Continuous venovenous hemofiltration (CVVH) or CVVH with additional diffusive dialysis (CVVH-D) has theoretical advantages in treating severe acute renal failure (ARF), but no prospective clinical ...trials or restrospective comparison studies have clearly shown its superiority over intermittent hemodialysis (HD). To evaluate this question, all 349 adult patients with ARF receiving renal replacement therapy (RRT) at our medical center during 1995 and 1996 were analyzed using multivariate Cox proportional hazards methods. Initial univariate analysis showed the odds of death when receiving initial CVVH to be more than twice those when receiving initial HD (risk for death, 2.03; P < 0.01). Progressive exclusion of patients in whom the RRT modality might not be open to choice and the risk for death was very high (systolic blood pressure < 90 mm Hg; total bilirubin level > 15 mg/dL; or total RRT < 48 hours) for total RRT left 227 patients in whom the risk for death was 1.09 (95% confidence interval CI, 0.67 to 1.80; P = 0.72) for initial CVVH, virtually equivalent to the risk for initial HD. Comorbid indicators significantly associated with death or failure to recover renal function included: older age; medical rather than surgical diagnosis; preexisting infection or trauma and liver disease as primary diagnoses; and abnormal bilirubin level or vital signs at initiation of RRT. These results show that the high crude mortality rate of patients undergoing CVVH was related to severity of illness and not the treatment choice itself. With the addition of more inclusive comorbidity data and a broader spectrum of interim outcomes, this type of analysis is a practical alternative to what would almost assuredly be a cumbersome and costly prospective, controlled trial comparing traditional HD with CVVH.
Background Screening for vascular risk factors is commonly assessed through self-report, despite reports of low sensitivity using this approach in healthy populations. The validity of self-reported ...vascular risk factors in a population at high risk for stroke has yet to be explored. Aims This study investigated the validity of self-reported cardiovascular risk factors (e.g., hypertension, hypercholesterolemia, and type II diabetes mellitus) in a population of patients with a recent history of high-risk transient ischemic attack or minor stroke. Methods Data were extracted from patient questionnaire responses and medical records (n = 101). Agreement between self-report and clinical measures (blood pressure, fasting blood glucose, lipid profile, and active medications) was assessed using estimates of sensitivity, specificity, and positive and negative predictive values for each vascular risk factor. Results Forty-nine percent of the study population inaccurately self-reported at least 1 vascular risk factor. Sensitivities of self-report for hypertension, hypercholesterolemia, and diabetes were 84.5% (confidence interval CI: 72.1-92.2), 57.5% (CI: 44.1-69.7), and 77.8% (CI: 57.3-90.6), respectively, while specificities were 76.7% (CI: 61.0-87.7), 83.3% (CI: 67.3-93.2), and 95.4% (CI: 87.8-98.9), respectively. Accuracy of self-report for hypercholesterolemia was significantly lower than that for diabetes ( P < .001) and hypertension ( P < .05), with 42.6% of those with high cholesterol under-reporting their diagnosis. Logistic regression revealed that odds of accurate self-report were greater among younger adults and males. Conclusions These results highlight the need for clinicians, scientists, and epidemiologists to be cautious when screening for vascular risk factors using self-report measures as cross validation against objectives measures reveals poor sensitivity. Our results also highlight a lack of public education concerning these significant conditions.
Approximately 50% of the mortality in hemodialysis patients is due to cardiovascular disease. Antioxidant vitamins and carotenoids may be protective because oxidation of low-density lipoproteins ...appears to be a necessary prerequisite for the development of atherogenesis, and hemodialysis itself may stimulate the generation of oxygen reactive species. African Americans comprise a substantial proportion of dialysis patients because they have higher rates of hypertension, glomerulonephritis, and diabetic end-stage renal disease than do whites. The purpose of this cross-sectional study was to determine the plasma concentrations of antioxidant vitamins and carotenoids in hemodialysis patients and to investigate whether differences in these concentrations in the major racial or ethnic groups exist. Plasma concentrations of alpha- and gamma-tocopherol, carotenoids, and retinol were measured with HPLC and plasma vitamin C was measured with a spectrophotometric method in 109 white and African American hemodialysis patients. Dietary intakes of selected micronutrients were also compared by using data from a food-frequency questionnaire. Overall, plasma vitamin C and alpha-tocopherol concentrations were comparable but plasma carotenoid concentrations were lower than those reported for other populations. African American patients had significantly higher mean plasma concentrations of retinol (P < 0.04), lutein (P < 0.02), and total carotenoids minus lycopene (P < 0.04); whites had significantly higher mean plasma concentrations of alpha-tocopherol (P < 0.02), independent of age and plasma lipid concentrations. Diabetes comorbidity had an independent negative association with plasma beta-carotene concentration but was not associated with other measures.
The literature indicates that cardiovascular disease (CVD; including stroke), older age, and availability of health care resources affect COVID-19 case fatality rates (CFRs). The cumulative effect of ...COVID-19 CFRs in global CVD populations and the extrapolated effect on access to health care services in the CVD population in Canada are not fully known. In this study we explored the relationships of factors that might affect COVID-19 CFRs and estimated the potential indirect effects of COVID-19 on Canadian health care resources.
Country-level epidemiological data were analyzed to study the correlation, main effect, and interaction between COVID-19 CFRs and: (1) the proportion of the population with CVD; (2) the proportion of the population 65 years of age or older; and (3) the availability of essential health services as defined by the World Health Organization Universal Health Coverage index. For indirect implications on health care resources, estimates of the volume of postponed coronary artery bypass grafting, percutaneous coronary intervention, and valve surgeries in Ontario were calculated.
Positive correlations were found between COVID-19 CFRs and: (1) the proportion of the population with CVD (ρ = 0.40; P = 0.001); (2) the proportion of the population 65 years of age or older (ρ = 0.43; P = 0.0005); and (3) Universal Health Coverage index (ρ = 0.27; P = 0.03). For every 1% increase in the proportion of the population 65 years of age or older or proportion of the population with CVD, the COVID-19 CFR was 9% and 19% higher, respectively. Approximately 1252 procedures would be postponed monthly in Ontario because of current public health measures.
Countries with more prevalent CVD reported higher COVID-19 CFRs. Strain on health care resources is likely in Canada.
La littérature indique que les maladies cardiovasculaires (MCV, incluant les accidents vasculaires cérébraux), l’âge avancé et la facilité d’accès aux ressources de soins de santé ont une incidence sur les taux de létalité (TL) des cas de COVID-19. L’effet cumulatif du TL de la COVID-19 dans l’ensemble de la population atteinte de MCV et l’impact anticipé sur l'accès aux services de santé dans la population atteinte de MCV au Canada ne sont pas entièrement connus. Cette étude a exploré les liens entre les facteurs pouvant influencer le TL des cas de COVID-19 et a estimé le potentiel impact indirect de la COVID-19 sur les ressources de soins de santé au Canada.
Les données épidémiologiques à l’échelle du pays ont été analysées pour étudier la corrélation, l’effet principal et l’interaction entre le TL de laCOVID-19 et : 1) la proportion de la population souffrant de MCV, 2) la proportion de la population ≥ 65 ans, et 3) l’accessibilité des services de santé essentiels tels que définis par l’indice de couverture sanitaire universelle (CSU) de l’Organisation Mondiale de la Santé. Pour les implications indirectes concernant les ressources de santé, des estimations du volume d’opération de pontages coronariens, d'interventions coronariennes percutanées et de chirurgies valvulaires reportées en Ontario ont été calculées.
Des corrélations positives ont été trouvées entre le TL de la COVID-19 et 1) la proportion de la population souffrant de MCV (ρ= 0,40, P = 0,001), 2) la proportion de la population ≥ 65 ans (ρ= 0,43, P = 0,0005), et 3) l’indice CSU (ρ= 0,27, P = 0,03). Pour chaque augmentation de 1 % de la proportion de la population ≥ 65 ans ou de la proportion de la population souffrant de MCV, le TL de la COVID-19 était respectivement supérieur de 9 % et 19 %. Environ 1 252 interventions seraient reportées chaque mois en Ontario en raison des mesures de santé publique actuelles.
Les pays où les MCV sont plus répandues ont signalé un TL de la COVID-19 plus élevé. Il est probable que les ressources de soins de santé soient soumises à de fortes contraintes au Canada.
Background The dose of intravenous tissue plasminogen activator (tPA) administered in acute ischemic stroke patients is calculated using the patient’s weight (0.9 mg/kg). Patients are rarely weighed ...before treatment in actual practice, although overestimating patient weights leads to higher doses of tPA, which may adversely influence outcome. Methods We investigated the weight used to calculate the dose of tPA compared to the actual measured weight in consecutive acute ischemic stroke patients treated over a 4-year period at our center. The rate of intracranial hemorrhage (ICH), discharge modified Rankin Scale (mRS) score, and mortality at 3 months were compared between groups, according to accuracy of the dose of tPA. Results We found that 140 of 164 (85%) acute ischemic stroke patients treated with tPA had a measured weight documented in the chart after treatment. Of these, 13 patients received ≥1.0 mg/kg and 16 patients received ≤0.8 mg/kg, based on a comparison of the weight used for the tPA dose calculation and the subsequent measured weight. Four of 13 (31%) patients treated with ≥1.0 mg/kg of tPA developed ICH. Patients who inadvertently received higher doses of tPA had a lower likelihood of a good functional outcome at discharge (mRS score 0-2; 0% v 34%; P = .009). No difference in 3-month mortality was observed, although patients who were not weighed in hospital had a threefold increase in discharge mortality (21% v 7%; P = .019). Conclusions Our findings provide support for the practice of accurately weighing all acute ischemic stroke patients before thrombolysis.
Access thrombosis remains an enormous problem for patients on hemodialysis. Current evidence suggests that decreasing access blood flow rate is an important predictor of future access thrombosis and ...failure. This article describes a method for determining access volume flow and detecting access pathology. The Doppler ultrasound signal downstream from the arterial needle as a function of the variable hemodialysis blood pump flow rate, is used to determine access blood flow. By using this variable flow (VF) Doppler technique compared with duplex volume flow estimates measured in 18 accesses (16 patients with 12 polytetrafluorethylene PTFE grafts and 6 autogenous fistulas), the results showed a correlation of 0.83 (p < 0.0001) between these methods. In grafts with lower blood flow rates, aberrant flow patterns were observed, including stagnant or reversed flow during diastole while forward flow was maintained during systole. When reversed diastolic flow was severe, it was accompanied by access recirculation. In conclusion, we report the theory and clinical feasibility of determining access blood flow by using a VF Doppler technique. Measurements are made without the need to determine the access cross sectional area required for duplex volume flow calculations and without the need to reverse the lines required for various indicator dilution techniques. Important information is also obtained about aberrant flow patterns in patients at risk of access failure.
Background
The incidence of stroke in young adults is increasing. While many young survivors are able to achieve a good physical recovery, subtle dysfunction in other domains, such as cognition, ...often persists, and could affect return to work. However, reported estimates of return to work and factors affecting vocational outcome post-stroke vary greatly.
Aims
The aims of this systematic review were to determine the frequency of return to work at different time points after stroke and identify predictors of return to work.
Summary of review
Two electronic databases (Medline and Embase) were systematically searched for articles according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A total of 6473 records were screened, 68 were assessed for eligibility, and 29 met all inclusion criteria (working-age adults with stroke, return to work evaluated as an outcome, follow-up duration reported, and publication within the past 20 years). Return to work increased with time, with median frequency increasing from 41% between 0 and 6 months, 53% at 1 year, 56% at 1.5 years to 66% between 2 and 4 years post-stroke. Greater independence in activities of daily living, fewer neurological deficits, and better cognitive ability were the most common predictors of return to work.
Conclusion
This review highlights the need to examine return to work in relation to time from stroke and assess cognition in working age and young stroke survivors. The full range of factors affecting return to work has not yet been explored and further evaluations of return to work interventions are warranted.
The outcomes of pregnancy and subsequent delivery of healthy neonates in women who have undergone previous near total hemispherectomy for Sturge-Weber syndrome (SWS) have rarely been reported.
A ...woman with SWS had two successful and uncomplicated pregnancies and deliveries under epidural anaesthesia after undergoing a near total hemispherectomy with subsequent unilateral cerebral palsy. Non-contrast MRI of the brain revealed post hemispherectomy changes with no residual meningeal angiomatosis.
As more women who undergo surgical resection for underlying SWS grow into the child-bearing years, additional reports of pregnancy and delivery outcomes in this patient population can be expected and will be valuable.
Medical professionals in nephrology are trained to think about improving quality and quantity of life with their patients, but only recently are they being urged to consider ways to improve ...end-of-life care. For many staff, this still feels contradictory. One nephrologist recently told these authors, "I was trained to help people live, not to help them die." The RWJF Promoting Excellence in End-of-Life Care work group has investigated, accumulated, and designed resources to help renal teams improve in this challenging arena. Peer mentoring is one such powerful resource, and, once in operation, is cost free. In conjunction with renal social work and the renal team, peer mentoring is a wonderful program that can decrease anxiety and preserve caring relationships in our burgeoning dialysis communities.
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