The association of postnatal urinary tract dilation risk score with clinical outcomes.

BACKGROUND: There are limited data on the predictive value of the consensus urinary tract dilation (UTD) score with respect to subsequent clinical diagnoses. We sought to define the relationship between postnatal UTD risk score and clinical outcomes during childhood. METHODS: Complete ultrasound image sets from a random selection of infants aged 0-90 days undergoing initial ultrasound at a single institution for prenatal hydronephrosis between 2012 and 2014 were assigned a UTD score by 1 pediatric urologist and 1 pediatric radiologist. Urinary tract dilation risk score was analyzed for association with a composite outcome comprising urinary tract infection, vesicoureteral reflux (VUR), ureteropelvic junction obstruction, non-refluxing megaureter (NRM), ureterocele, bladder outlet obstruction (BOO), and chronic kidney disease. Surgical intervention and resolution of UTD were evaluated separately. Descriptive and survival analyses were performed. RESULTS: Urinary tract dilation scores for 494 subjects were P0 in 23.5%, P1 in 26.5%, P2 in 23.5%, and P3 in 26.5%. Seventy-four percent were male. Median age at initial imaging was 28 days; median follow-up was 19.8 months. The composite outcome occurred in 138 of 494 patients (27.9%) and varied significantly (p < 0.001) by UTD score: 11.2% for P0, 10.7% for P1, 29.3% for P2, and 58.8% for P3. On survival analysis (Summary Figure), higher UTD grade was significantly associated with the composite outcome (hazard ratio for P3 vs. P0 was 7.4 [95% CI: 3.44-15.92, p < 0.001]). Urinary tract infection and VUR diagnosis varied by UTD score (p = 0.03 and p < 0.001, respectively). Ureteropelvic junction obstruction was diagnosed (based on MAG3 results) in 6.3% of patients, 84% of whom were P3. Non-refluxing megaureter was diagnosed in 7.7%. Ureterocele and BOO were uncommon (1.4%, and 0.6%, respectively). Surgical intervention was also associated with UTD risk, with 46% of P3 undergoing surgery vs. 1% of P0, 1% of P1, and 6% of P2 (p < 0.001). Resolution of UTD occurred in 41% (median 10.1 months) and varied significantly by UTD risk (p < 0.001). DISCUSSION: Urinary tract dilation risk score is associated with clinical events, although ascertainment bias may influence some of the differences in outcomes, particularly for VUR, because VCUG utilization varied by the UTD group. The lack of any significant difference in outcomes between patients with UTD P0 versus P1 suggests that the P1 category could be eliminated as it does not meaningfully distinguish between outcome risk. CONCLUSIONS: Higher UTD risk scores are strongly associated with genitourinary diagnoses during the first two years of life.

Ventilation, temperature, and HVAC characteristics in small and medium commercial buildings in California.

UNLABELLED: This field study of 37 small and medium commercial buildings throughout California obtained information on ventilation rate, temperature, and heating, ventilating, and air-conditioning (HVAC) system characteristics. The study included seven retail establishments; five restaurants; eight offices; two each of gas stations, hair salons, healthcare facilities, grocery stores, dental offices, and fitness centers; and five other buildings. Fourteen (38%) of the buildings either could not or did not provide outdoor air through the HVAC system. The air exchange rate averaged 1.6 (s.d. = 1.7) exchanges per hour and was similar between buildings with and without outdoor air supplied through the HVAC system, indicating that some buildings have significant leakage or ventilation through open windows and doors. Not all buildings had sufficient air exchange to meet ASHRAE 62.1 Standards, including buildings used for fitness centers, hair salons, offices, and retail establishments. The majority of the time, buildings were within the ASHRAE temperature comfort range. Offices were frequently overcooled in the summer. All of the buildings had filters, but over half the buildings had a filter with a minimum efficiency reporting value rating of 4 or lower, which are not very effective for removing fine particles. PRACTICAL IMPLICATIONS: Most U.S. commercial buildings (96%) are small- to medium-sized, using nearly 18% of the country's energy, and sheltering a large population daily. Little is known about the ventilation systems in these buildings. This study found a wide variety of ventilation conditions, with many buildings failing to meet relevant ventilation standards. Regulators may want to consider implementing more complete building inspections at commissioning and point of sale.

Detection of circulating tumor cells in patients with urothelial cancer.

BACKGROUND: Approximately 50% of patients with metastatic urothelial cancer (UC) respond to chemotherapy and several months of therapy is required to assess for radiographic response. Blood-based biomarkers may identify patients in whom a specific therapy provides clinical benefit, and this study sought to characterize circulating tumor cells (CTCs) in patients with metastatic UC. PATIENTS AND METHODS: Peripheral blood from patients with metastatic UC was evaluated for CTCs using the CellSearch system. We assessed for associations between CTC counts and the number and sites of metastatic disease. RESULTS: CTC evaluations were carried out in 33 patients with metastatic UC. Fourteen of 33 patients (44%; 95% confidence interval 27% to 59%) had a positive assay (range 0-87 cells/7.5 ml of blood) with 10 patients (31%) having five or more CTCs. A significantly higher number of CTCs was seen in patients with two or more sites of metastases compared with those with less than one or one site of metastases (3.5 versus 0, P = 0.04). CONCLUSIONS: CTCs, detected by antibody capture technology, are present in 44% of patients with metastatic UC. Higher numbers of CTCs are seen in patients with a greater number of metastatic sites. One-third of patients have five or more CTCs providing a potential early marker to monitor response to chemotherapy.

Vertebroplasty in multiple myeloma: outcomes in a large patient series.

BACKGROUND AND PURPOSE: Despite the literature supporting the efficacy of vertebroplasty for treatment of osteoporotic vertebral compression fractures, few reports exist documenting its use in the treatment of compression fractures in multiple myeloma patients. Accordingly, we sought to characterize the imaging characteristics, clinical course, and outcomes in myeloma patients treated with vertebroplasty. MATERIALS AND METHODS: We performed a retrospective review of clinical outcome data from 67 multiple myeloma patients treated with vertebroplasty since October 2000. Quantitative outcome data including the Roland Morris Disability Questionnaire (RDQ) and Visual Analog Scales for pain and qualitative outcome data (self-reported pain, mobility, and narcotic use) were collected preoperatively, immediately after vertebroplasty, and at 1 week, 1 month, 6 months, and 1 year after treatment. RESULTS: Significant improvements in all of the outcome measures were observed postoperatively and throughout the duration of follow-up. Quantitative outcome measures (RDQ, analog pain scale 0-10, with rest and activity) improved by 11.0 (48%; P < .0001), 2.7 (25%; P < .001), and 5.3 (48%; P < .0001) points, respectively, with persistent improvement at 1 year (P < .01; P < .03; P < .001). Eighty-two percent and 89% of patients experienced a significant improvement in subjective rest pain and activity pain, respectively. Subjective scores achieved durable improvements, with 65% of patients requiring fewer narcotics after vertebroplasty and 70% having improved mobility. CONCLUSION: Vertebroplasty provides significant and durable pain relief for patients with intractable spinal pain secondary to compression fractures resulting from multiple myeloma.

The effects of cement volume on clinical outcomes of percutaneous vertebroplasty.

BACKGROUND AND PURPOSE: There exists significant variability in the volume of polymethylmethacrylate cement injected during percutaneous vertebroplasty. Larger cement volumes injected may be associated with better clinical outcomes, but larger volumes may also be associated with greater risk of complications related to cement leakage. We describe an analysis of the association between clinical and procedural variables, including cement volume injected, and the clinical outcomes of patients treated with single-level vertebroplasty. METHODS: Retrospective analysis of 158 patients treated with single-level vertebroplasty was performed. Relationships among patient and procedural variables and relationships between these variables and ordinal clinical outcome scores of pain and medication use at postprocedure time points from 1 week to 2 years were evaluated with bivariate and multivariable analyses. RESULTS: There was no significant association between the volume of cement injected and the clinical outcomes of postprocedure pain (P = .159-.871) and medication use (P = .223-.875). CONCLUSION: Vertebroplasty operators need not feel compelled to achieve particular cement volumes injected in the pursuit of better clinical outcomes but should strive to achieve the maximal safe filling of individual vertebral bodies.

Does vertebroplasty cause incident vertebral fractures? A review of available data.

Vertebroplasty has been in practice in the United States for approximately 10 years and has been described as providing significant benefit to patients with painful vertebral compression fractures. Although the procedure appears to provide dramatic pain relief, it is not without complications. The primary point of discussion in this paper is whether vertebroplasty predisposes patients to the development of additional vertebral fractures, at a rate higher than that seen in the absence of vertebroplasty. To date there remains no definitive answer to this question. There is, however, a significant body of data available in the literature that relates to this issue. This review explores and attempts to synthesize the data both supporting and refuting a relationship between vertebroplasty and the development of subsequent fractures.

Subsequent vertebral fractures after vertebroplasty: association with intraosseous clefts.

BACKGROUND AND PURPOSE: Patients with vertebral fractures containing intraosseous clefts may represent a distinct subgroup of vertebroplasty patients, yet the development of subsequent vertebral fractures in this population has not been explored. We tested the hypothesis that after vertebroplasty for intraosseous clefts, subsequent fractures would occur earlier and more frequently than after treatment of non-cleft-containing fractures. METHODS: We retrospectively reviewed 362 patients treated with vertebroplasty for osteoporotic fractures. The location, frequency, and timing of subsequent fractures were compared between 2 subgroups: group 1, patients treated at fractures containing clefts, and group 2, treated patients without clefts. A vertebra-by-vertebra analysis was used to compare the relative risk and timing of subsequent fractures adjacent to vertebrae with or without clefts. RESULTS: Group 1 included 63 patients treated at 65 vertebrae and group 2 included 250 patients treated at 399 vertebrae. Group 1 demonstrated a nearly twofold increased risk of subsequent fracture (odds ratio [OR], 1.90; 95% confidence interval [CI], 1.04-3.49, P = .037). At the vertebral level, the relative risk of subsequent fracture was 2.02 (95% CI, 1.46-2.58; P = .013) times greater adjacent to a treated cleft. Fractures adjacent to any treated level occurred significantly sooner than nonadjacent fracture (P = .0004). The presence of a cleft was not significantly associated with the timing of subsequent fractures. CONCLUSIONS: Patients with osteoporotic vertebral fractures containing clefts are at increased risk for subsequent fractures and treatment of these clefts is associated with increased rates of adjacent fracture. There is no significant difference in the timing of subsequent fractures based on the presence of a cleft.

New fractures after vertebroplasty: adjacent fractures occur significantly sooner.

BACKGROUND AND PURPOSE: Whether vertebroplasty increases the risk of adjacent-level vertebral fractures remains uncertain. Biomechanical and clinical studies suggest an increased risk, but compelling data have not yet been put forth to settle this difficult issue. We believe that an analysis of the time interval between vertebroplasty and subsequent fractures may shed additional light on this debate. We specifically hypothesized that subsequent fractures would occur sooner and more frequently in the vertebrae adjacent to the treated level. METHODS: We performed a retrospective analysis of the risk and timing of subsequent fractures in patients previously treated with vertebroplasty. Multiple linear regression was used to explore factors that influence the time to new fracture following vertebroplasty. Fractures were then divided on the basis of whether they occurred adjacent or non-adjacent to the treated level. Survival analysis was used to compare time to new fracture among the 2 groups, and the relative risk of both types of fracture was calculated. RESULTS: In this study, 186 new vertebral fractures occurred in 86 (19.9%) of 432 patients. Seventy-seven (41.4%) fractures were of vertebrae adjacent to the level treated with vertebroplasty. Median times until diagnosis of new adjacent and non-adjacent level fractures were 55 days and 127 days, respectively. Time to fracture was significantly different between the 2 groups (logrank <0.0001). Distance of the new fracture from the treated level was also significantly associated with time to new fracture (P < .0001). Relative risk of adjacent level fracture was 4.62 times that for non-adjacent level fracture. CONCLUSION: These data demonstrate an association between vertebroplasty and new vertebral fractures. Specifically, following vertebroplasty, patients are at increased risk of new-onset adjacent-level fractures and, when these fractures occur, they occur sooner than non-adjacent level fractures.

Direct capillary electrophoretic detection of carbohydrate-deficient transferrin in neat serum.

Transferrin, an iron transport protein found in serum and cerebrospinal fluid, is known to be microheterogeneous with respect to its carbohydrate and sialic acid content. The forms of transferrin deficient in sialic acid and/or carbohydrate, termed carbohydrate-deficient transferrin (CDT), have been of clinical interest for almost two decades as a result of the initial finding that elevated CDT concentrations are associated with chronic, excessive alcohol abuse. We demonstrate the utility of capillary electrophoresis for examining the CDT sialoform profile via the direct electrophoresis of serum. The need for negligible preelectrophoresis sample preparation and absence of postelectrophoresis processing dramatically decreases analysis time compared to slab gel-based separations. Using a fluorocarbon-coated capillary containing a hydroxyethyl cellulose/borate buffer, the high resolution separation of serum components is effected in less than 30 min. Under these conditions, the beta region proteins (including transferrin) are well resolved from the alpha-2 and gamma zone proteins in a window where the individual transferrin sialoforms can be detected. The usefulness of this method is demonstrated with the electrophoresis of serum from subjects known to be either non-alcoholic and alcoholic.

Patient satisfaction investigations and the emergency department: what does the literature say?

BACKGROUND: Patient satisfaction is an indicator of the quality of care provided by emergency department (ED) personnel. It is this perception of satisfaction that becomes the basis for future ED choice or the recommendation of a specific ED to other potential patients. OBJECTIVE: To perform an evidence-based literature review to: 1) characterize measures of "patient satisfaction"; 2) identify factors that have been associated with overall ED patient satisfaction; 3) critique the methods used to assess patient satisfaction in the literature; and 4) address how this information can be beneficial to those reading the satisfaction literature or designing a satisfaction survey instrument. METHODS: The MEDLINE database was searched for studies addressing ED patient satisfaction, from January 1976 through July 1999, using MeSH terms and a text word search. Bibliographies of manuscripts also were searched for additional relevant articles and each clinical study was used as a search criterion in Science Citation Index, from the date of publication through July 1999. RESULTS: Multiple measures have been used to evaluate overall patient satisfaction. Sixteen studies were found associating ED patient satisfaction with service and patient factors. Most studies are observational and of these, most are cross-sectional. Hence, cause-and-effect determination of factors responsible for patient satisfaction cannot be resolved using the current literature. CONCLUSIONS: Despite considerable methodologic variability, key themes (e.g., association of satisfaction with patient information, provider-patient interpersonal factors, and perceived waiting time) emerge from review of the ED patient satisfaction literature. To standardize future investigations, clinicians and investigators should use a common definition for the state of overall patient satisfaction, e.g., when the patient's own expectations for treatment and care are met (or exceeded). This common definition should be incorporated into the instrument used to measure overall ED patient satisfaction.

Dynamically-coated capillaries allow for capillary electrophoretic resolution of transferrin sialoforms via direct analysis of human serum.

Transferrin sialoforms with fewer than three sialic acid residues (carbohydrate deficient transferrin; CDT) have been implicated as a marker of certain liver pathologies. Transferrin sialoforms in human sera from alcoholic and non-alcoholic patients was analyzed by capillary electrophoresis (CE) using diaminobutane (DAB) to dynamically-coat the capillary wall to minimize protein-wall interactions. Using a DAB concentration of 3 mM, transferrin sialoforms were adequately resolved to allow for direct detection of CDT without extensive treatment of the sera. Serum immunoglobulins, which migrated close to the CDT region, were removed via subtraction with protein A, enhancing the detection of CDT. The reproducibility of sialoform separation in dynamically-coated capillaries was found to be acceptable with run-to-run relative standard deviation values of 0.15% for a sample on a given day and 0.29+/-0.06% for four samples day-to-day. These results suggest that dynamic-coating approaches may provide a simple alternative to the use of covalently-coated capillaries for the CE separation of complex samples.

Normative data for the Novaco Anger Scale from a non-clinical sample and implications for clinical use.

OBJECTIVES: To provide non-clinical normative data for the Novaco Anger Scale. To identify the ability of the scale to discriminate between clinical and non-clinical populations. DESIGN: Postal survey of individuals from a non-clinical sample. METHOD: A non-clinical sample of 212 NHS employees was sent a questionnaire pack, including the Novaco Anger Scale. A clinical sample of 58 outpatient anger-management referrals was identified from a retrospective case-note analysis. RESULTS: Descriptive data are presented for both samples. t-score conversions are provided, based on the non-clinical data. Results from a discriminant function analysis demonstrated that the Novaco Anger Scale classified participants as clinical or non-clinical with 94% accuracy. CONCLUSION: From this study it appears that the Novaco Anger Scale is able to discriminate between clinical and non-clinical populations. These data offer further support to the validity of the Novaco Anger Scale and its use in clinical assessment.

Comparison of routes of flumazenil administration to reverse midazolam-induced respiratory depression in a canine model.

OBJECTIVE: To determine whether flumazenil, a drug used to reverse benzodiazepine-induced respiratory depression and approved only for i.v. use, is effective by alternative routes. METHODS: A randomized, controlled, nonblinded, crossover canine trial was performed to evaluate reversal of midazolam-induced respiratory depression by flumazenil when administered by alternative routes. Mongrel dogs were sedated with thiopental 19 mg/kg i.v., then tracheally intubated. With the dogs spontaneously breathing, tidal volume, end-tidal CO2, and O2 saturation were observed until a stable baseline was achieved. Incremental doses of midazolam were administered until respiratory depression (30% decline in tidal volume, 10% decrease in O2 saturation, and 15% increase in end-tidal CO2) occurred. Flumazenil was administered by a randomly selected route [0.2 mg followed 1 minute later by 0.3 mg i.v., sublingual (s.l.) or intramuscular (i.m.); or 1 mg followed 1 minute later by 1.5 mg per rectum (PR)]. Time to return to baseline respiratory functions was recorded ("time to reversal"). Each of 10 dogs was studied using all 4 routes of flumazenil administration with a washout period of at least 7 days. An additional dog served as a control (no flumazenil). RESULTS: The control time to reversal was 1,620 seconds. The i.v. route was significantly faster (mean 120 +/- 24.5 sec) than the other 3 routes (p < 0.005). The SL route was the second fastest (mean 262 +/- 94.5 sec), the IM route was the third fastest (mean 310 +/- 133.7 sec) and the PR route was the s;owest (mean 342 +/- 84.4 sec). The SL, IM, and PR routes did not differ significantly from one another. CONCLUSIONS: Flumazenil administered by all 4 routes reversed midazolam-induced respiratory depression in a dog model. For the selected dosages used, the i.v. route was significantly faster than all 3 other routes, and SL was the second fastest.

Acidic and basic fibroblast growth factors prolong the in-vitro survival of murine peritoneal macrophages.

To examine the role of fibroblast growth factors on the proliferation present during angiogenic processes, we analyzed the effects of in vitro cell culture with acidic (FGF-1) and basic (FGF-2) fibroblast growth factors on murine peritoneal exudate cell survival. FGF-1 or FGF-2 in the presence of heparin resulted in a significantly greater cell viability for exudate cells at 24 hours of culture relative to heparin alone or medium controls. Cultures supplemented with FGF-1 or FGF-2 plus heparin showed a slight increase in tritiated[3H] thymidine uptake over heparin or medium alone. No specific change in [3H] uridine incorporation or LDH release was detectable between FGF-1, FGF-2, heparin or medium alone cultures. Our results suggest that FGF-1 and FGF-2 may enhance survival both in vitro and in vivo of a subset of peritoneal exudate cells. This attribute may play a role during inflammatory or tumor-like states.

Lipid and polypeptide components of the crystalline yolk system from Xenopus laevis.

The polypeptide and lipid components of the crystallinelipoprotein-phosphoprotein from the yolk system of Xenopus laevis are described. This lipoprotein complex contains 17% lipid of which 75% is phospholipid. The phospholipid fraction consists of mostly phosphatidylcholine and phosphatidylethanolamine. The neutral lipid fraction contains mainly triglyceride. The phosphoprotein, phosvitin, has been separated from the lipoprotein, lipovitellin, by classical methods. Three polypeptide chains can be observed in the lipoprotein and their molecular weights as determined by sodium dodecyl sulfate gel electrophoresis are 105,500, 35,500, and 32,000. Phosvitin behaves abnormally on these gels, but analysis of the results suggests Mr = approximately 16,000 to 19,000/polypeptide chain. The lipovitellin component of the yolk complex contains approximately 100 bound lipid molecules/dimer. The stoichiometry of the components of this crystalline lipoprotein system is discussed in terms of the results obtained in this study and those of other workers.