Evaluation of Expanded Criteria Donors Using the Kidney Donor Profile Index and the Preimplantation Renal Biopsy

The increasing comorbidity of kidney transplant (KT) donors make it necessary to develop scores to correctly assess the quality of kidney grafts. This study analyzes the usefulness of the preimplantation biopsy and the Kidney Donor Profile Index (KDPI) as indicators of KT survival from expanded criteria donors (ECD). Retrospective study of KT in our center between January 2010 to June 2019 who received a kidney from an ECD and underwent a preimplantation biopsy. 266 KT were included. Graft survival was categorized by KDPI quartiles: Q1 = 86%, Q2 = 95%, Q3 = 99% and Q4 = 100%. KT from KDPI Q1 presented better survival (p = 0.003) and Q4 donors had worse renal function (p = 0.018) and poorer glomerular filtration rate (3rd month; p = 0.017, 1st year; p = 0.010). KT survival was analyzed according to KDPI quartile and preimplantation biopsy score simultaneously: Q1 donors with biopsy score ≤3 had the best survival, especially comparing against Q3 with a biopsy score >3 and Q4 donors (p = 0.014). In multivariable analysis, hyaline arteriopathy, glomerulosclerosis, and KDPI Q4 were predictors for graft survival. High KDPI and a greater histological injury in the preimplantation biopsy, especially glomerular and vascular lesions, were related to a higher rate of KT loss from ECD.

Characteristics of warfarin underprescription in older adults with atrial fibrillation

Objectives

The prevalence of atrial fibrillation (AF) and atrial flutter (AFl) increases with age. Prior research suggests that underprescription of anticoagulants, such as warfarin, in older adults can lead to increased morbidity and mortality. We analyzed rates and patterns of warfarin prescription in older adults.

Methods

In this prospective observational study, we enrolled 2179 consecutive patients with admission diagnosis of AF or AFl. Those placed on a non-warfarin anticoagulation (189 patients) were excluded. Patients were then divided into “older cohort” (≥75 years of age) and “younger cohort” (<75 years of age). Within the older cohort, prescription patterns of warfarin were analyzed. Serial prospective follow-up was 3.1±2.06 years.

Results

Of the 1990 patients, 46.9% were ≥75 years older, of which 51.1% were prescribed warfarin. There was no difference between mean CHA2DS2-VASc score and warfarin prescription (OR=1.06 (95% CI 0.93–1.21), p=0.388) in the older cohort. After adjusting for hypertension, glomerular filtration rate, and Black race, appropriate warfarin prescription in older adults was independently associated with lower aspirin prescription rates (OR=0.57 (95% CI 0.43–0.75), p<0.001), lower body mass index (OR=1.03 (95% CI 1.01–10.6), p=0.018), and lower hemoglobin levels (OR=1.11 (95% CI 1.04–1.19), p=0.002).

Conclusions

In our study, adults 75 years and older with AF and AFl tended to have lower rates of warfarin prescription despite higher CHA2DS2-VASc score and higher risk of thromboembolic events. Anemia, lower weight, and aspirin use were characteristics associated with warfarin underprescription. These patterns can shed light on clinicians' perceived hesitancy to anticoagulate certain older adults.

Funding Acknowledgement

Type of funding sources: None.

Cryoneurolysis to treat the pain and symptoms of knee osteoarthritis: a multicenter, randomized, double-blind, sham-controlled trial

OBJECTIVE

Evaluate the efficacy and safety/tolerability of cryoneurolysis for reduction of pain and symptoms associated with knee osteoarthritis (OA).

DESIGN

Randomized, double-blind, sham-controlled, multicenter trial with a 6-month follow-up in patients with mild-to-moderate knee OA. Patients were randomized 2:1 to cryoneurolysis targeting the infrapatellar branch of the saphenous nerve (IPBSN) or sham treatment. The primary endpoint was the change from baseline to Day 30 in the Western Ontario and McMaster Osteoarthritis Index (WOMAC) pain score adjusted by the baseline score and site. Secondary endpoints, including visual analogue scale (VAS) pain score and total WOMAC score, were tested in a pre-defined order.

RESULTS

The intent-to-treat (ITT) population consisted of 180 patients (n = 121 active treatment, n = 59 sham treatment). Compared to the sham group, patients who received active treatment had a statistically significant greater change from baseline in the WOMAC pain subscale score at Day 30 (P = 0.0004), Day 60 (P = 0.0176), and Day 90 (P = 0.0061). Patients deemed WOMAC pain responders at Day 120 continued to experience a statistically significant treatment effect at Day 150. Most expected side effects were mild in severity and resolved within 30 days. The incidence of device- or procedure-related adverse events was similar in the two treatment groups with no occurrence of serious or unanticipated adverse device effects (ADE).

CONCLUSIONS

Cryoneurolysis of the IPBSN resulted in statistically significant decreased knee pain and improved symptoms compared to sham treatment for up to 150 days, and appeared safe and well tolerated.

The natural history of perforated foregut ulcers after repair by omental patching or primary closure

BACKGROUND

The treatment of perforated foregut ulcers by omental patching (OP) or primary closure has mostly replaced vagotomy and pyloroplasty/antrectomy (VPA). We sought to determine the natural history and recurrence rate of ulceration in patients treated by omental patching or primary closure.

STUDY DESIGN

An 11-year retrospective study.

RESULTS

From 2004 through 2015, 94 patients had perforated foregut ulcers, 53 gastric, and 41 duodenal. 77 (82%) were treated by OP alone (study group) and 17 (18%) were treated with VPA (comparison group). All OP patients were discharged on PPIs, but only 86% took the drugs for a median of 22 months (1-192, SD 40). Endoscopy in the OP group showed recurrent ulcers in nine (12% recurrence rate) and gastritis in three (4%) This group also had three later recurrent perforations. Another recurrent ulcer hemorrhaged causing death (3% late mortality). Two other patients required non-emergent re-do ulcer operations for recurrent disease/symptoms (surgical re-intervention rate 4%). Total length of follow-up was median 44 months (1-192, SD 40) and was complete in 82 (87%). 18 (23%) patients in the OP group developed recurrent abdominal pain attributed to ulcer disease during follow-up, compared to 2 (12%) in the VPA group (p = 0.15). No patient in the VPA group had an endoscopic recurrence or re-intervention.

CONCLUSION

Omental patching does not correct the underlying disease process which causes foregut perforation, and has a 12% endoscopically proven recurrent ulceration rate and a 23% incidence of recurrent symptoms within 44 months. Patients tend to stop taking PPIs after 22 months at which time their risk increases.

Oral Ulcers Produced by Mycophenolate Mofetil in Two Liver Transplant Patients

Oral ulcers are a frequent problem in transplant medicine. It is important to consider infectious etiologies, exacerbated by the immunosuppressive treatment, but other etiologies are also possible, like adverse drug reactions. Mycophenolate mofetil (MMF) is an immunosuppressive medication that has been used in combination with calcineurin inhibitors and steroids. Reports of renal transplant patients with oral ulcers related to MMF have appeared lately and herein we have described 2 cases in liver transplant patients. Their oral ulcers resolved quickly after suspension of the medication. Our 2 cases in liver transplant patients represented a unique setting for this type of complication.

A test for evaluation of exercise with apneic episodes in synchronized swimming

In synchronized swimming, complex maneuvers are developed in the water alternating air breathing and apnea episodes, which activate complex and adjusted mechanisms for respiratory compensation. The aim of this study is to propose a specific laboratory test for the assessment of the functional respiratory adaptations during exercise with apnea periods in synchronized swimmers. We studied 25 women, of which 13 were elite synchronized swimmers and the other 12 were a control group. A laboratory test was performed on a cycle ergometer consisting of 4 minutes pedalling at a constant intensity of 1.5 watts/kg (test 1). After 30 minutes at rest, a new test was performed alternating free respiration and apnea periods of 15 seconds at the same intensity (test 2). In both tests HR, VE, VT, BF, VO2, VCO2, and lactate were analyzed. We observed an increase in VE, VO2, and VCO2 in the 13 swimmers in test 2, with no change in HR and lactate, and a constant relationship between VE and VCO2 equal for tests 1 and 2. In the control group only 6 women completed test 2, the other 6 stopped before the third minute. In this group, important differences were observed in relation to the swimmers: both heart rate and lactate increased in test 2 and showed an increase in the VE vs. VCO2 relationship which involved a different slope for test 1 and test 2. We conclude that functional respiratory adaptations induced by apnea during synchronized swimming are essential in this sport and the test proposed may be a useful tool to assess the physical performance in synchronized swimmers.

A nomogram for assessment of breathing patterns during treadmill exercise

OBJECTIVE

To assess the breathing patterns of trained athletes under different conditions. The hypothesis is that the breathing pattern during a progressive treadmill exercise is independent of the protocol, at least in healthy people, and can be assessed using a nomogram.

METHODS

A total of 43 male and 21 female athletes from different sports were studied. They performed one of two different protocols (steps or ramp) on a treadmill. The two protocols started at the same speed and had the same rate of increase in work. During the test, the expired air was analysed for CO2 and O2. Ventilation (VE) was continuously recorded, and tidal volume (Vt) and breathing frequency (BF) at the same intensity were analysed for both protocols, as well as Vt/T(i) and T(i)/T(tot).

RESULTS

No significant differences were observed in Vt and BF between the two protocols in either the men or women at any level (confidence intervals up to 0.958 in all the groups). T(i)/T(tot) remained constant, and all increases in VE were strongly related to the respective increases in Vt/T(i). Plots of data for men and women showed a curvilinear relation between Vt and BF which could be fitted with an exponential function with a strong correlation (R2 = 0.98 for men and 0.97 for women).

CONCLUSIONS

Graphic expression of Vt v BF is a useful nomogram for the routine assessment of ventilatory response during exercise in healthy trained subjects.

Hantavirus pulmonary syndrome due to Andes virus in Temuco, Chile: clinical experience with 16 adults

STUDY OBJECTIVES

To describe the clinical features and laboratory abnormalities of 16 adults with confirmed Hantavirus pulmonary syndrome (HPS) due to Andes virus in Temuco, Chile.

DESIGN

A retrospective chart review abstracting clinical, radiologic, laboratory, and epidemiologic data.

SETTING

ICU of the university teaching hospital in Temuco, Chile.

PATIENTS

Sixteen patients with HPS treated between 1997 and 1999.

RESULTS

Patients were aged from 19 to 45 years, 82% were men, and 88% were farm or timber workers with occupational acquisition of HPS. After an incubation period ranging from 5 to 25 days, a prodromal influenza-like phase frequently was accompanied by abdominal symptoms. From 1 to 7 days later, respiratory insufficiency and hemodynamic instability suddenly appeared. In 81%, hemorrhage was evident; in 63%, moderate-to-severe bleeding occurred. The most prominent laboratory abnormalities were hemoconcentration, leukocytosis, thrombocytopenia, altered partial thromboplastin time (PTT), creatine kinase, transaminases, and hyponatremia. Creatinine elevation was common, with clinical importance in two patients. All patients had severe hypoxemia and pulmonary edema. Fifteen patients received supportive treatment, and 5 patients were treated with corticosteroids. The mortality rate was 43.8%.

CONCLUSIONS

Bad prognostic factors appeared to be severe hypotension, lower PaO(2)/fraction of inspired oxygen values, prolonged PTT, hemorrhage, greater volume load, and profuse bronchorrhea. The effects of treatment with corticosteroids could not be determined. Hemorrhage and renal involvement were common in our patients, features not often described in the North American literature of Sin Nombre virus HPS.

Family risk factors associated with adolescent pregnancy: study of a group of adolescent girls and their families in Ecuador

PURPOSE

To identify characteristics within the family that were associated with adolescent pregnancy in a group of adolescent girls in Quito, Ecuador.

METHODS

Of 135 female adolescents (12-19 years of age), 47 were pregnant and seen at the adolescent prenatal care clinic at an inner city hospital in Quito, and 88 were students from schools located within the same geographic area. Family variables were compared for pregnant and nonpregnant adolescents using chi-square, Student's t-test, and analysis of variance.

RESULTS

More nonpregnant adolescents lived with their biological parents when compared with their pregnant peers (p < .002). Pregnant adolescents reported lower mother-daughter and father-daughter communication (p < .02), lesser life satisfaction and happiness in general, and more school and economic difficulties (p < .001). They were less likely to find support for their problems in or outside the family (p < .0001) and showed higher levels of depression and sexual abuse than their nonpregnant peers (68.8% vs. 34.5%, and 14.9% vs. 4.5%, respectively). Nonpregnant adolescents showed higher school performance and expectations regarding school achievement and future perspectives (p < .001). Values such as respect for others and religiosity were higher among nonpregnant adolescents (p < .0001). Parental education was lower in the families of pregnant adolescents (p < .05). Among nonpregnant adolescents, both parents worked outside the home (p < .006), whereas mothers of pregnant adolescents usually stayed at home.

CONCLUSION

The current study showed that parental separation or divorce, and poor parent-daughter communication were associated with adolescent pregnancy. Families of nonpregnant adolescents had a higher educational level, and both parents worked to provide financial support to the family in an environment where family authority is shared by both parents. There were also better problem-solving strategies and parent-daughter communication, higher levels of cohesion, connectedness, and life satisfaction in general, and higher future expectations.

Evaluation of MK filters for recovery of enteroviruses from tap water

The MK filter is an electropositively charged filter that can be used to concentrate enteroviruses from large volumes (400 to 1,000 liters) of water. This filter is less expensive than the commonly used 1MDS electropositive filter. In this study, we compared the recovery of poliovirus 1 (PV1) and that of coxsackievirus B3 (CB3) from 378 liters of tap water, using both the MK and the 1MDS filters. Viruses were eluted from the filters with 3% beef extract buffered with 0.05 M glycine (pH 9.5) and reconcentrated via organic flocculation. At high virus inputs (approximately 10(6) PFU), the overall recovery (after elution and reconcentration) of PV1 and CB3 from tap water with the MK filter was less than that achieved with the 1MDS filter (P < 0.05). The recoveries of PV1 from tap water with the MK and 1MDS filters were 73.2% +/- 26% (n = 5 trials) and 90.2% +/- 5.9% (n = 5 trials), respectively. The recoveries of CB3 from tap water with the MK and 1MDS filters were 32.8% +/- 34.5% (n = 4 trials) and 95.8% +/- 12.0% (n = 4 trials), respectively. This study indicated that the MK filter consistently provided lower recovery, with wider variability, of PV1 and CB3 from tap water than the 1MDS filter.

Discrepancies between cerebral computed tomography and western blot in the diagnosis of neurocysticercosis. The Cysticercosis Working Group in Peru (Clinical Studies Coordination Board)

Serum samples from sequential patients who underwent cerebral computed axial tomography (CT) scan in a Peruvian radiologic clinic were tested by the highly sensitive and specific enzyme-linked immunoelectrotransfer blot (EITB) test to detect antibodies to Taenia solium. The results of the EITB test were compared with those obtained by CT scan for the diagnosis of neurocysticercosis. Of the 383 patients sampled, 32 (8%) were seropositive. The results of CT and EITB were frequently discrepant. When compared with the EITB assay, the CT scan was 44% sensitive and 95% specific. The sensitivity of CT increased to 63% if less specific images (single calcifications, granulomas, or hydrocephalus) were included. The CT scan for diagnosis of cysticercosis can best be used in conjunction with a reliable serologic test such as the EITB.

Case-control study of Cryptosporidium parvum infection in Peruvian children hospitalized for diarrhea: possible association with malnutrition and nosocomial infection

A retrospective, hospital-based case-control study was used to investigate whether there were any clinical characteristics that could distinguish Cryptosporidium parvum-infected children with diarrhea from other non-C. parvum-infected children with diarrhea. Ten percent (24 of 248) of children admitted to a rehydration ward at Cayetano Heredia University Hospital, Lima, Peru, were infected with C. parvum. The 24 patients infected with C. parvum (cases) were matched to an equal number of noninfected patients (controls). C. parvum-infected patients were more likely to be malnourished than were children without this infection (P less than 0.05). Also nosocomial infection caused by C. parvum occurred in three severely malnourished patients, two of whom died. No other clinical or laboratory characteristics were found that would distinguish children with diarrhea caused by C. parvum from other children with diarrhea. In children hospitalized for diarrhea C. parvum infection occurs most frequently in malnourished children.