Poor Nutritional Status Is Associated with Death in a Population of Dialyzed Older Persons.

BACKGROUND: Older patients in hemodialysis have high prevalence of malnutrition that is often associated with rapid weight loss till cachexia. OBJECTIVES: We aimed to investigate whether in older patients undergoing hemodialysis the association between poor nutritional status and mortality may be independent of comorbidities and other risk factors. DESIGN: Retrospective longitudinal study. SETTING: Unit of Nephrology, Dialysis and Kidney Transplantation of the Policlinic Hospital of Milan, Milan, Italy. PARTICIPANTS: A total of 107 prevalent patients undergoing hemodialysis for at least three months. MEASUREMENTS: Sociodemographic, clinical, and biological data were recorded. Unintentional weight loss (UWL) was defined as loss of body weight > 5% in 3 months or > 10% in 6 months. We computed a 21-item Frailty Index that included clinical conditions associated with malnutrition and mortality in this population. Unadjusted and adjusted Cox proportional hazard models were performed to test the association of UWL, albumin and transferrin levels with death. Survival analyses based on Kaplan-Meier estimates were performed. RESULTS: Patients' age was 79 (±7.7) years; 38 (35%) were women. Thirty-one patients (29%) died during follow-up. Eighteen (16.8%) patients experienced UWL during the follow-up period. UWL was positively associated with death in the unadjusted model and even after the progressive inclusion of potential confounders. Low albumin levels were positively associated with death only in the unadjusted and partially adjusted models while low transferrin levels were not associated with death in none of the models. Mortality was significantly higher in those patients experiencing both UWL and albumin levels below 3.5 mg/dL. CONCLUSIONS: In older patients undergoing chronic hemodialysis UWL is associated with mortality independently of comorbidities and other risk factors. Patients presenting both UWL and low albumin levels were those experiencing the worst outcomes in terms of mortality.

Comparison of low-dose dobutamine ventriculography with low-dose dobutamine echocardiography for predicting regional improvement in left ventricular function after coronary artery bypass grafting.

The demonstration of a contractile reserve during low-dose dobutamine echocardiography (LDDE) identifies viable myocardium and predicts recovery of left ventricular (LV) function after myocardial revascularization in patients with chronic coronary artery disease. However, a technically difficult transthoracic visualization may limit the use of LDDE, thus requiring an alternative diagnostic procedure. The present study compares LDDE with low-dose dobutamine ventriculography (LDDV) in predicting an improvement in regional LV function after surgical revascularization. We studied 18 patients with coronary artery disease and LV dysfunction who were to undergo coronary artery bypass grafting. Preoperatively, all patients were evaluated for the presence of viable myocardium using LDDE and LDDV. Follow-up echocardiography at rest and left ventriculography were performed 4 months after successful revascularization to assess recovery of LV function. The sensitivity and specificity of LDDE to identify dysfunctional segments capable of recovering function were 63% and 71%, respectively, with a diagnostic accuracy of 68%. The sensitivity, specificity, and diagnostic accuracy of LDDE improved to 81%, 72%, and 76% when patients with optimal transthoracic evaluation were selected, whereas they were 30%, 77%, and 57%, respectively, in those who underwent suboptimal evaluation. The sensitivity, specificity, and diagnostic accuracy of LDDV were 66%, 75%, and 71%, respectively, with no difference in subgroups of patients. This study demonstrates that LDDV can be considered a useful technique for identifying the presence of myocardial viability and may provide an advantage over LDDE in patients with suboptimal echocardiographic visualization.

Evaluation of small intestine submucosa and acellular dermis as diaphragmatic prostheses.

BACKGROUND/PURPOSE: The repair of large congenital diaphragmatic defects in the neonate continues to be a challenge. Polytetrafluoroethylene (PTFE) is the synthetic material most widely used for reconstruction in instances of partial and complete diaphragmatic agenesis. Recurrent hernia is a frequent complication, because this material does not grow with the infant. This study evaluates two novel materials; small intestine submucosa (SIS; Cook Biotech, Lafayette, IN), and acellular dermis (AlloDerm; Lifecell Corp, The Woodland, TX) for diaphragm reconstruction in growing animals. METHODS: Sprague-Dawley rats (100 g, n = 87) were anesthetized and underwent laparotomy. The control group (n = 18) underwent a sham laparotomy with a left subcostal incision and closure. The other two groups underwent central excision of the left hemidiaphragm (50% loss) and reconstruction with either a SIS (n = 35) or AlloDerm (n = 19) patch sutured circumferentially with 6-0 prolene. Seventy-two animals survived the operation, and were killed at five separate time intervals (2 weeks, 1, 2, 3, and 4 months). Chest radiographs were performed monthly and before death. Radiographs were reviewed in a blinded fashion by two observers as were the necropsies, and rib deformity was noted if present. Histological examination of the diaphragm patch was performed in each animal. RESULTS: There was no evidence of rib deformity noted on gross examination at necropsy or on chest radiograph in either experimental group. At necropsy, all patches were intact without hernia, eventration, or contraction. Histology findings initially showed acute and chronic inflammatory changes in both patch materials that lessened at the 2-month time interval. Both prosthetic patches began to thin at 3 months and was most prominent in the SIS rats. At 4 months, both SIS and AlloDerm remained viable without evidence of necrosis. Each patch showed evidence of fibroblastic incorporation and small capillary ingrowth. These changes were more prominent in the AlloDerm group. There was no evidence of skeletal muscle ingrowth. CONCLUSIONS: These data indicate SIS and AlloDerm may be useful materials for prosthetic repair in instances of partial or total agenesis of the diaphragm. Further investigation in a large animal model over a longer duration is indicated.

Cardiac autonomic adjustments to normal human pregnancy: insight from spectral analysis of R-R interval and systolic arterial pressure variability.

OBJECTIVE: To assess the adaptation in autonomic control mechanisms that accompanies the marked haemodynamic changes, such as increases in cardiac size and output, that occur in the course of normal human pregnancy. DESIGN: We studied 14 healthy pregnant women (aged 30+/-1 years) before the 6th week (early stage) and within weeks 32-34 (late stage) of pregnancy, while they were at rest or in a state of active orthostatism (standing), which enhances sympathetic activity. METHODS: We used echocardiography to assess cardiac volumes and mass, and spectral analysis of the R-R interval and systolic arterial pressure variability to obtain indices of autonomic regulation of the circulation. This non-invasive methodology, recently validated with direct recordings of muscle sympathetic nerve activity, furnishes quantitative markers of sympathetic modulation of the sino-atrial node (low frequency component, LF in normalized units, nu), vagal modulation (high frequency component, HF in normalized units, nu) and the overall arterial pressure-heart rate baroreflex gain (alpha index). RESULTS: Late pregnancy was characterized by an increase in cardiac size and volumes and by a reduction of R-R interval, R-R interval variance and the alpha index, together with an increase in the LF/HF ratio (from 1.4+/-0.4 to 5.6+/-1.9). Changes in markers of autonomic modulation of the sino-atrial node normally induced by the standing position were blunted. CONCLUSIONS: The late stage of normal human pregnancy appears to be characterized by alterations in the autonomic control of the circulation and by attenuated responsiveness to active standing, possibly as a consequence of the accompanying increase in cardiac size.

Intestinal atresia and stenosis: a 25-year experience with 277 cases.

OBJECTIVE: To evaluate the causes, clinical presentation, diagnosis, operative management, postoperative care, and outcome in infants with intestinal atresia. DESIGN: Retrospective case series. SETTING: Pediatric tertiary care teaching hospital. PATIENTS: A population-based sample of 277 neonates with intestinal atresia and stenosis treated from July 1, 1972, through April 30, 1997. The level of obstruction was duodenal in 138 infants, jejunoileal in 128, and colonic in 21. Of the 277 neonates, 10 had obstruction in more than 1 site. Duodenal atresia was associated with prematurity (46%), maternal polyhydramnios (33%), Down syndrome (24%), annular pancreas (33%), and malrotation (28%). Jejunoileal atresia was associated with intrauterine volvulus, (27%), gastroschisis (16%), and meconium ileus (11.7%). INTERVENTIONS: Patients with duodenal obstruction were treated by duodenoduodenostomy in 119 (86%), of 138 patients duodenotomy with web excision in 9 (7%), and duodenojejunostomy in 7 (5%) A duodenostomy tube was placed in 3 critically ill neonates. Patients with jejunoileal atresia were treated with resection in 97 (76%) of 128 patients (anastomosis, 45 [46%]; tapering enteroplasty, 23 [24%]; or temporary ostomy, 29 [30%]), ostomy alone in 25 (20%), web excision in 5 (4%), and the Bianchi procedure in 1 (0.8%). Patients with colon atresia were managed with initial ostomy and delayed anastomosis in 18 (86%) of 21 patients and resection with primary anastomosis in 3 (14%). Short-bowel syndrome was noted in 32 neonates. MAIN OUTCOME MEASURES: Morbidity and early and late mortality. RESULTS: Operative mortality for neonates with duodenal atresia was 4%, with jejunoileal atresia, 0.8%, and with colonic atresia, 0%. The long-term survival rate for children with duodenal atresia was 86%; with jejunoileal atresia, 84%; and with colon atresia, 100%. The Bianchi procedure (1 patient, 0.8%) and growth hormone, glutamine, and modified diet (4 patients, 1%) reduced total parenteral nutrition dependence. CONCLUSIONS: Cardiac anomalies (with duodenal atresia) and ultrashort-bowel syndrome (<40 cm) requiring long-term total parenteral nutrition, which can be complicated by liver disease (with jejunoileal atresia), are the major causes of morbidity and mortality in these patients. Use of growth factors to enhance adaptation and advances in small bowel transplantation may improve long-term outcomes.

Improvement of left ventricular function and cardiovascular neural control after endoventriculoplasty and myocardial revascularization.

OBJECTIVE: To investigate the effects of endoventriculoplasty (EVP) and myocardial revascularization on left ventricular function and on sympathovagal balance modulating sinus node and vasomotor activity, we studied patients with left anterior, septal or anteroseptal ventricular aneurysm, before and after surgery. It has been demonstrated that, compared to the standard aneurismectomy, EVP associated with coronary grafting has a lower operative mortality and improves ventricular function, clinical status and prognosis. METHODS: We collected pre- and post-operative echocardiographic and angiographic data to determine morphological and hemodynamic changes. The pre- and post-operative neural cardiovascular control was assessed by power spectrum analysis of heart rate and systolic arterial pressure (SAP) variabilities during rest and tilt. RESULTS: As expected, post-operative ventricular function improved significantly: ejection fraction increased from 33 +/- 2 to 46 +/- 3% (p < 0.01) when assessed by echocardiography and from 40 +/- 4 to 55 +/- 5% (p < 0.01) when assessed by angiography; left ventricular end-diastolic pressure fell from 22 +/- 3 to 13 +/- 2 mmHg (p < 0.05). Pre-operatively sympathovagal balance responsiveness was blunted: tilt test did not induce, in respect to resting values, any significant change in low frequency (LFRR) and high frequency (HFRR) components of RR variability (in normalized units, n.u.) and in LFSAP. Post-operatively, tilt induced significant changes in LFRR and HFRR (in n.u.), in LF/HF ratio and LFSAP in respect to resting values. The pre- and post-operative percent differences--delta%--, from rest to tilt, of LFRR, HFRR, LF/HF and LFSAP were also significantly different (p < 0.01, p < 0.05, p < 0.05, p < 0.05). In addition, we compared data obtained from survivors and non-survivors (6 out of 19 patients died within 4 months because of heart failure). Non-survivors were characterized by significantly lower RR variance (184 +/- 80 vs. 1193 +/- 309 ms2 at rest, 196 +/- 87 vs. 546 +/- 104 ms2 during tilt, p < 0.05) and lower LFRR (15 +/- 7 vs. 61 +/- 6 at rest, 23 +/- 10 vs. 58 +/- 6 during tilt, in n.u., p < 0.01). CONCLUSIONS: (1) The improvement of ventricular function induced by EVP and myocardial revascularization is accompanied by a restored capability to oscillate of cardiovascular neural regulatory mechanisms; (2) the drastic reduction of variance and LF component from RR variability seems to be associated with an ominous outcome.

Reoperation after Nissen fundoplication in children with gastroesophageal reflux: experience with 130 patients.

OBJECTIVE: The authors evaluate reoperation for recurrent gastroesophageal reflux (GER) after a failed Nissen fundoplication. SUMMARY BACKGROUND DATA: Nissen fundoplication is an accepted treatment for GER refractory to medical therapy. Wrap failure and recurrence of GER are noted in 8% to 12%. METHODS: Medical records of 130 children undergoing a second antireflux operation for recurrent GER from January 1985 to June 1996 retrospectively were reviewed. RESULTS: One hundred one patients (78%) were neurologically impaired (NI), 74 (57%) had chronic pulmonary disease, and 8 had esophageal atresia. Recurrent symptoms included vomiting (78%), growth failure (62%), choking-coughing-gagging (38%), and pneumonia (25%). Gastroesophageal reflux was confirmed by barium swallow, gastric scintigraphy, and endoscopy. Operative findings showed wrap breakdown (42%), wrap-hiatal hernia (30%), or both (21%). A second Nissen fundoplication was performed in 128 children. Complications included bowel obstruction (18), wound infection (10), pneumonia (6) and tight wrap (9). There were two postoperative (<30 days) deaths (1.5%). Of 124 patients observed long term, 89 (72%) remain symptom free. Eight were converted to tube feedings. Twenty-seven required a third fundoplication, and 19 (70%) were successful outcome. Two with repetitive wrap failure due to gastric atony underwent gastric resection and esophagojejunostomy. CONCLUSION: Nissen fundoplication was successful in 91% of patients. In 9% with wrap failure, a second Nissen fundoplication was successful in 72%. Reoperation is justified in properly selectedpatients. Conversion to jejunostomy feedings is suggested for neurologically impaired after two wrap failures and a partial wrap in those with esophageal atresia and severe esophageal dysmotility. Repeated wrap failure due to gastric atony requires gastric resection and esophagojejunostomy.

The effect of atrial fibrillation and the ventricular rate control on exercise capacity.

BACKGROUND: Atrial fibrillation (AF) is a common cardiac arrhythmia, affecting approximately 1.5 million patients in the United States. HYPOTHESIS: This study was designed to determine the effect of AF and the ventricular rate control during AF on cardiovascular performance as measured by exercise endurance on a standard Bruce protocol. METHODS: Sixty-three patients with AF who underwent exercise stress testing during both sinus rhythm and AF were analyzed. Heart rate, blood pressure, heart rate acceleration, exercise duration, and left ventricular (LV) systolic function were measured. RESULTS: Atrial fibrillation resulted in a small but statistically significant decrease in exercise endurance (426 +/- 180 vs. 402 +/- 168 s, p < 0.05). The drop in exercise tolerance was consistent regardless of the underlying heart condition or adequate ventricular rate control during AF. Heart rate in AF was consistently faster than in sinus rhythm, at rest, and at peak exercise (63 vs. 79 beats/min and 125 vs. 149 beats/min, respectively, p < 0.001). CONCLUSION: Our analyses indicated that (1) the loss of atrioventricular synchrony had minimal effect on cardiovascular performance in patients with preserved LV function, (2) the decrease in cardiovascular performance was related to loss of atrioventricular synchrony but not to underlying heart disease or ventricular rate control, and (3) compensation for the loss of the atrial contribution was provided by consistently faster heart rate during AF.

Predictive value of enzyme-linked immunosorbent assay-detected IgG anti-HLA antibodies for pediatric renal allograft rejection.

BACKGROUND: Measurement of panel-reactive antibody (PRA) with an enzyme-linked immunosorbent assay using soluble HLA class I molecules (PRA-STAT) in adult renal transplant recipients predicted graft loss and rejection. We sought to confirm this finding in pediatric recipients, an immunologically distinct group. METHODS: The population consisted of 158 renal transplants in 146 patients (age range, 1-21 years). PRA was determined with PRA-STAT and microlymphocytotoxicity (CDC), using final cross-match sera. An elevated test was defined as > or =5% reactivity. Statistical analysis for rejection used the chi-square test and for graft survival used the log-rank test. RESULTS: Thirty-five patients (22%) had %PRA-STAT > or =5%, compared with 26 (16%) with %PRA-CDC > or =5%. The percentage with elevated %PRA-STAT was found to correlate with subsequent transplantations (first, 15%; second, 67%; third, 75%). Subsequent analyses utilized only the 136 primary recipients, of whom 20 (15%) had %PRA-STAT > or =5% and 16 (12%) had %PRA-CDC > or =5%. Elevated %PRA-STAT correlated with rejection at 3 months (65% vs. 36%), 12 months (84% vs. 50%), and 24 months (84% vs. 54%) (P<0.05). No association was found between elevated %PRA-CDC and rejection. Patients with %PRA-STAT > or =5% vs. %PRA-STAT <5% had graft survival at 1 year of 89% vs. 84%, at 2 years of 88% vs. 77%, and at 3 years of 61% vs. 72% (not significant). CONCLUSIONS: Use of %PRA-STAT > or =5% identifies pediatric recipients who are at increased risk for rejection and may benefit from more potent immunosuppression and/or closer monitoring of graft function.