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.

The Number of Medications Is Associated with Fractures in a Population of Dialyzed Older Patients with Frailty.

Older persons with chronic kidney disease (CKD) undergoing hemodialysis represent a growing portion of patients characterized by high vulnerability but still marginally studied. This study aimed at exploring the relationship between the number of prescriptions and fractures in older patients with CKD undergoing hemodialysis. A 24-item Frailty Index (FI) based on sociodemographic, clinical and biological data was computed. Unadjusted and adjusted logistic regression models were performed to test the association of prescribed medications with history of fractures. A total of 107 older patients undergoing hemodialysis (38 [35.5%] women, mean age 79.1 standard deviation, SD=7.7) were included in the study. Mean number of prescribed medications was 9.9 (SD=3.9) and was significantly associated with fractures (OR 1.18, 95% CI 1.06-1.32, p=0.003), even after adjustment for potential confounders (OR 1.16, 95% CI 1.03-1.30, p=0.016). If these results will be confirmed, interventions based on deprescribing will become essential in older persons undergoing hemodialysis.

An analysis of erectile function after intensity modulated radiation therapy for localized prostate carcinoma.

Radiation therapy for prostate cancer can cause erectile dysfunction (ED). Intensity Modulated Radiation Therapy (IMRT) can reduce the amount of radiation to surrounding tissues associated with ED. We characterize the incidence of and factors associated with ED in prostate cancer patients after IMRT at the National Naval Medical Center (NNMC). Patients potent by definition of the Sexual Health Inventory for Men (SHIM) before treatment completed the specific erectile questions of the SHIM after IMRT. Statistical analyses were performed to examine the relationships between several factors and ED. Thirty-two of 45 patients with mean age of 68.2 years (50-86 years) completed the SHIM. The median follow-up was 36.8 months (16-63.6 months) as defined by the time from completion of therapy to reassessment with the SHIM. Eight of 32 patients (25%) had no post-treatment ED (SHIM score 22-25), three of 32 (9%) had mild post-treatment ED (SHIM score 17-21), five of 32 (16%) had mild to moderate ED (SHIM score 12-16), five of 32 (16%) had moderate ED (SHIM score 8-11) and 11 of 32 (34%) had severe post-treatment ED (SHIM score<8). Post-treatment potency was significantly associated with the pre-treatment SHIM score (P=0.001) and history of hypertension (P=0.03). The mean radiation dose to the penile bulb and volume of penile bulb treated were not associated with post-treatment potency (P=0.38, 0.76, respectively). IMRT maintains potency in the majority of patients. This analysis compares favorably in preserving erectile function to previously reported series using conventional external beam radiation therapy techniques. The dose of radiation received by the penile bulb and volume of penile bulb were not associated with post-treatment ED in this analysis.

Intramedullary spinal cord metastasis from renal cell carcinoma: detection by positron emission tomography.

Although positron emission tomography (PET) is an established diagnostic method in brain and lung cancer, its use is often confined to research. The authors report a case of a minimally symptomatic intramedullary spinal cord metastasis, an uncommon and often diagnostically challenging lesion, that was confirmed by PET. A 37-year-old man with a history of metastatic renal cell carcinoma treated with systemic agents, an autologous stem cell transplant, and local palliative radiotherapy with a 2-month history of vague right foot numbness and right leg dysesthesias was found to have an intramedullary lesion at the level of T12. Although the findings of magnetic resonance imaging suggested central necrosis, a PET scan revealed a metabolically active lesion and confirmed the diagnosis of intramedullary metastasis. PET can be used to detect and confirm intramedullary spinal cord metastatic carcinoma. PET imaging may have a vital role in clinical diagnosis by helping to distinguish diagnostically troublesome lesions based on metabolic activity.

Diagnoses, demographics, and utilization of care as encountered by three U.S. Navy general medical officers.

U.S. Navy general medical officers (GMOs) are physicians serving as general practitioners. Although exceptions exist, most GMOs are not board-certified in a specialty. They are post-graduate year 1 (PGY-1)-trained, state-licensed physicians analogous to civilian general practitioners. We conducted a retrospective study using data generated from patient visits with active duty males and females from June 1 to 30, 1998, to describe diagnoses, demographics, and utilization of care patterns encountered by three PGY-1-trained GMOs at an ambulatory clinic. A total of 781 patient encounters with 123 diagnoses from a patient population of 3,178 were recorded. This is an average of 260 patient encounters per GMO, at a rate of 2.52 patients seen per patient-care hour. Fifty-seven consultations/referrals were requested (7.3% of encounters, 1.8% of the patient population). Personnel assigned to the clinic accounted for 4.2% of visits (2% of the patient population). Patient satisfaction was rated as "excellent" to "satisfactory," and no significant morbidity was observed at 1.5-year follow-up. With PGY-1 training, GMOs provide primary care to a substantial volume of prescreened patients and treat patients with a majority of diagnoses without referral or unacceptable complications. The role of GMOs, and perhaps other physicians without specialty training (i.e., general practitioners), in selected settings seems valid and may have advantageous medicoeconomic implications for military and civilian managed care systems.

Excision and radiotherapy for heterotopic ossification of the elbow.

Radiotherapy has a well-defined role in prophylaxis of recurrent heterotopic ossification of the hip, but has been described infrequently in other situations. This article reports the use of excision and low-dose external beam radiotherapy in three patients with heterotopic ossification of the elbow treated between February 1995 and September 1996. Radiotherapy was delivered in a single fraction of 7-8 Gy within 48 hours postoperatively using opposed anteroposterior portals. After a median follow-up of 10.5 months, all three patients demonstrated a significant increase in range of motion without any evidence of recurrence. These results indicate adjuvant postexcision radiotherapy may be used for prophylaxis of recurrent heterotopic ossification of the elbow.

Effects of cryopreservation and deconstruction on the dermal glycosaminoglycan content of human skin.

Since the concept of a fabricated skin replacement was first proposed, it has been recognized that a permanent skin replacement must contain a functional complex structure consisting of epidermis integrated with dermis. Although a practical solution for the replacement of missing epidermis exists through the culture expansion of the autologous epidermis, a practical solution for permanently replacing missing dermis has not been achieved. While it is generally recognized that the insoluble matrix components--largely collagen and elastin--are essential, the role of other matrix components such as glycosaminoglycans (GAGs) and proteoglycans remains undefined. This article describes both the qualitative and quantitative GAG composition of fresh and cryopreserved human dermis. Through the use of 2 different colorimetric assays and cellulose acetate electrophoresis, we found the following: 1) the principal dermal GAGs are those of the heparin family; 2) dermatan sulfate is the second most predominant GAG component; 3) chondroitin-6-sulfate is found at concentrations of 2 orders of magnitude less than the heparins; and 4) hyaluronan and keratan sulfate were both found as only minor constituents. When the GAG composition of fresh skin was compared with that of cryopreserved skin, no significant differences were observed. This study also examined the time course of GAG leaching during the preparation of deconstructed human dermis, which is human dermis reduced to the native insoluble matrix components by exhaustive saline soaking. We found that GAG leaching was readily detectable even within the first day. Sixty percent of total GAG leaching occurred by day 7. These investigations establish a benchmark for the reproduction of GAGs in synthetic dermal constructs. Further, the results of the leaching study generate important considerations for short-term skin storage and long-term skin banking. Because GAG leaching commences immediately, appropriate precautions must be taken to minimize the potential functional compromise of cryopreserved human dermis.