Strong relationship between vitamin D status and bone mineral density in anorexia nervosa

BackgroundAnorexia nervosa (AN) is associated with impaired bone health and low bone mineral density (BMD) as a consequence of an inadequate peak bone mass in adolescence and bone loss in young adulthood. The vitamin D status with its implications for bone health in patients affected by AN has only been examined previously in small studies.ObjectiveTo evaluate the prevalence of vitamin D deficiency and test the hypothesis that patients with AN and vitamin D deficiency might have worse bone metabolism and lower bone density as compared with AN with adequate vitamin D repletion.DesignWe analysed the vitamin D status and bone metabolism in a large cohort (n = 89) of untreated patients affected by AN, with amenorrhoea.ResultsVitamin D deficiency is widespread in untreated patients with AN: 16.9% had 25OH vitamin D levels below 12 ng/ml, 36% below 20 ng/ml and 58.4% below 30 ng/ml. PTH values were higher and BMD at both femoral sites were lower in patients with vitamin D < 20 ng/ml. Progressively higher values of BMD were observed by 4 ranks of 25 OH vitamin D values (severe deficiency: < 12 ng/ml, deficiency: ≥ 12 ng/ml and < 20 ng/ml, insufficiency: ≥ 20 and < 30 ng/ml and normal: ≥ 30 ng/ml). In patients with severe vitamin D deficiency BMD at the hip were significantly lower than that measured in groups with values over 20 ng/ml (p < 0.001 for trend). The level of significance did not change for values adjusted for BMI or body weight.ConclusionWe found a strong relationship between vitamin D status and hip BMD values with additional benefits for those with 25OHD levels above 20 ng/ml. Our results support the design of a randomized placebo-controlled clinical trial on the effect of vitamin D on BMD in patients with AN. The second point, whether 25OHD should be above 20 or 30 ng/ml remains a discussion point.     

CT-guided infiltration of greater occipital nerve for refractory craniofacial pain syndromes other than occipital neuralgia

PurposeThe purpose of this study was to evaluate the effectiveness of computed tomography (CT)-guided infiltration of greater occipital nerve (GON) for the treatment of refractory craniofacial pain syndromes other than occipital neuralgia.Materials and methodsFifty-six patients suffering from refractory craniofacial pain syndromes were included between 2011 and 2017. There were 33 women and 23 men with a mean age of 50.7 years ± 13.1 (SD) (range: 27–74 years). CT-guided infiltration was performed at the intermediate site of the GON with local anesthetics and cortivazol. Twenty-six (26/56; 46%) patients suffered from chronic migraine, 14 (14/56; 25%) from trigeminal neuralgia and 16 (16/56; 29%) from cluster headaches. Clinical success at 1, 3, and 6 months was defined by a decrease of at least 50% of pain as assessed using visual analog scale (VAS).ResultsMean overall VAS score before infiltration was 8.7 ± 1.3 (SD) (range: 6 - 10). Mean overall VAS scores after infiltration were 2.3 ± 3 (SD) (range: 0 - 10) (P < 0.01) at one month, 3.5 ± 3.3 (SD) (range: 0 - 10) (P < 0.01) at three months and 7.6 ± 1.3 (SD) (range: 1–10) (P < 0.01) at six months. After infiltration, clinical success was achieved in 44 patients (44/56; 78.5%) at 1 month, 37 patients (37/56; 66%) at 3 months and 13 patients (13/56; 23%) at 6 months. Clinical success according to the clinical presentation were as follows: 88% (23/26) at one month, 73% (19/26) at 3 months, and 23% (6/26) at 6 months in patients with chronic migraine, 81% (13/16), 69% (11/16) and 31% (5/16) in those with cluster headaches and 57% (8/14), 50% (7/14) and 14% (2/14) in those with trigeminal neuralgia. No major complications due to CT-guided GON infiltration were reported in any patient.ConclusionCT-guided infiltration at the intermediate site of the GON appears as an effective treatment of craniofacial pain syndromes especially in patients with chronic migraine and those with cluster headaches.     

Cirugía bariátrica de conversión por fallo de la técnica inicial: 25 años de experiencia en una Unidad especializada de Cirugía de la Obesidad en España

ObjectivesTo evaluate the effectiveness of conversion surgery in a bariatric surgery unit with 25 years of experience.MethodRetrospective observational study of patients with type II obesity or higher who were reoperated by means of conversion surgery due to weight regain, residual body mass index (BMI) >35 kg/m² or < 50% of excess weight loss. The demographic and anthropometric data, comorbidities and perioperative data were analyzed in 5 periods of time: initial, post-surgery1, pre-surgery2, post-surgery2 and current.ResultsA total of 112 patients were included, with a mean age of 40.2 years, who initially underwent vertical banded gastroplasty (VBG) (32.1%), gastric banding (GB) (23.2%), Roux-en-Y gastric bypass (RYGB) (21.4%) and sleeve gastrectomy (SG) (23.2%). The conversion techniques, with a median time between the two surgeries of 70 months, included: RYGB, SG, one-anastomosis gastric bypass (OAGB), shortening of the common loop (SCL) and biliopancreatic diversion (BPD). There was a reduction of the initial weight from 144.2 ± 30.3 to 101.5 ± 21.8 kg after surgery-1; from 115.6 ± 24.0 to 91.5 ± 19.0 kg after surgery-2. The weight at present is 94.7 ± 16.4 kg, with a median follow-up of 27.5 months. Similar results were seen with the BMI. The improvement of comorbidities mainly occurred after the first intervention.ConclusionsConversion surgery causes a weight reduction that does not exceed the loss achieved after the first surgery; however, it does manage to stabilize weight over time. The perioperative morbidity rate is acceptable and would justify its application, despite the limited impact on comorbidities.     

Relationship between vitamin D deficiency and bone fragility in sickle cell disease: A cohort study of 56 adults

BackgroundRecent studies suggest that patients with sickle cell disease (SCD) have profound vitamin D (VD) deficiency. Limited data exist on the effect of VD deficiency on bone fragility in these patients.ObjectivesTo assess the prevalence of VD deficiency in adults with SCD and its consequences on bone metabolism and fragility.MethodsThis prospective study included 56 SCD adult patients (mean age 29.8 ± 9.5 years), in a clinically steady state. Clinical and laboratory data were recorded. Bone mineral density (BMD) was measured using dual X-ray absorptiometry. Fracture history, BMD, avascular osteonecrosis, H-shaped vertebra and markers of mineral metabolism were compared between two groups of patients presenting very low (≤ 6 ng/mL, n = 26) (group 1) and low (> 6 ng/mL, n = 26) (group 2) 25(OH)D concentration, respectively.ResultsMedian 25(OH)D concentration was 6 ng/mL. VD deficiency (25(OH)D < 10 ng/mL) was found in 42 out of 56 patients (75%) and secondary hyperparathyroidism in 40 (71.4%). History of fracture was documented in 17 patients (30.3%), osteopenia and/or osteoporosis in 39.6% of patients. Overall, patients of group 1 were more likely to have sustained a fracture (42.8%) compared to patients of group 2 (17.8%) (p = 0.04). These patients had also lower body mass index and significantly higher parathyroid hormone, C-terminal telopeptides of type I-collagen and bone-specific alkaline phosphatase serum levels. There was no difference between group for BMD, avascular osteonecrosis history, H-shaped vertebra, and disease severity markers.ConclusionThis study suggests that VD deficiency is a key feature in SCD-bone disease. It is highly prevalent and associated with hyperparathyroidism, bone resorption markers, and history of fracture. The optimal supplementation regimen remains to be determined.     

Transient effectiveness of vitamin D2 therapy in pediatric cystic fibrosis patients

BackgroundThe effectiveness of current treatment recommendations for vitamin D insufficiency in children with CF is unknown. Therefore, we assessed the effectiveness of vitamin D₂ 50,000 IU once daily for 28 days for vitamin D insufficiency.MethodsRetrospective chart review of pediatric CF patients from 2006–2008. Vitamin D₂ 50,000 IU daily for 28 days was given to patients with 25-OHD < 30 ng/mL and repeat 25-OHD levels were obtained after completion of therapy.ResultsOne hundred forty-seven levels from 97 individuals were assessed. Success of treatment was 54% (n = 80/147). Seventeen of 39 patients (43%) followed for an additional 6–18 months were able to maintain levels of ≥ 30 ng/mL.ConclusionsVitamin D₂ 50,000 IU daily for 28 days was effective in correcting vitamin D insufficiency in approximately 50% of subjects. However, almost half of successfully treated patients were unable to maintain normal 25-OHD levels > 6 months after completion of therapy, implying that this effect is transient.     

Characteristics of undetected prostate cancer on diffusion-weighted MR Imaging at 3-Tesla with a b-value of 2000 s/mm2: Imaging-pathologic correlation

ObjectiveTo assess the accuracy of Diffusion-Weighted MR Imaging (DW-MRI) at 3-Teslas (3 T) with a b-value of 2000 s/mm² (b-2000 DW-MRI) to detect prostate cancer (PCa) and to describe the histological features of missed tumors.MethodsPrior to radical prostatectomy, 35 patients with a mean age of 64 ± 6.2 years old [51–77 years old] had a b-2000 DW-MRI at 3-T, without rectal coil (acquisition time: 2 min, 15 s), and were analysed on an eight-sector basis by two independent readers blinded to the rest of the multiparametric-MRI protocol. Pathological tumor foci were matched with high intensity focal areas on MRI and correlated for Gleason score, sector location and largest axial diameter.ResultsOf the 280 sectors analysed, histology showed PCa in 113 (113/280, 40%). Overall DW-MRI sensitivity, specificity and accuracy for tumor detection were 79–81%, 99–95% and 92–82% for readers 1 and 2, respectively (kappa test: 0.78). Of all, 28 (28/113, 25%) and 22 (22/113, 20%) tumor foci were not detected by reader 1 and 2 respectively. These undetected tumor foci had a mean pathological axial axis of 5 mm (range: 3–15 mm) and a Gleason score of 6, 7 (3 + 4), 7 (4 + 3) and > 7 in 15/28 (54%), 9/28 (32%), 3/28 (10%) and 1/28 (4%) of cases for reader 1, and in 11 (50%), 5 (23%), 5 (23%) and 1 (4%) of cases for reader 2.ConclusionA normal b-2000 DW-MRI at 3-T may miss small tumors without or with a minor Gleason 4 component.     

Early attained weight and length predict growth faltering better than velocity measures in infants with CF

BackgroundCF infants often do not grow as expected which adversely affects later clinical outcomes, thus sensitive early measures of growth deficiency are important. This study compared attained growth for age with velocity standards to determine which better predicts growth deficits at 24 months of age.MethodsGrowth deficiency in infancy based on weight and length velocity, and attained growth was calculated for 1992 infants in the US CF Foundation National Registry using the World Health Organization (WHO) and US growth standards. One, two and three month increments were used for calculating velocity and pooled for each age interval. Sensitivity and specificity of early indicators to predict growth deficiency at 24 months were calculated.ResultsObserved prevalence of weight deficiency (< 10th percentile) during the first year of life was 26.8% higher (95% CI = (25.6, 28.1%), p < 0.001) on average when measured by attained weight for age than velocity. Attained weight for age at four months was a more sensitive predictor of diminished weight for age (< 10th percentile) at 24 months (sensitivity = 100%, 95% CI = (87, 100%)) than weight velocity (sensitivity = 40%, 95% CI = (23, 59%)). Attained length at four months was more sensitive to detecting subsequent stunting (< 10th percentile length for age) (77%, 95% CI = (62, 87%)) than length velocity (30%, 95% CI = (19, 45%)).ConclusionsIn CF infancy, attained weight or length is more sensitive than velocity-based definitions for predicting subsequent diminished growth.     

Prosthetic Carotid Bypass Grafts for Atherosclerotic Lesions: A Prospective Study of 198 Consecutive Cases

ObjectivesCarotid endarterectomy (CEA) is the standard treatment for atherosclerotic lesions involving the carotid bifurcation. However, CEA can be challenging under some conditions. The goal of this study was to determine the outcome and durability of prosthetic carotid bypass grafting (PCB) with polytetrafluoroethylene (PTFE) grafts as an alternative to CEA.MethodsThis is a prospective series of 198 consecutive patients with PCB, representing 12.4% of 1595 patients with a carotid reconstruction procedure performed in our department between September 1986 and December 2006. Qualifying event was stroke in 67 patients (34%) and transient ischaemic attack (TIA) in 45 (23%), and 86 patients (43%) were asymptomatic. Primary indications for PCB were extensive atherosclerotic lesions (n = 71; 36%), carotid stenosis associated with kinking (n = 49; 25%), recurrent stenosis (n = 47; 23%), stenosis after radiation therapy (n = 18; 9%) and technical failure of CEA (n = 13; 7%), with excessive arterial wall thinning and perforation after endarterectomy (n = 10) or intimal flap on completion digital angiography (n = 3).ResultsThe combined stroke and death rate at 30 days were 0.5% (one stroke). Median follow-up was 9.5 years (interquartile range (IQR): 6.2–18.3 years). At 10 years, primary patency was 97.9 ± 3.4%. Six PCBs (3.0%) became occluded during follow-up; one patient had a restenosis greater than 50% and 18 patients (9.1%) had a restenosis of less than 50%. Five patients had an ipsilateral stroke (one postoperative stroke, one at 103 days with a patent PCB and three related to occlusion of the PCB at 4, 13 and 15 years after the procedure). At 10 years, cumulative stroke-free survival was 98.4 ± 3.2%, and cumulative survival was 78.8 ± 7.0%.ConclusionsPCB is a safe surgical alternative and is durable, with a low incidence of graft restenosis, when CEA seems hazardous.     

Predictive Value of Immune Cell Functional Assay for Non-Cytomegalovirus Infection in Lung Transplant Recipients: A Multicenter Prospective Observational Study

IntroductionImmune cell functional assay (ImmuKnow®) is a non-invasive method that measures the state of cellular immunity in immunosuppressed patients. We studied the prognostic value of the assay for predicting non-cytomegalovirus (CMV) infections in lung transplant recipients.MethodsA multicenter prospective observational study of 92 patients followed up from 6 to 12 months after transplantation was performed. Immune cell functional assay was carried out at 6, 8, 10, and 12 months.ResultsTwenty-three patients (25%) developed 29 non-CMV infections between 6 and 12 months post-transplant. At 6 months, the immune response was moderate (ATP 225–525 ng/mL) in 14 (15.2%) patients and low (ATP < 225 ng/mL) in 78 (84.8%); no patients had a strong response (ATP ≥ 525 ng/mL). Only 1 of 14 (7.1%) patients with a moderate response developed non-CMV infection in the following 6 months compared with 22 of 78 (28.2%) patients with low response, indicating sensitivity of 95.7%, specificity of 18.8%, positive predictive value (PPV) of 28.2%, and negative predictive value (NPV) of 92.9% (AUC 0.64; p = 0.043). Similar acute rejection rates were recorded in patients with mean ATP ≥ 225 vs. <225 ng/mL during the study period (7.1% vs. 9.1%, p = 0.81).ConclusionAlthough ImmuKnow® does not seem useful to predict non-CMV infection, it could identify patients with a very low risk and help us define a target for an optimal immunosuppression.     

Insuffisance rénale aiguë dans les formes graves du paludisme chez les enfants vivant à Kinshasa

BackgroundData on acute renal failure in complicated malaria in children in the Democratic Republic of Congo are sparse. The objective of this study was to document the profile of acute renal failure in severe malaria in admitted patients in pediatric hospitals from Kinshasa.MethodsA prospective cohort study was conducted from January 2008 to December 2008 in children admitted in emergency units of five hospitals in Kinshasa for severe malaria.ResultsIn our series, 378 children with severe malaria were included. There were 226 boys and 152 girls (sex ratio 1.49). One hundred and ninety four (194) of these patients were under 5 years old. Acute renal failure was observed in 89 children (23.6%) and 87 of them had blackwater fever (BWF). This form of severe malaria was predominant in children older than 5 years. Quinine was the commonest antimalarial drug involved in the genesis of BWF. Dialysis was indicated in 23 children (24.0%) and was effective (acute peritoneal dialysis) in 21 patients. The death rate in children with ARF was 12.6% (n = 87). Recovery of renal function was obtained by conservative treatment in the remained group.ConclusionThis study confirmed the emergence of BWF in seemed protected autochthon children older than 5 years. BWF remained the leading cause of acute renal failure in complicated malaria among Congolese children in Kinshasa.     

Seasonal changes in serum calcium,PTH and vitamin D levels in patients with primary hyperparathyroidism

BackgroundSeasonal variations of 25-hydroxyvitamin D, PTH and calcium levels are not well characterized in primary hyperparathyroidism (PHPT). Our objectives were to characterize seasonal changes in these parameters in PHPT patients, and to assess whether these seasonal changes affect clinical decision making.MethodsThis is a retrospective study based on the electronic medical records of Clalit Health service in the south of Israel between 2000 and 2012. Patients 18 years and older with PHPT (PTH > upper limit of norm (ULN) and serum calcium > 10.5 mg%) were included. Patients with renal failure or on Thiazide diuretics were excluded. All serum levels of calcium, PTH and 25-hydroxyvitamin D were collected and then stratified according to season.Results792 patients were classified as PHPT (72.2% female) and had a total of 2659 PTH tests, 1395 25-hydroxyvitamin D tests and 7426 calcium test. Fifty six percent of 25-hydroxyvitamin D levels were < 50 nmol/L. Seasonality was demonstrated in all three parameters: mean 25-hydroxyvitamin D was 13% higher in the summer compared to the winter (P < 0.001), median PTH values showed opposite trend with a fall of about 8.4% in summer compared to winter (P < 0.001). Calcium levels were higher during the autumn with a rise of about 0.2 mg/dL in the mean calcium levels compared to spring and summer (P < 0.001). The odds ratio of calcium level above 11.5 mg/dL is highest in the autumn (OR = 1.275, P = 0.018).ConclusionWe show seasonal variation in serum 25-hydroxyvitamin D, PTH, and calcium levels in patients with PHPT. These seasonal variations cause transition to pathological values that may influence diagnosis and treatment of PHPT patients.     

Low utility of serum 25–hydroxyvitamin D3 and 1, 25-dihydroxyvitamin D3 in predicting peripheral Treg and Th17 cell counts in ESRD and renal transplant patients

BackgroundVitamin D has shown an immune-modulatory effect in different studies. Vitamin D stimulates Tregs and inhibits Th17 cells. The immune-modulatory role of vitamin D in chronic kidney disease (CKD) and renal transplant patients is unclear. We measured whether different serum levels of vitamin D were associated with an increased or decreased presence of lymphocyte subsets including Treg and Th17 cells in end-stage renal disease (ESRD) and renal transplant recipients.MethodsEighty-seven renal transplant recipients and 53 end-stage renal disease (ESRD) patients were enrolled in this study. The absolute counts of CD4 + and CD8 + T, CD16 + CD56 + NK, CD19 + B, CD4 + CD25 + CD127- Foxp3 + (Tregs), Helios + Tregs, CD38 + Tregs, and CD4 + CD17 + (Th17) cells were analyzed in peripheral blood in both patient groups. In addition, serum 25 (OH) D₃, 1, 25 (OH)₂ D₃, IL-6, IL-17, IL-23, and TGF-β₁ were measured. The association between lymphocyte subset counts and 1, 25 (OH)₂ D₃ or 25 (OH) D₃ was studied, as was the association between serum IL-6, IL-17, IL-23, or TGF-β₁ and 1,25 (OH)₂ D₃ or 25 (OH) D₃.ResultsSerum 25 (OH) D₃ and 1,25 (OH)₂ D₃ levels were not independently associated with peripheral CD4 + T, CD19 + B, CD16 + CD56 + NK, Treg, or Th17 cell counts. In contrast to serum 25 (OH) D₃, serum1, 25 (OH)₂ D₃ was positively associated with CD8 + T cells counts in renal transplant recipients.ConclusionOur findings indicate low utility of serum 25 (OH) D₃ and 1, 25 (OH)₂ D₃ levels in predicting a change in lymphocyte subset counts in ESRD and renal transplant patients.     

Risk factors for complications after abdominal surgery in children with sickle cell disease

BackgroundAbdominal surgery in children with sickle cell disease (SCD) carries an increased risk of postoperative complications. Preoperative transfusions are frequently given to decrease the risk of vasoocclusive events. However, risk factors for postoperative complications are not well-defined in the pediatric population.MethodsPediatric patients with SCD undergoing common abdominal operations were identified from the National Surgical Quality Improvement Program–Pediatric (NSQIP-P) database from 2012 to 2018. Outcomes of interest were the incidence rates of 1) any complication or readmission, and 2) serious SCD-related complications (stroke, new onset seizure, ventilator support > 24 h postoperatively, or readmission with SCD crisis within 30 days of surgery).Patients were categorized by transfusion approach (transfusion within 48 h before surgery vs. no transfusion) and preoperative hematocrit (< 21.0, 21.0–23.9, 24.0–26.9, 27.0–29.9, ≥ 30.0).Stratified bivariate analyses and multivariable logistic regression were used to identify independent risk factors for complications.ResultsA total of 813 patients met inclusion criteria. There were 470 cholecystectomy, 251 splenectomy, 39 appendectomy, and 53 combination procedures; 13% of cases were urgent or emergent. Preoperative hematocrit levels were < 21.0 in 3%, 21.0–23.9 in 10%, 24.0–26.9 in 17%, 27.0–29.9in 30%, and ≥ 30.0 in 41% of patients; 52% received perioperative transfusion. The 30-day incidences of any complication/readmission and SCD-related complications were 12% and 4%, respectively. On bivariate analyses, urgent/emergent case status was the only significant predictor of complications, carrying risk of 20% and 8% for overall and SCD-related complications, respectively; this finding persisted on multivariable logistic regression (OR 1.83, 95% CI 1.0.2–3.29, p = 0.04). Neither preoperative transfusion nor preoperative hematocrit level was associated with complication risk, although there was a trend toward higher SCD-related complications in patients with preoperative hematocrit < 21.0 (p = 0.07).ConclusionIn this large cohort of pediatric SCD patients undergoing abdominal surgery, there was no clear association between postoperative complications and the transfusion approach or the preoperative hematocrit level within the range above 21.0. Urgent/emergent surgical procedures carried a nearly two-fold higher complication risk compared to elective procedures.Future studies should prospectively evaluate preoperative transfusion approaches and compare immediate and delayed operative management to nonoperative management in this population.Level of evidenceIII Retrospective review.     

Prevalence of dyslipidemia in adults with cystic fibrosis

BackgroundA high fat calorie diet is advocated for patients with cystic fibrosis (CF) however the lipid profiles of individuals with CF, including those with CF-related diabetes (CFRD), are not well studied.MethodsWe conducted a retrospective review of adult CF patients attending St Michael's Hospital between January 2005 and December 2007.Results334 patients (77% pancreatic insufficient (PI)) were included in the study. Mean HDL cholesterol was significantly lower in males (p < 0.0001) with 44% of males having HDL cholesterol < 38.7 mg/dL(1 mmol/L). Pancreatic sufficient patients were more likely than PI subjects to have total cholesterol > 201 mg/dL(5.2 mmol/L) (p < 0.01). 5% of subjects had triglyceride concentrations > 195 mg/dL(2.2 mmol/L). Diabetes was diagnosed in 23% of subjects. Lipid profiles were similar between diabetics and non-diabetics. Total cholesterol and triglycerides both increased with increasing age and increasing BMI (p < 0.01).ConclusionDyslipidemia occurs in CF patients however no differences in lipid profiles were seen between those with diabetes and those without. Fasting lipids should be monitored in CF patients, particularly those with PS, older age, and high BMI. As survival in CF increases, the prevalence of dyslipidemia may increase resulting in clinically important complications.     

Chronic Mycobacterium abscessus infection and lung function decline in cystic fibrosis

BackgroundAlthough nontuberculous mycobacteria (NTM) are recognized pathogens in cystic fibrosis (CF), associations with clinical outcomes remain unclear.MethodsMicrobiological data was obtained from 1216 CF patients over 8 years (481 ± 55 patients/year). Relationships to clinical outcomes were examined in the subset (n = 271, 203 ± 23 patients/year) with longitudinal data.ResultsFive hundred thirty-six of 4862 (11%) acid-fast bacilli (AFB) cultures grew NTM, with Mycobacterium abscessus (n = 298, 55.6%) and Mycobacterium avium complex (n = 190, 35.4%) most common. Associated bacterial cultures grew Stenotrophomonas or Aspergillus species more often when NTM were isolated (18.2% vs. 8.4% and 13.9% vs. 7.2%, respectively, p < 0.01). After controlling for confounders, patients with chronic M. abscessus infection had greater rates of lung function decline than those with no NTM infection (− 2.52 vs. − 1.64% predicted FEV₁/year, p < 0.05).ConclusionsNTM infection is common in CF and associated with particular pathogens. Chronic M. abscessus infection is associated with increased lung function decline.     

Preemptive therapy for cytomegalovirus based on real-time measurement of viral load in liver transplant recipients

BackgroundReal-time PCR has emerged as the preferred diagnostic assay for CMV. However, its utility as a preemptive therapy tool for CMV disease and related outcomes in liver transplant recipients has not been fully defined.MethodsPatients comprised 117 consecutive liver transplant recipients who underwent CMV surveillance monitoring using real-time PCR. Preemptive therapy with valganciclovir was employed upon detection of viremia. Baseline viral load was considered high based on log values (median).ResultsCMV viremia developed in 54% (63/117) of the patients, including 77% of R−/D+, 63% of R+/D+, 43% of R+/D−, and 10% of R−/D− patients. Overall, 23% (15/63) of the patients had recurrent viremia; R− serostatus (p = 0.065) but not initial viral load correlated with recurrent viremia (p = 0.80). At 12 months post-transplant, CMV disease occurred in 0.85% (1/117) of the patients (R+/D + recipient). None (0/30) of the R−/D + patients had CMV disease. Patients with CMV viremia treated preemptively did not differ significantly from those who never developed CMV viremia with regards to bacterial or fungal infections, rejection, graft loss, mortality rate, and probability of survival at 12 months (p > 0.05 for all variables). The above outcomes also did not differ for patients with high (> 1.9 logs) vs. low viral load (< 1.9 logs) (p > 0.05 for all outcomes).ConclusionsPreemptive therapy guided by real-time PCR based monitoring led to outcomes in all patients or in those with high viral loads that were comparable to outcomes in patients who never developed viremia or had low viral loads, respectively. Late-onset CMV disease at 12 months was observed in < 1% of all patients.     

Impact du pharmacien clinicien sur la iatrogénie médicamenteuse chez le patient greffé rénal

IntroductionDrug related problems (DRP) can lead to severe consequences in kidney recipients. The aim of the study was to assess the impact of the clinical pharmacist interventions on the incidence of DRP.MethodThe number of DRP were evaluated according to 3 periods: Without intervention, with medication reconciliation at admission, and with medication reconciliation at admission associated with an interview with the clinical pharmacist at discharge.ResultsPatients concerned were mainly men, 55 years old (median age), stage 3 of CKD, transplanted for less than 3 months or more than 1 year, with cardiovascular risk factors and receiving an average of 9 drugs/day. Among the DRP, 20% were avoidable and severe in most cases. In period 1, 27.7% patients had at least 1 DRP, in period 2, 21.3% patients had at least 1 DRP, and in period 3, 17.4% of patients had at least 1 DRP (P = 0.03). One hundred and ten patients had medication reconciliation at admission with a mean of 0.6 unintentional discrepancies per patient (omission in 81% of cases). The main drugs involved concerned the digestive-metabolic (24.5%), cardiovascular (23%), and nervous (23%) system. Sixty-eight interviews at discharge were realized and revealed self-medication habits.ConclusionOur study shows that medication reconciliation at admission associated with an interview with the clinical pharmacist at discharge can help to reduce DRP in kidney recipients. Further studies are needed to confirm our results.     

Internal tibial torsion is related to syndesmosis injury in a large osteological collection

BackgroundThe long-term consequences of tibial torsion remain unclear. This study evaluated whether syndesmotic injuries are associated with tibial torsion.MethodsA collection of over 3000 cadaveric skeletons was screened for irregular bony prominence along the lateral distal tibia, consistent with previous syndesmosis injury. Tibial torsion was measured and compared to 1034 control cadaveric tibiae.ResultsMean torsion of 236 specimens with syndesmotic injury was 6.2 ± 8.9 degrees, while that of control specimens was 7.9 ± 8.8 degrees (P = 0.008). Multiple regression analysis showed a non-statistically significant trend toward internal torsion and syndesmotic injury (standardized beta = −0.051, P = 0.059). Syndesmosis injury was present in 48/200 specimens (24.0%) with internal torsion and 31/199 specimens (15.6%) with external torsion (P = 0.035).ConclusionThis association between internal tibial torsion and syndesmotic injury suggests that internal tibial torsion might not be an entirely benign condition and merits further study.     

Anticoagulant prescribing practices and anesthetic interventions among anticoagulated pregnant patients: a retrospective study

BackgroundThe peripartum management of anticoagulated patients poses important challenges for obstetric anesthesiologists, especially when deciding to perform neuraxial block. However, there is limited evidence evaluating anticoagulant prescribing practices and neuraxial block utilization in this setting. Our objective was to examine peripartum anticoagulant prescribing and anesthetic practices in a cohort of anticoagulated patients receiving subcutaneous enoxaparin, and subcutaneous or intravenous unfractionated heparin.MethodsWe performed a retrospective study of anticoagulant prescribing patterns and anesthetic interventions among patients receiving enoxaparin and/or unfractionated heparin who delivered at a USA obstetric center over a seven-year period.ResultsWe identified 101 patients who received enoxaparin and/or unfractionated heparin before delivery. Thirty-nine (38.6%) patients received enoxaparin only, 41 (40.6%) patients received enoxaparin bridged to subcutaneous unfractionated heparin, 11 (10.9%) patients received enoxaparin and were converted to intravenous unfractionated heparin and 10 (9.9%) patients received only subcutaneous unfractionated heparin. The overall rate of neuraxial block utilization was 80.2%. The median [IQR] time-period between the last dose of enoxaparin and neuraxial block was significantly shorter for patients who received only enoxaparin vs. enoxaparin with subcutaneous unfractionated heparin (54 h [12–192 h] (n = 26) vs. 216 h [39–504 h] (n = 23), P = 0.04). Among patients who received only subcutaneous unfractionated heparin, the time period between unfractionated heparin and neuraxial block was 24 h [19–51 h].ConclusionIn this study, the neuraxial block rate was high among patients receiving enoxaparin and/or subcutaneous unfractionated heparin with patients undergoing relatively long periods off anticoagulation. Careful multidisciplinary planning is recommended for the peripartum management of anticoagulated pregnant patients.