reporting headache 7 days after injury and those reporting no headaches. The two groups were compared regarding on-field markers of concussion severity at the time of injury and symptoms and neurocognitive test results collected via ImPACT, a computerized neuropsychological test battery and postconcussion symptom scale, at a mean of 6.8 days after injury.

RESULTS

Athletes reporting posttraumatic headache demonstrated significantly worse performance on reaction time and memory ImPACT neurocognitive composite scores. These athletes also reported significantly more symptoms other than headache and were more likely to have demonstrated on-field anterograde amnesia.

CONCLUSIONS

Findings suggest that any degree of postconcussion headache in high school athletes 7 days after injury is likely associated with an incomplete recovery after concussion.

Recovery from mild concussion in high school athletes

OBJECT

A computerized neuropsychological test battery was conducted to evaluate memory dysfunction and self-reporting of symptoms in a group of high school athletes who had suffered concussion.

METHODS

Neuropsychological performance prior to and following concussion was compared with the test performance of an age-matched control group. Potentially important diagnostic markers of concussion severity are discussed and linked to recovery within the 1st week of injury.

CONCLUSIONS

High school athletes who had suffered mild concussion demonstrated significant declines in memory processes relative to a noninjured control group. Statistically significant differences between preseason and postinjury memory test results were still evident in the concussion group at 4 and 7 days postinjury. Self-reported neurological symptoms such as headache, dizziness, and nausea resolved by Day 4. Duration of on-field mental status changes such as retrograde amnesia and posttraumatic confusion was related to the presence of memory impairment at 36 hours and 4 and 7 days postinjury and was also related to slower resolution of self-reported symptoms. The results of this study suggest that caution should be exercised in returning high school athletes to the playing field following concussion. On-field mental status changes appear to have prognostic utility and should be taken into account when making return-to-play decisions following concussion. Athletes who exhibit on-field mental status changes for more than 5 minutes have longer-lasting postconcussion symptoms and memory decline.

Diagnostic peritoneal lavage analysis: should trauma guidelines be revised?

OBJECTIVES

Diagnostic peritoneal lavage (DPL) is used to detect intraperitoneal bleeding in patients sustaining blunt and penetrating abdominal trauma. The procedure should be performed by an experienced general surgeon, and the fluid obtained analysed by haematology technicians. Current Advanced Trauma Life Support guidelines are very clear on what constitutes a positive result, mandating laparotomy. The aim of this work was to assess whether DPL could actually be performed in practice.

METHODS

A telephone survey was performed of a random selection of haematology technicians in 40 major trauma units in the UK, to assess whether they could actually analyse a DPL sample if it were sent to them. This was performed both during the day, and "out of hours". Secondly the experience of performing DPL was determined among 1797 general surgical trainees and consultants, by means of a questionnaire.

RESULTS

Between 9 am and 5 pm 29 of 40 haematology technicians questioned were able to analyse a sample of DPL fluid. This compared with a figure of 9 of 40 when the questionnaire was administered "out of hours". A total of 854 (48%) questionnaires were received from surgical trainees and consultants. Approximately 60% of those questioned had performed less than 10 DPLs throughout the whole of their careers.

DISCUSSION

These results suggest that UK surgeons have little experience in performing DPL, and even if they do it is unlikely that any haematology departments will be able to analyse the sample, especially if performed after 5 pm. ATLS guidelines should be changed, and this investigation abandoned in favour of abdominal ultrasound.