Clinical features of community-acquired <Emphasis Type="Italic">Pseudomonas aeruginosa</Emphasis> urinary tract infections in children

This retrospective chart review sought to determine clinical, radiological, and gender-associated characteristics of community-acquired Pseudomonas aeruginosa (PA) urinary tract infections (UTIs) among children admitted to two medical centers. The records of 73 children with community-acquired PA UTIs were compared with records of 109 children with community-acquired UTIs caused by other pathogens. The mean age of both groups was similar. The PA UTI group included more boys. Features significantly more common in the PA UTI group were the number of patients who had undergone urinary tract surgery, patients with skeletal and/or neurological malformation, patients with >1 previous episode of UTI, patients on prophylactic antibiotic treatment on admission, and patients with pathological renal ultrasound and voiding cystourethrography (VCUG) findings. Multivariate logistic regression analysis revealed the following to be associated with PA UTI: >1 episode of UTI in the past [odds ratio (OR) = 35.5; 95% confidence interval (CI) 11.6–108.7], previous urinary tract surgery (OR = 34.1; 95% CI 7.00–166.2), and pathological VCUG results (OR = 2.62; 95% CI 0.96–7.15). In conclusion, PA UTI is associated with >1 previous UTI, urinary tract abnormalities, and past urinary tract surgery. We recommend that when UTI is suspected in children with these risk factors, a thorough radiologic investigation, including a VCUG, should be considered. Drs. Goldman and Rosenfeld-Yehoshua contributed equally to this work.     

Urinary transforming growth factor beta-1 as a marker of renal dysfunction in sickle cell disease

Renal dysfunction affects 5–18% of patients with sickle cell disease (SCD). To date, no studies have described urinary levels of transforming growth factor β-1 (TGF-β1), a marker of fibrosis, and neutrophil gelatinase-associated lipocalin (NGAL), a marker of acute/chronic kidney disease, as biomarkers in identifying patients at risk of developing renal disease in SCD. We hypothesized that SCD subjects will have increased urinary excretion of TGF-β1 and NGAL compared with healthy controls (CTR). We examined 51 SCD subjects: 42 HbSS, 8 HbSC, and 1 HbSD. Sixteen out of 42 patients with HbSS were on hydroxyurea (HU). Urinary excretion of TGF-β1 was 26.4 ± 1.5 pg/mgCr in SCD subjects vs 15.0 ± 2.4 pg/mgCr in CTR (p < 0.00001). SCD patients with hemoglobin < 9 g/dl had higher urinary TGF-β1 than patients with milder anemia (p = 0.002). Urinary TGF-β1 trended lower in HbSS patients treated with HU (23.61 ± 2.6 pg/mgCr), vs patients not on HU (27.69 ± 1.8 pg/mgCr; p = 0.055). There was no correlation between urinary TGF-β1 and microalbuminuria or estimated glomerular function. There was no difference in urinary NGAL in SCD patients vs CTR. We suggest that urinary TGF-β1 may serve as a marker of early renal injury in SCD.     

Transient urethral obstruction predisposes to ascending pyelonephritis and tubulo-interstitial disease: studies in rats

Chronic tubulo-interstitial disease, an important cause of end-stage renal disease, often results from the combined effects of a disturbed urinary outflow tract and urinary tract infection. Acute unilateral ureteral obstruction in rats rapidly induces foci of medullary necrosis, confined to the region of the papilla and fornices. This injury may provide a nidus for bacterial invasion and may invoke reactive and regenerative changes, ultimately leading to chronic pyelonephritis and tubulo-interstitial nephropathy. To explore this possibility, adult rats underwent renal morphological evaluation 2–7 days following transient 24-h unilateral ureteral obstruction. In some experiments the bladder was inoculated with bacteria (10⁸–10⁹ cfu/ml Escherichia coli in 0.5 ml) after release of ureteral obstruction, with subsequent cultures obtained from the pelvis of both kidneys and from the urinary bladder. Morphologic evaluation of perfusion-fixed kidneys, 2–7 days after the release of 24-h ureteral obstruction disclosed papillary necrosis, urothelial proliferation, marked inner-stripe interstitial expansion, and fibrosis and proximal tubular (S₃) dilatation. The lateral (perihilar region) was predominantly affected, with lesions spreading from the fornices. There was some progression of interstitial fibrosis during the postobstructive time course or following more prolonged ureteral obstruction. By contrast, infection hardly contributed to the tubulointerstitial changes. In rats subjected to infection, cultures were positive in all 15 postobstructive kidneys, as opposed to five contralateral kidneys (P < 0.0001). Viable counts from the postobstructive kidney were also higher than those from the contralateral side (79,000 ± 12,000 vs 2900 ± 1600 cfu/ml, mean ± SEM, P < 0.0001), and were comparable to those obtained from the bladder (77,000 ± 13,000 cfu/ml). We conclude that transient ureteral obstruction predisposes to ascending pyelonephritis and to tubulointerstitial disease. This vulnerability may relate to altered urodynamics and medullary tissue destruction. Received: 28 December 1999 / Accepted: 28 September 2000     

Procalcitonin as a predictor of renal scarring in infants and young children

The aim of this study was to evaluate the usefulness of procalcitonin (PCT) as a marker of renal scars in infants and young children with a first episode of acute pyelonephritis. Children aged 7 days to 36 months admitted for first febrile urinary tract infection (UTI) to a pediatric emergency department were prospectively enrolled. The PCT concentration was determined at admission. Acute ^99mTc-dimercaptosuccinic acid (DMSA) scintigraphy was performed within 7 days of admission and repeated 12 months later when abnormal findings were obtained on the first scan. Of the 72 children enrolled in the study, 52 showed signs of acute pyelonephritis (APN) on the first DMSA scan. A follow-up scintigraphy at the 12-month follow-up performed on 41 patients revealed that 14 (34%) patients had developed renal scars; these patients also presented significantly higher PCT values than those without permanent renal lesions [2.3 (interquartile range 1–11.6) vs. 0.5 (0.2–1.4) ng/mL; p = 0.007]. A comparison of the PCT concentration in patients with febrile UTI without renal involvement, with APN without scar development and with APN with subsequent renal scarring revealed a significant increasing trend (p = 0.006, Kruskal–Wallis test). The area under the ROC curve for scar prediction was 0.74 (95% confidence interval 0.61–0.85), with an optimum statistical cut-off value of 1 ng/mL (sensitivity 78.6%; specificity 63.8%). Based on these results, we suggest that serum PCT concentration at admission is a useful predictive tool of renal scarring in infants and young children with acute pyelonephritis.     

Vitamin D insufficiency and effect of cholecalciferol in children with chronic kidney disease

Vitamin D insufficiency is common in patients with chronic kidney disease (CKD) and may contribute to mineral bone disease. In a prospective interventional study, we estimated the prevalence of vitamin D insufficiency (serum 25-hydroxyvitamin D3 [25OHD] < 30 ng/ml), and examined the effect of high-dose (600,000 IU) cholecalciferol supplementation after 6 weeks on serum 25OHD and parathyroid hormone (PTH) levels in children with CKD stages 2–4. Forty-two children (86% boys) with a mean age of 7.7 ± 3.8 (range 2-–5) years were studied. Thirty-seven children (82.1%) had vitamin D insufficiency; 18 (42.8%) had 25OHD < 16 ng/ml. The median 25OHD increased significantly from 16.7 (95% CI 11.3, 19.8) to 46.2 (34.5, 44.6) ng/ml in patients with vitamin D insufficiency (P <0.001). The median PTH decreased significantly from 51.3 (95% CI 46.7, 71.5) to 37.1 (29.0, 54.6) pg/ml (P = 0.003). Nineteen patients (47.5%) had >30% reduction in the PTH after supplementation. Serum calcium, phosphorus, and estimated GFR did not change significantly. We conclude that vitamin D insufficiency is highly prevalent in children with CKD stages 2–4. High-dose cholecalciferol is safe and effective in correcting vitamin D insufficiency and results in a significant reduction in PTH levels in vitamin D-insufficient children.     

Urine IL-8 concentrations in infectious and non-infectious urinary tract conditions

Urine IL-8 concentrations are known to be elevated in urinary tract infection (UTI), as well as in vesicoureteral reflux (VUR) even in the absence of infection. In this study we further investigated urine IL-8 in infants with congenital anomalies of the kidneys and urinary tract and with antenatally diagnosed isolated pelvic dilatation. Urine IL-8 was measured in 159 infants aged 1 month to 1 year with acute UTI (group A, n = 26), resolved UTI (group B, n = 16), VUR without recent UTI (group C, n = 44), non-VUR congenital urinary anomalies without recent UTI (group D, n = 30), isolated antenatal pelvic dilatation (group E, n = 14) and in infants without known urinary tract condition (control group F, n = 29). Median values of urine IL-8/creatinine levels were 61.5, 4.64, 15.5, 14.3, 1.06 and 4.19 pg/μmol in groups A, B, C, D, E and F respectively. Compared with the control group, urine IL-8 was elevated in infants with acute UTI, VUR without acute UTI and congenital anomalies without acute UTI (p < 0.0001; p < 0.005; and p = 0.027 respectively), but not in infants with resolved UTI or with antenatal pelvic dilatation. Urine IL-8 levels are elevated in a variety of infectious and non-infectious urinary tract conditions, and hence may serve as a sensitive but not specific screening biomarker of urinary tract diseases.     

Planned cesarean section versus planned vaginal delivery: comparison of lower urinary tract symptoms

We compared the prevalence and risk of lower urinary tract symptoms in healthy primiparous women in relation to vaginal birth or elective cesarean section 9 months after delivery. We performed a prospective controlled cohort study including 220 women delivered by elective cesarean section and 215 by vaginal birth. All subjects received an identical questionnaire on lower urinary tract symptoms in late pregnancy, at 3 and 9 months postpartum. Two hundred twenty subjects underwent elective cesarean section, and 215 subjects underwent vaginal delivery. After childbirth, the 3-month questionnaire was completed by 389/435 subjects (89%) and the 9-month questionnaire by 376/435 subjects (86%). In the vaginal delivery cohort, all lower urinary tract symptoms increased significantly at 9 months follow-up. When compared to cesarean section, the prevalence of stress urinary incontinence (SUI) after vaginal delivery was significantly increased both at 3 (p < 0.001) and 9 months (p = 0.001) follow-up. In a multivariable risk model, vaginal delivery was the only obstetrical predictor for SUI [relative risk (RR) 8.9, 95% confidence interval (CI) 1.9–42] and for urinary urgency (RR 7.3 95% CI 1.7–32) at 9 months follow-up. A history of SUI before pregnancy (OR 5.2, 95% CI 1.5–19) and at 3 months follow-up (OR 3.9, 95% CI 1.7–8.5) were independent predictors for SUI at 9 months follow-up. Vaginal delivery is associated with an increased risk for lower urinary tract symptoms 9 months after childbirth when compared to elective cesarean section.     

The Prevalence of Urinary Tract Infections in Patients with Gestational Diabetes Mellitus

Microbiologic evidence of urinary tract infection was studied in 447 pregnant women with (n= 149) or without (control group, n= 298) gestational diabetes mellitus after mid-pregnancy. Laboratory investigations included chemical analysis, microscopic examination and culture of a clean midstream voided urine specimen. Nineteen women (4.2%) had asymptomatic bacteriuria (7 study, 12 contorl, P = 0.7). Of these, 7 (38%) developed symptomatic infection despite treatment with antibiotics (2 study, 5 control, P = 0.7) and 6 (31%) had recurrent bacteriuria later in pregnancy (3 study, 3 control, P = 0.3). Twelve more women (2.6%) had symptomatic infection (5 study, 7 control, P = 0.5), 7 had acute cystitis (3 study, 4 control, P = 0.5) and 5 had acute pyelonephritis (2 study, 3 control, P = 0.7). Escherichia coli was the commonest pathogen, accounting for 22 (71%) infection episodes. Gestational diabetes mellitus was not associated with increased risk of urinary tract infections nor of maternal and perinatal morbidity as a result of infection.     

Randomized cross-over trial comparing albumin and frusemide infusions in nephrotic syndrome

The contribution of hypoalbuminemia to impaired diuretic responsiveness can be overcome by administering larger doses of loop diuretics. However, the clinical efficacy of the combination of loop-acting diuretics with human albumin remains controversial. In the study reported here, 16 children with nephrotic syndrome and refractory edema were randomized in a cross-over trial to receive either the combination of 20% human albumin and frusemide infusion (HA+FU infusion group) or frusemide infusion alone (FU infusion group). At the end of study, median urine volume was 3.27 [95% confidence interval (CI) 2.04–4.50] ml/kg per hour in the HA+FU infusion group and 1.33 (95% CI 0.79–1.88) ml/kg per hour in the FU infusion group (P = 0.01); the median daily sodium excretion was 58 (95% CI 30–366) mEq and 30 (95% CI 10–122) mEq (P = 0.08), respectively The changes in other variables included weight loss [HA+FU 5.2% (95% CI 3.1–8.8); FU 0.8% (95% CI −1.9 to 4.1); P = 0.006]; urine osmolality [HA+FU 315 (95% CI 220–426) mOsm/kg; FU 368 (95% CI 318–446) mOsm/kg; P = 0.13]; osmolal clearance [HA+FU 1600 (95% CI 916–4140) ml/day; FU 880 (95% CI 510–2105) ml/day; P = 0.01; free water clearance [HA+FU −190 (95% CI −960 to 280) ml/day; FU −162 (95% CI −446 to −70) ml/day; P = 0.18]. The findings from this study suggest that the co-administration of albumin and frusemide infusions is more effective than the administration of frusemide infusion alone in inducing diuresis and natriuresis in patients with nephrotic syndrome.     

Urinary interleukin-6 and interleukin-8 in children with urinary tract infection

Urinary interleukin-6 (UIL-6) and urinary interleukin-8 (UIL-8) concentrations were measured by immunoassay in 39 and 34 patients respectively, hospitalized with febrile urinary tract infection (UTI), and in 37 and 32 age-, race- and sex-matched febrile control children respectively, with negative urine cultures. UIL-6 and UIL-8 concentrations, measured in picograms per milliliter and corrected for creatinine, were compared with clinical and laboratory indicators of inflammation and bacterial virulence factors of Escherichia coli. Median UIL-6 concentrations at the time of admission were 397 pg/ml (range 0–65,789 pg/ml) in the 37 patients compared to 0 pg/ml (range 0–473.8 pg/ml) in the 37 controls (P<0.0001). Median UIL-8 concentrations at the time of admission were 5809 pg/ml (range 0–347,368 pg/ml) in the 32 patients compared to 0 pg/ml (range 0–2231 pg/ml) in the 32 controls (P<0.0001). UIL-6 and UIL-8 concentrations were lower (P<0.0001 for UIL-6 and P=0.0005 for UIL-8) in follow-up urine samples from UTI patients, obtained 48 h after the initiation of antibiotic therapy. UIL-6 and UIL-8 concentrations were statistically significantly correlated with urine white blood cells (WBC). UIL-8 concentrations were elevated in patients with E. coli organisms producing hemolysin. UIL-6 and UIL-8 are elevated in children with febrile UTI and decrease in response to antibiotic therapy. Magnitude of UIL-8 response is associated with hemolysin production, a bacterial virulence factor of E. coli. UIL-6 and UIL-8 concentrations are statistically correlated with urine WBC. UIL-6 and UIL-8 may be mediators of inflammation in children with febrile UTI. Received: 30 June 1999 / Revised: 29 June 2000 / Accepted: 5 July 2000     

Transurethral microwave thermotherapy for treatment of benign prostatic hyperplasia: results obtained with the Prostalund device

The 6-month results of treatment with transurethral microwave thermotherapy (Prostalund) of 28 patients with lower urinary tract symptoms (LUTS) due to benign hyperplasia of the prostate are reported. The median International Prostate Symptom Score (I-PSS) fell from 16.5 (range 9–33) to 10.5 (range 3–30; P < 0.00005). Quality-of-life assessment improved from a median value of 4 (range 2–6) to 2 (range 1–5; P = 0.0001). In the Danish Prostate Symptom Score (DAN-PSS) the median total score fell from 20 (range 5–55) to 5 (range 0–43; P = 0.001). The median peak urinary flow increased from 10.6 to 11.5 ml/s (P = 0.20). Pressure-flow studies revealed no decrease in the median detrusor pressure at peak uroflow (Pdet_Qmax) from 56 cmH₂O preoperatively to 56 cmH₂O after 6 months (P = 0.36). No change was found in postvoid residual urinary volume or in the calculated prostate volume. Complications included hematuria in most patients, urinary tract infections in 6 (21.4%) patients, and transient retention in 3 (10.7%) patients. In all, 20 (71.4%) patients responded to treatment with good symptomatic relief, but only minor changes were observed in urodynamic parameters.     

Effects of treatment with fluoride on bone mineral density and fracture risk - a meta-analysis

Summary Fluoride has fallen into discredit due to the absence of an anti-fracture effect. However, in this meta-analysis, a fracture reducing potential was seen at low fluoride doses [≤20 mg fluoride equivalents (152 mg monofluorophosphate/44 mg sodium fluoride)]: OR = 0.3, 95% CI: 0.1–0.9 for vertebral and OR = 0.5, 95% CI: 0.3–0.8 for non-vertebral fractures. Introduction Fluoride is incorporated into bone mineral and has an anabolic effect. However, the biomechanical competence of the newly formed bone may be reduced. Methods A systematic search of PubMed, Embase, and ISI web of science yielded 2,028 references. Results Twenty-five eligible studies were identified. Spine BMD increased 7.9%, 95% CI: 5.4–10.5%, and hip BMD 2.1%, 95% CI: 0.9–3.4%. A meta-regression showed increasing spine BMD with increasing treatment duration (5.04 ± 2.16%/year of treatment). Overall there was no significant effect on the risk of vertebral (OR = 0.8, 95% CI: 0.5–1.5) or non-vertebral fracture (OR = 0.8, 95% CI: 0.5–1.4). With a daily dose of ≤20 mg fluoride equivalents (152 mg monofluorophosphate/44 mg sodium fluoride), there was a statistically significant reduction in vertebral (OR = 0.3, 95% CI: 0.1–0.9) and non-vertebral (OR = 0.5, 95% CI: 0.3–0.8) fracture risk. With a daily dose >20 mg fluoride equivalents, there was no significant reduction in vertebral (OR = 1.3, 95% CI: 0.8–2.0) and non-vertebral (OR = 1.5, 95% CI: 0.8–2.8) fracture risk. Conclusions Fluoride treatment increases spine and hip BMD, depending on treatment duration. Overall there was no effect on hip or spine fracture risk. However, in subgroup analyses a low fluoride dose (≤20 mg/day of fluoride equivalents) was associated with a significant reduction in fracture risk.     

Urinary levels of TGF β-1 and of cytokines in patients with prenatally detected nephrouropathies

This study aimed to identify noninvasive biomarkers of clinically significant nephrouropathies in patients with antenatal renal and/or urinary tract alterations. Spot-urine levels of interleukin-6 (IL-6), transforming growth factor-β1 (TGF-β1) and tumor necrosis factor-α (TNF-α) were measured in 100 patients with antenatal detected nephrouropathies. Patients were divided in idiopathic hydronephrosis (n = 47), urinary tract malformations (n = 35), and dysplastic kidneys (n = 18). Urinary concentrations of TGF-β1, IL-6, and TNF-α were compared between groups according to clinical and image findings. Receiver-operating characteristic (ROC) curves were analyzed for the overall diagnostic accuracy of TGF-β1, IL-6, and TNF-α levels in discriminating infants with nephrouropathies. No significant differences in urinary TGF- β1, IL-6, and TNF-α levels were found in the comparison between the groups. TGF-β1 levels tended to be higher in patients with renal hypodysplasia compared to idiopathic hydronephrosis (p = 0.07). Twenty-nine patients had reduced DMSA uptake. In these cases, absolute urinary concentration of TGF-β1 and levels standardized for creatinine were significantly higher than in patients with normal DMSA uptake, while IL6 and TNF-α did not differ between groups. Urinary cytokine measurements were not useful as a screening test for clinically significant nephrouropathies. Conversely, increased concentrations of TGF-β1 pointed out to renal damage as indicated by reduced DMSA uptake.     

Enteral versus Parenteral Nutrition after Gastrointestinal Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials in the English Literature

Background Although previous studies recommend the use of enteral nutrition (EN), the benefit of EN after elective gastrointestinal surgery has not been comprehensively demonstrated as through a meta-analysis. Our aim is to determine whether enteral nutrition is more beneficial than parenteral nutrition. Methods A search was conducted on Medline, Web of Science, the Cochrane Library electronic databases, and bibliographic reviews. The trials were based on randomization, gastrointestinal surgery, and the reporting of at least one of the following end points: any complication, any infectious complication, mortality, wound infection and dehiscence, anastomotic leak, intraabdominal abscess, pneumonia, respiratory failure, urinary tract infection, renal failure, any adverse effect, and duration of hospital stay. Results Twenty-nine trials, which included 2,552 patients, met the criteria. EN was beneficial in the reduction of any complication (relative risk (RR), 0.85; 95% confidence interval (CI), 0.74–0.99; P = 0.04), any infectious complication (RR, 0.69; 95% CI, 0.56–0.86; P = 0.001), anastomotic leak (RR, 0.67; 95% CI, 0.47–0.95; P = 0.03), intraabdominal abscess (RR, 0.63; 95% CI, 0.41–0.95; P = 0.03), and duration of hospital stay (weighted mean difference, −0.81; 95% CI, −1.25–0.38; P = 0.02). There were no clear benefits in any of the other complications. Conclusion The present findings would lead us to recommend the use of EN rather than PN when possible and indicated. The preliminary report of this work was presented in the poster session of the 46th Annual Meeting of the Society for Surgery of the Alimentary Tract at the Digestive Disease Week in Chicago on May 2005. There are no sources of support, including grants, fellowships, and gifts of materials.     

Transient type 1 pseudo-hypoaldosteronism: report on an eight-patient series and literature review

Eight boys aged 2–12 weeks with urinary tract malformations (UTMs) exhibited features of transient type 1 pseudo-hypoaldosteronism (TPHA1) in the course of urinary tract infection (UTI). Hyponatremia (120.9 ± 5.8 mmol/l), hyperkalemia (6.9 ± 0.9 mmol/l), metabolic acidosis (plasma bicarbonate 11 ± 1.4 mmol/l), and a rise in serum creatinine levels (145 ± 101 μmol/l) were associated with high urinary sodium (Na) and low potassium (K) excretion. Tubular resistance to aldosterone was indicated by high plasma aldosterone concentrations (170.4 ± 100.5 ng/dl), high levels of the plasma aldosterone to potassium ratio (25.2 ± 15.6), and diminished urinary K/Na values (0.31 ± 0.19). With appropriate therapy, serum electrolytes, creatinine, and acid–base balance normalized within 2 weeks. A Medline search revealed another 85 cases of TPHA1 reported to date. All of the 93 patients were less than 7 months of age and 90% were less than 3 months of age, 90.3% suffered from UTM, with associated UTI in 89% of them, 11% had UTM in the absence of UTI, and 9.7% showed isolated UTI. These findings indicate that early infancy is the main contributing factor for TPHA1 to occur and that UTI and UTM are additional factors, with at least one being required for its development.     

Diagnostic significance of clinical and laboratory findings to localize site of urinary infection

The aim of this study was to define in children younger than 2 years of age the diagnostic significance of clinical and laboratory findings to localize site of febrile urinary tract infection. We reviewed the records of 185 children younger than 2 years of age admitted to hospital with febrile urinary tract infection. Patients were divided into having either acute pyelonephritis or acute cystitis according to the presence or absence of acute lesions on dimercaptosuccinic acid (DMSA) renal scintigraphy. Clinical and laboratory [white blood cell count (WBC), urinalysis, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP)] findings were compared between the two groups using Student’s t test, chi-square test, and multivariate analysis. Patients with pyelonephritis had statistically significant higher age, WBC, ESR, and CRP than those with cystitis. Although the sensitivity of the tests was 80–100%, their specificity was <28%. On multivariate analysis, 33% of patients with cystitis were diagnosed as having pyelonephritis, whereas 22% of those with pyelonephritis were considered to have cystitis. Given the low specificity of clinical findings and available laboratory tests to define the site of urine infection in this age group, we recommend DMSA renal scintigram as the test of choice to make the diagnosis of acute pyelonephritis in these patients.     

Clinical risk factors for osteoporotic fractures in Brazilian women and men: the Brazilian Osteoporosis Study (BRAZOS)

Summary  The Brazilian Osteoporosis Study (BRAZOS) is the first epidemiological study carried out in a representative sample of Brazilian men and women aged 40 years or older. The prevalence of fragility fractures is about 15.1% in the women and 12.8% in the men. Moreover, advanced age, sedentarism, family history of hip fracture, current smoking, recurrent falls, diabetes mellitus and poor quality of life are the main clinical risk factors associated with fragility fractures. Introduction  The Brazilian Osteoporosis Study (BRAZOS) is the first epidemiological study carried out in a representative sample of Brazilian men and women aged 40 years or older with the purpose of identifying the prevalence and the main clinical risk factors (CRF) associated with osteoporotic fracture in our population. Methods  A total of 2,420 individuals (women, 70%) from 150 different cities in the five geographic regions in Brazil, and all different socio-economical classes were selected to participate in the present survey. Anthropometrical data as well as life habits, fracture history, food intake, physical activity, falls and quality of life were determined by individual quantitative interviews. The representative sampling was based on Brazilian National data provided by the 2000 and 2003 census. Low trauma fracture was defined as that resulting of a fall from standing height or less in individuals 50 years or older at specific skeletal sites: forearm, femur, ribs, vertebra and humerus. Sampling error was 2.2% with 95% confidence intervals. Logistic regression analysis models were designed having the fragility fracture as the dependent variable and all other parameters as the independent variable. Significance level was set as p < 0.05. Results  The average of age, height and weight for men and women were 58.4 ± 12.8 and 60.1 ± 13.7 years, 1.67 ± 0.08 and 1.56 ± 0.07 m and 73.3 ± 14.7 and 64.7 ± 13.7 kg, respectively. About 15.1% of the women and 12.8% of the men reported fragility fractures. In the women, the main CRF associated with fractures were advanced age (OR = 1.6; 95% CI 1.06–2.4), family history of hip fracture (OR = 1.7; 95% CI 1.1–2.8), early menopause (OR = 1.7; 95% CI 1.02–2.9), sedentary lifestyle (OR = 1.6; 95% CI 1.02–2.7), poor quality of life (OR = 1.9; 95% CI 1.2–2.9), higher intake of phosphorus (OR = 1.9; 95% CI 1.2–2.9), diabetes mellitus (OR = 2.8; 95% CI 1.01–8.2), use of benzodiazepine drugs (OR = 2.0; 95% CI 1.1–3.6) and recurrent falls (OR = 2.4; 95% CI 1.2–5.0). In the men, the main CRF were poor quality of life (OR = 3.2; 95% CI 1.7–6.1), current smoking (OR = 3.5; 95% CI 1.28–9.77), diabetes mellitus (OR = 4.2; 95% CI 1.27–13.7) and sedentary lifestyle (OR = 6.3; 95% CI 1.1–36.1). Conclusion  Our findings suggest that CRF may contribute as an important tool to identify men and women with higher risk of osteoporotic fractures and that interventions aiming at specific risk factors (quit smoking, regular physical activity, prevention of falls) may help to manage patients to reduce their risk of fracture.     

Risk factor stratification after simultaneous liver and colorectal resection for synchronous colorectal metastasis

Background/aim This study was conducted to devise a prognostic model for patients undergoing simultaneous liver and colorectal resection. Materials and methods A retrospective analysis was performed on 138 colorectal patients who underwent simultaneous liver and colorectal resection between September 1994 and September 2005. The primary endpoint of the study was overall survival. Three patients with positive liver resection margin were excluded from the analysis. Results At multivariate level, poor prognostic factors were liver resection margin ≤5 mm (P = 0.047; relative risk, 1.684; 95% CI = 1.010–2.809), CEA greater than 5 ng/ml (P = <0.001; relative risk, 2.507; 95% CI = 1.499–4.194), number of liver metastasis > 1 (P = <0.042; relative risk, 1.687; 95% CI = 1.020–2.789), and lymph node ≥ 4 (P = <0.012; relative risk, 1.968; 95% CI = 1.158–3.347). The risk stratification grouping of the 135 patients was performed according to the following criteria: low risk group, 0–1 factor; intermediate risk group, 2 factors; high-risk group, 3–4 factors. Of 135 patients, 86 patients (63.0%) were categorized as low-risk group, 36 patients (26.6%) as intermediate risk group, and 14 patients (10.4%) as high-risk group. Median survival times for low, intermediate, high-risk groups were 68.0, 43.6 (95% CI, 24.7–62.4), and 23.5 months (95% CI, 9.4–31.5), respectively. The high-risk group demonstrated an approximately threefold (relative risk, 3.1; 95% CI, 1.6–6.0) increased risk of death. Conclusions A simple risk factor stratification system was proposed to evaluate the chances of cure of patients after simultaneous resection of liver metastases and primary colorectal carcinoma. The risk factor stratification showed three groups with distinct survival. The risk stratification may help to predict patient survival after simultaneous liver and colorectal resection. This system needs further prospective validation.     

Co-morbidity is a Strong Predictor of Early Death and Multi-organ System Failure among Patients with Acute Pancreatitis

A small but significant percentage of patients with acute pancreatitis die within 2 weeks of hospitalization, usually with multiorgan system failure. To determine the effect of chronic medical comorbidities on early death, we conducted a retrospective analysis of all patients who were hospitalized in California with first-time pancreatitis between 1992 and 2002. Among 84,713 patients, 1514 (1.8%) died within 2 weeks. In a risk-adjusted multivariate model, the strongest predictors of early death were age 65 to 75 years (OR = 2.6, 95% CI: 2.2–3.1 versus <55 years), age over 75 years (OR = 5.2, 95% CI: 4.4–6.1), and the presence of either two chronic comorbid conditions (OR = 3.5, CI: 2.7–4.6) or three or more comorbidities (OR = 7.4, 95% CI: 5.7–9.5). Among the 14,280 patients younger than 55 years who had no chronic comorbid conditions, only 14 (0.1%) died in the first 14 days compared to 701 (5.9%) of 24,852 patients 64 years or older who had three or more comorbidities (RR = 29, 95% CI: 17–50). Comorbid conditions associated with early death included recent cancer, heart failure, renal disease, and liver disease. We conclude that advancing age and the number of chronic comorbid conditions are very strong predictors of early death among patients with acute pancreatitis. This study was supported by the Hibbard E. Williams endowment at UC Davis.     

Acute kidney injury is independently associated with mortality in very low birthweight infants: a matched case–control analysis

The independent impact of acute kidney injury (AKI) on survival in very low birthweight (VLBW; ≤1,500 g) critically ill infants has not been studied. Cases (non-survivors n = 68) were matched to, at most, two controls (survivors n = 127) by incidence density sampling with replacement, birthweight (± 50 g), gestational age (± 1 week), and availability of serum creatinine (SCr) levels before the index patient’s time of death. Maternal/infant demographic characteristics, co-morbidities, complications and interventions were explored. No difference existed between patients and controls in mean gestational age and birthweight (the matching variables), race, or gender. Compared with the controls, cases had younger mothers, less placental separation, fewer occurrences of hyponatremia, more intra-ventricular hemorrhage, and received chest compressions and cardiac drugs. A 1 mg/dl increase in SCr was associated with almost two-times higher odds of death [odds ratio (OR) = 1.94, 95% confidence interval (95% CI) 1.13–3.32]. OR increased when confounding variables were adjusted (adjusted OR 3.44, 95% CI 1.23–9.61). Similarly, a 100% increase in SCr from trough level was associated with an increased OR = 1.53 (95% CI 1.14–2.04) and became stronger, after adjustment of variables (adjusted OR = 1.90, 95% CI 1.10–3.27). After confounding variables had been controlled for, AKI was independently associated with mortality in VLBW infants. Further prospective multi-center studies are needed to determine whether this association exists.