Abstract Background Multidisciplinary care is advocated as an effective chronic kidney disease treatment program in a few, but not all, studies. Our study aimed to evaluate the effect of ...multidisciplinary care on renal outcome and patient survival using a larger cohort. Method A total 1382 chronic kidney disease patients, ages 18-80 years, with chronic kidney disease stage 3B-5, in nephrology outpatient clinics were enrolled. Using age, sex, chronic kidney disease stage, and diabetes mellitus as variables, 592 multidisciplinary care program participants were matched with 614 nonmultidisciplinary care patients. The primary outcomes were long-term renal replacement therapy and mortality. Secondary outcomes included changes of biochemical markers and blood pressure, infection hospitalization, cardiovascular events, and emergent start of long-term dialysis. Annual medical costs were compared. Results There were no between-group differences regarding mortality. In the multivariate competing-risk regression model, the multidisciplinary care group had a better renal survival (hazard ratio 0.640; 95% confidence interval, 0.484-0.847; P = .002). This effect was most prominent in stage 4 (hazard ratio 0.375; 95% confidence interval, 0.219-0.640; P < .001), but not in stage 3B and 5 patients. The multidisciplinary care group showed a slower estimated glomerular filtration rate decline (−2.57 vs −3.74 mL/min/1.73 m2 , P = .021), and a smaller increase in phosphate (+ 0.03 vs + 0.33 mg/dL, P = .013). Cardiovascular and infection events were both decreased in the multidisciplinary care group ( P < .001). There was also less requirement of emergent start dialysis (39.6% vs 54.5%, P = .001). The annual cost for the multidisciplinary care group was lower than the nonmultidisciplinary care group (US $2372 vs $3794, P < .001). In addition, considering the reduction of patients requiring renal replacement therapy, the multidisciplinary care program saved a total US $1931 per patient annually. Conclusions Our analysis demonstrated that the multidisciplinary care program provided better health care and reduced renal replacement therapy in patients with advanced chronic kidney disease. By decreasing hospitalizations, emergent start, and the need for renal replacement therapy, the multidisciplinary care program was cost-effective.
To investigate the effects of adjuvant chemotherapy in nasopharyngeal carcinoma (NPC) patients with persistently detectable plasma Epstein-Barr virus DNA (pEBV DNA) after curative radiation therapy ...plus induction/concurrent chemotherapy.
The study population consisted of 625 NPC patients with available pEBV DNA levels before and after treatment. Eighty-five patients with persistently detectable pEBV DNA after 1 week of completing radiation therapy were eligible for this retrospective study. Of the 85 patients, 33 were administered adjuvant chemotherapy consisting of oral tegafur-uracil (2 capsules twice daily) for 12 months with (n=4) or without (n=29) preceding intravenous chemotherapy of mitomycin-C, epirubicin, and cisplatin. The remaining 52 patients who did not receive adjuvant chemotherapy served as the control group.
Baseline patient characteristics at diagnosis (age, sex, pathologic type, performance status, T classification, N classification, and overall stage), as well as previous treatment modality, were comparable in both arms. After a median follow-up of 70 months for surviving patients, 45.5% (15 of 33 patients) with adjuvant chemotherapy and 71.2% (37 of 52 patients) without adjuvant chemotherapy experienced tumor relapses (P=.0323). There were a significant reduction in distant failure (P=.0034) but not in local or regional recurrence. The 5-year overall survival rate was 71.6% for patients with adjuvant chemotherapy and 28.7% for patients without adjuvant chemotherapy (hazard ratio 0.27; 95% confidence interval 0.17-0.55; P<.0001).
Our retrospective data showed that adjuvant chemotherapy can reduce distant failure and improve overall survival in NPC patients with persistently detectable pEBV DNA after curative radiation therapy plus induction/concurrent chemotherapy.
The spot urine protein/creatinine ratio (UPCR) is proposed to be a substitute for 24-hour urinary protein (24h-UP). This study is aimed to determine whether the predictive accuracy of 24h-UP using ...UPCR can be improved by simply multiplying estimated daily urine creatinine excretion (eUCr) and UPCR together.
This study enrolled 120 participants to investigate the correlation between spot UPCR and 24h-UP. Three sets of spot urine samples were randomly collected throughout the day and night, along with the first morning void. UPCR was weighted by eUCr to investigate the improvement of accuracy in using spot urine samples to predict 24h-UP.
There were strong correlation and concordance between UPCR and 24h-UP irrespective of the time of spot urine sampling, and the correlation, concordance and agreement were improved after multiplying the UPCR value by the eUCr. Greater improvement was found in the subgroups with measured daily urine creatinine excretion ≤ 0.8 g/d and ≥ 1.2 g/d.
This investigation demonstrated that multiplying UPCR by eUCr can improve the accuracy of only using UPCR to predict 24h-UP.
Background Endobronchial masses obstruct the central airway, and cryotechnology is reportedly a feasible means of managing such masses. However, few reports have explored the role of cryotechnology ...in diagnosing endobronchial masses. Methods All endobronchial masses were sampled for pathologic diagnosis by forceps biopsy and cryotechnology, performed during flexible bronchoscopy. The diagnostic accuracy of forceps biopsy and that of cryotherapy were compared by the χ2 test, and the obtained specimen sizes were compared by the t test. Results Between 2007 and 2011, 75 patients with a median age of 64 years (interquartile range IQR, 49–76; 48 men; 27 women; and 52 smokers 69.3%) were diagnosed with endobronchial masses. The sites of these masses included the trachea (n = 17), left main bronchus (n = 16), right main bronchus (n = 11), right upper lobe bronchus (n = 11), right intermediate bronchus (n = 8), right lower lobe bronchus (n = 4), left upper lobe bronchus (n = 3), left lower lobe bronchus (n = 3), and right middle lobe bronchus (n = 2). Fifty-nine lesions were malignant, and 16 were benign. Lung squamous cell carcinoma (n = 23) was the leading cause of malignancy, and endobronchial tuberculosis (n = 9) was the most common benign disease. The diagnostic accuracy of cryotechnology was significantly higher than that of forceps biopsy (100% vs 69.3%, p < 0.0001). The specimen size obtained by cryotechnology was also significantly larger than that obtained by forceps biopsy (13.8 ± vs 1.9 ± 0.6 mm, p < 0.0001). Conclusions The current study supports the view that cryotechnology is a good tool for diagnosing endobronchial masses. Cryotechnology also provides a better diagnostic specimen and has greater diagnostic accuracy than traditional forceps biopsy.
Abstract Favorable results have been reported for tibialis posterior tendon transfers, which can effectively restore the dorsiflexion of the ankle and normal heel-to-toe gait. However, the commonly ...used methods for anchoring the transplanted tendon have some drawbacks. Therefore, we developed a new tendon-anchoring method to improve fixation of the transferred tendon and reduce the related complications. The new method entails tying the anchoring suture to the navicular bone instead of the button on the plantar foot to avoid wound complications. It requires no additional skin incisions or special equipment. We retrospectively evaluated 24 feet of 19 pediatric patients (13 females and 6 males) who had undergone anterior transfer of the tibialis posterior tendon with our new method from 2000 to 2013. All patients were clinically followed up. At the final follow-up visit, they were evaluated while standing and walking, and the range of motion of the foot was evaluated. The mean age at surgery was 7.8 (range 2 to 16) years. At the longest follow-up point, all the patients exhibited improved gait, except for 1 patient who required a secondary procedure. All the transferred tibialis posterior tendons could be palpated with certainty during active dorsiflexion or withdrawal of the foot. No tendon displacements, wound infections, or postoperative complications were observed. Fixation of a transferred tibialis posterior tendon by tying the suture to the navicular bone is simple and reliable. This technique can efficiently prevent the plantar ulcers that can develop with the traditional pull-out button method and provides a solution when appropriate-size bioabsorbable interference screws are unavailable.
Abstract Objectives The purpose of this study was to explore the predictor index of mortality in patients with pyogenic liver abscess (PLA). Methods We performed a retrospective review that enrolled ...431 patients 18 years and older hospitalized due to PLA between January 2005 and December 2010. Clinical characteristics, laboratory results, treatments, and outcomes retrieved from medical records were analyzed. Multiple logistic regression and receiver operating characteristic curve analyses were performed. Results The mean age of the 431 patients identified with PLA was 56.9 ± 15.0 years. The mean Mortality in Emergency Department Sepsis (MEDS) score on admission was 4.8 ± 4.1 (range, 0-17). During hospitalization, 94 patients (22%) required intensive care. Of the 431 patients, 63 died, yielding a 15% case fatality rate. Multivariate analysis revealed that higher MEDS scores on admission ( P < .0001) and the presence of underlying malignancy ( P = .006), multiple abscesses ( P = .001), anaerobic infections ( P < .0001), hyperbilirubinemia ( P < .0001), and higher serum creatinine levels ( P < .0001) were significantly associated with PLA mortality. The estimated area under the receiver operating characteristic curve for MEDS in predicting PLA mortality was 0.829 (95% confidence interval, 0.791-0.864; P < .0001). The optimal cutoff MEDS value of 7 or higher had a sensitivity of 76% sensitivity and a specificity of 81%, with a 10.7-fold PLA mortality risk ( P < .0001) and a 26.2-fold intensive care unit admission risk ( P < .0001). Conclusions The MEDS scores on admission represent a significant prognostic indicator for patients with PLA.
To compare the prevalence of potentially inappropriate medications (PIMs) using the 2012 and 2003 Beers Criteria in frail older patients receiving home health care services (HHS), and to explore the ...correlates of PIMs based on the 2012 Beers criteria.
A total of 145 older patients (mean age, 80.9 ± 7.6 years) with Barthel scale ≤ 60 receiving regular HHS from a university hospital between January 2013 and June 2013 were retrospectively enrolled. The 2003 and 2012 Beers criteria were used separately to detect PIMs. Logistic regressions, receiver-operating-characteristic curve analyses and number needed to harm were used, where appropriate.
The 2012 Beers Criteria identified more PIM cases than did the 2003 Beers Criteria (66.9% versus 55.9%, P < 0.05). Multivariate analysis revealed that PIM identified by the 2012 Beers Criteria was associated with an increased number of medications prescribed (P = 0.019) and the presence of psychiatric diseases (P = 0.001). Moreover, the area under the receiver-operating-characteristic curve for the number of drugs to predict the risk of PIM was 0.674 (P < 0.001) with the optimal cutoff value of 6 medications. After adjusting for age, sex, Charlson comorbidity index and psychiatric disorders, patients taking ≥6 drugs (adjusted odds ratio, 2.33; adjusted number needed to harm, 3.93; P < 0.05) had a significantly higher risk for PIM than those taking <6 drugs.
Our data showed that the 2012 Beers Criteria was more sensitive in detecting PIMs than the 2003 Beers Criteria. Furthermore, frail older patients receiving HHS with polymedication and with psychiatric illnesses had higher risk of PIM when using the 2012 criteria. The number of medications prescribed could be a useful index for risk stratification, and at the same time help physicians to be aware of the high risk for PIM when prescribing 6 or more drugs to frail older adults during in-home visits.
The impact of smoking in primary spontaneous pneumothorax Cheng, Yeung-Leung, MD, PhD; Huang, Tsai-Wang, MD; Lin, Chih-Kung, MD ...
The Journal of thoracic and cardiovascular surgery,
07/2009, Letnik:
138, Številka:
1
Journal Article
Recenzirano
Odprti dostop
Background The crucial role of cigarette smoking in the development of pneumothorax is unclear because nonsmokers can also develop primary spontaneous pneumothorax. The purpose of this study was to ...clarify the pathophysiologic effects of cigarette smoking and its clinical correlations in primary spontaneous pneumothorax. Methods Included were 115 specimens of lung tissue from patients with primary spontaneous pneumothorax who underwent video-assisted thoracoscopic surgery from January 2001 to December 2002. We reviewed the clinical features of 56 smokers and 59 nonsmokers with an average follow-up of 67 months. The pathologic findings of resected lung specimens were analyzed retrospectively. Results There were no statistical differences in sex, age, body height, body weight, body mass index, or the presence of blebs/bullae on computed tomography scans of the lung or under thoracoscopy between the 2 groups. In the smoking group, patients had more extensive respiratory bronchiolitis ( P < .001), a high prevalence of tobacco pigmentation ( P < .001), and a higher recurrence rate without or after surgery than the nonsmoking group (57% vs 22%, P = .001 and 8.9% vs 1.7%, P = .02, respectively). Patients with extensive respiratory bronchiolitis had significantly higher nonoperative and postoperative recurrences than patients with nonextensive respiratory bronchiolitis ( P = .004 and P < .001, respectively). Conclusion Cigarette smoking is associated with the pathophysiologic consequences of extensive respiratory bronchiolitis, which had a significant impact on the recurrence rates of primary spontaneous pneumothorax.
Abstract Background Uncovering the correct diagnosis of chronic hypokalemia with potassium (K+ ) wasting from the kidneys or gut can be fraught with challenges. We identified clinical and laboratory ...parameters helpful for differentiating the causes of chronic hypokalemia. Methods Normotensive patients referred to our tertiary academic medical center for the evaluation of chronic hypokalemia were prospectively enrolled over 5 years. Clinical features, laboratory examinations—including blood and spot urine electrolytes, acid-base status, biochemistries, and hormones—as well as genetic analysis, were determined. Results Ninety-nine patients with chronic normotensive hypokalemia (serum K+ 2.8 ± 0.4 mmol/L, duration 4.1 ± 0.9 years) were enrolled. Neuromuscular symptoms were the most common complaints. Although Gitelman syndrome (n = 33), Bartter syndrome (n = 10), and distal renal tubular acidosis (n = 12) were the predominant renal tubular disorders, 44 patients (44%) were diagnosed with anorexia/bulimia nervosa (n = 21), surreptitious use of laxatives (n = 11), or diuretics (n = 12). Patients with gastrointestinal causes and surreptitious diuretics use exhibited a female predominance, lower body mass index, and less K+ supplementation. High urine K+ excretion (transtubular potassium gradient >3, urine K+ /Cr >2 mmol/mmol) was universally present in patients with renal tubular disorders, but also found in >50% patients with gastrointestinal causes. Of interest, while urine sodium (Na+ ) and chloride (Cl− ) excretions were high and coupled (urine Na+ /Cl− ratio ∼1) in renal tubular disorders and “on” diuretics use, skewed or uncoupled urine Na+ and Cl− excretions were found in anorexia/bulimia nervosa and laxatives abuse (urine Na+ /Cl− ratio: 5.0 ± 2.2, 0.4 ± 0.2, respectively) and low urine Na+ and Cl− excretions with fixed Na+ /Cl− ratios (0.9 ± 0.2) when “off” diuretics. Conclusion Besides body mass index, sex, and blood acid-base status, integrated interpretation of the urine Na+ :Cl− excretion and their ratio is important to make an accurate diagnosis and treatment plan for patients with chronic normotensive hypokalemia.
Abstract Introduction The prognostic significance of the new classification of lung adenocarcinoma proposed by the 2015 World Health Organization (WHO) has been validated. This study aimed to compare ...the preoperative classification of the adenocarcinoma subtype based on the computed tomography-guided 18-gauge core needle biopsy (CTNB) or radial probe endobronchial ultrasound (R-EBUS) specimens, with the postoperative classification based on the resected specimens. Methods We retrospectively analyzed a consecutive series of 128 patients (60 CTNB and 68 R-EBUS) who underwent surgery for preoperatively confirmed lung adenocarcinoma during 2010–2014. Comprehensive histologic subtyping was performed according to the 2015 WHO classification. Diagnostic concordance of subtypes between small biopsy and resection specimens was assessed. Results Concordant subtyping of adenocarcinoma between the predominant pattern on resection and biopsy section was observed in 58.6% (75/128; 95% CI, 49.9-66.8%) cases. Preoperative subtyping was accurate in only 30% (3/10) of samples with a predominance of solid patterns. None of the five micropapillary predominant cases was detected by CTNB or R-EBUS. For the concordance of the presence or absence of micropapillary/solid component, the sensitivity was as low as 16.5% (95% CI, 9.1-26.5). The detection rate by CTNB/R-EBUS increased with the increase in the percentage of the micropapillary/solid component. However, even in the ≥40% micropapillary/solid group, only 24% of cases were detected by CTNB/R-EBUS. Conclusions The accurate estimation of adenocarcinoma histologic subtype based on preoperative biopsy sections was not satisfactory.
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