BK virus encoded microRNAs are present in blood of renal transplant recipients with BK viral nephropathy.

BK viral infection is an important cause of renal transplant dysfunction and failure. Current strategies utilize surveillance for infection with DNA polymerase chain reaction assays and modulation of immunosuppression. Many viruses including polyomaviruses encode microRNAs (miRNAs). We have detected BK virus (BKV) encoded miRNAs in the blood of infected renal transplant recipients, and see a strong correlation between BKV encoded miRNA and BKV DNA in blood and a relationship between levels of bkv-miR-B1-5p and the presence of biopsy-proven BK viral nephropathy. Further research is needed to determine whether the detection of this and other virally encoded miRNAs may be useful in the diagnosis of active viral replication.

The survival of patients with not-for-resuscitation orders.

BACKGROUND: Studies have shown higher in-hospital mortality rates in patients with not-for-resuscitation (NFR) decisions. Long-term survival of these patients after their discharge from acute care is largely unknown as is communication of such decisions to primary care givers through letters or discharge summaries. AIM: To evaluate the in-hospital mortality and post-discharge survival of general medical patients with documented resuscitation decisions as well as the prevalence of these decisions being communicated to primary health care providers through discharge summaries. DESIGN: Retrospective cross-sectional study. METHODS: The medical records of 618 general medical patients admitted to an Australian tertiary referral teaching hospital between January and December 2007 were reviewed to determine the documentation of resuscitation decisions. Mortality rates in-hospital and up to 5 years post-discharge were assessed in relation to the nature of any resuscitation decisions. Communication of these decisions in the discharge summaries was also evaluated. RESULTS: One hundred and thirty-six (22%) patients had resuscitation decisions documented of whom 91 (67%) did not want resuscitation (NFR). For this NFR group, the in-hospital mortality rate was 20%, and their cumulative 1- and 5-year mortality rates were 53 and 85%, respectively. Of the 112 patients with resuscitation decisions who survived to discharge, 104 of them (93%) had discharge summaries completed but only 9 (8.4%) had resuscitation decisions documented in those discharge summaries. CONCLUSION: Many general medical patients with a documented NFR decision survive beyond 1 year after their index admission. The rate of communication of resuscitation decisions in hospital discharge summaries is low.

The significance of reduced kidney function among hospitalized acute general medical patients.

BACKGROUND: Inpatient general medical units often look after older patients who have more complex co-morbidity including renal insufficiency. The consequences of renal insufficiency with respect to length of hospital stay (LOS) and mortality have not been well described in hospitalized general medical patients. AIM: To use a general medical inpatient population to evaluate the impact of reduced kidney function. DESIGN: Retrospective cross-sectional study. METHODS: We studied 504 acute medical admissions through an Acute Assessment Unit between February and November 2007. Patients were classified as having chronic kidney disease (CKD), acute kidney injury (AKI), neither (control) or both. LOS, in-hospital mortality and post-discharge survival were evaluated. RESULTS: Renal impairment was present in 151 patients. Ninety patients had CKD only and 61 had AKI with or without CKD. In-hospital mortality was increased in those with renal impairment compared with controls (9.3 vs. 3.4%; P = 0.006). Within 4 years of admission, 187 (39%) patients had died. Post-discharge mortality was significantly higher in all renal failure populations (hazard ratio: 2.57-4.38; P < 0.01). Adjustment for patient age, gender and Charlson index explained the increased mortality during and after hospital admission but did not explain increased LOS. Only a small proportion (13%) of admitted patients with renal insufficiency had renal disease documented in their discharge summaries. CONCLUSION: Many general medical inpatients (30%) have reduced kidney function at the time of admission. This study provides validation of the Modification of Diet in Renal Disease equation as a predictor of poor outcomes. Reduced renal function was associated with increased hospital LOS and mortality. Mortality rose with AKI and was explicable on the basis of the patients' age and co-morbidities. Renal insufficiency is documented infrequently in discharge summaries.

Visual deterioration caused by vitamin A deficiency in patients after bariatric surgery.

Vitamin A deficiency (VAD) after bariatric surgery is recognised as a significant post-operative complication that can lead to visual impairment. We report two cases of night blindness and visual impairment caused by VAD after malabsorptive bariatric surgery. Both patients were treated with intramuscular vitamin A replacement and made near complete recovery in their vision. Ocular complications due to VAD should be diagnosed and treated promptly in patients after bariatric surgery because these complications are reversible.

Quality of resuscitation orders in general medical patients.

BACKGROUND: Documentation of resuscitation status in hospitalized patients has relevance in the management of cardiopulmonary arrest. Its association with mortality, Length Of hospital Stay (LOS) and the patients' primary diagnosis has not been established in general medical inpatients in hospitals in Australia and New Zealand. AIM: To investigate the association of resuscitation orders with in-hospital mortality and LOS in a range of diagnoses, adjusting for severity of illness and other covariates. DESIGN: Retrospective study. METHODS: The admission notes of 1681 medical admissions to four tertiary care teaching hospitals across Australia and New Zealand were reviewed retrospectively for frequency and nature of resuscitation documentation and its association with mortality, LOS and primary diagnosis. RESULTS: Resuscitation orders were documented in 741 patients (44.7%). For the 232 patients with a Not For Resuscitation (NFR) order, the in-hospital mortality rate was higher than in control patients (14% vs. 1.2%, P<0.005). The mortality rate remained significantly higher in the NFR group after propensity matching of the controls for age and co-morbidity (14% vs. 5%, P<0.005). The death-adjusted LOS for the NFR group was also significantly higher compared to the control patients (9.7 days vs. 4.7 days, P<0.005) and this difference remained after propensity matching (9.7 days vs. 7.7 days, P<0.05). Those patients with a primary diagnosis of respiratory tract infection or cardiac failure were more likely to be documented NFR compared to those with cellulitis or urinary tract infection. CONCLUSIONS: The documentation of NFR in a patient's admission notes is associated with increased in-hospital mortality and LOS. This is only partly explicable in terms of these patients' greater age and co-morbidity.

Simple clinical score is associated with mortality and length of stay of acute general medical admissions to an Australian hospital.

BACKGROUND: In a rural Irish hospital, a simple clinical score (SCS) determined at the time of admission enabled stratification of acute general medical admissions into five categories that were associated incrementally with patients' immediate and 30-day mortality. The aim of this study was to examine the representative performance of this SCS in predicting the outcomes of general medical admissions to an Australian teaching hospital. METHODS: A retrospective chart review was undertaken of a representative sample from 480 admissions in 2007 to an urban university teaching hospital in Australia. The SCS was calculated and related to that patient's outcome in terms of mortality, length of stay, nursing home placement on discharge, the occurrence of medical emergency team call and intensive care unit transfer. These data were compared, where possible, with the outcomes reported in the Irish hospital. RESULTS: Four hundred and seventeen complete sets of data allowed calculation of the SCS. There were significant linear correlations of the SCS (divided into quintiles) and patients' in-hospital and 30-day mortality, their length of stay and their discharge to a nursing home. There was no association of the SCS and the patients' readmission rate, intensive care unit transfer rate or likelihood of a medical emergency team call. The significant trends replicated those from the Irish hospital. CONCLUSION: The SCS can predict significant outcomes for general medical admissions in an Australian hospital despite obvious differences to the hospital of its derivation. A wider study of Australasian hospitals and the performance of the SCS as a predictor of general medical admission outcomes is underway.

Successful control of Scedosporium prolificans septic arthritis and probable osteomyelitis without radical surgery in a long-term renal transplant recipient.

Scedosporium species are increasingly isolated from immunocompromised and immunocompetent patients. Scedosporium infections are generally resistant to multiple antifungals, and Scedosporium prolificans is particularly resistant to all single antifungal agents currently in use with in vitro testing. We report here a long-term renal transplant recipient who developed isolated S. prolificans septic monoarthritis and probable osteomyelitis. The infection was successfully treated with a combination of voriconazole and terbinafine in addition to joint washout but did not require radical surgery. This combination has been shown to have synergistic in vitro effect, and anecdotal in vivo success has also been reported recently. We also review the clinical presentation, treatment, and outcome of S. prolificans infection in patients with solid organ transplantation.