Is the Fear Avoidance Model Associated With the Reduced Level of Aerobic Fitness in Patients With Chronic Low Back Pain?

Smeets RJ, van Geel KD, Verbunt JA. Is the fear avoidance model associated with the reduced level of aerobic fitness in patients with chronic low back pain?

Objectives

To compare aerobic fitness of patients with chronic low back pain (CLBP) against healthy controls and to assess whether variables of the fear avoidance model are associated with loss of aerobic fitness.

Design

A case-comparison study.

Setting

Rehabilitation centers.

Participants

Patients with CLBP (n=223), and normative data from healthy subjects (n=18,082).

Interventions

Not applicable.

Main Outcome Measures

Maximal oxygen uptake (V?o₂max) was estimated on the basis of a modified submaximal Åstrand bicycle test performed by patients with CLBP (observed level of aerobic fitness) and compared with the normative data of healthy controls matched for age, sex, and level of sport activity (expected level of aerobic fitness). Pain (visual analog scale); disability (Roland Disability Questionnaire); pain-related fear (Tampa Scale for Kinesiophobia); depression (Beck Depression Inventory); catastrophizing (Pain Catastrophizing Scale); and the level of activity during sport, work/household, and leisure time (Baecke Physical Activity Questionnaire) were assessed. Multiple linear regression analysis was performed with the difference of the observed and expected level of aerobic fitness as dependent variable and putative influential factors including those of the fear avoidance model as independent variables.

Results

V?o₂max could be calculated in 175 (78%) of the patients. Both men and women with CLBP had significant lower V?o₂max than expected (10.3mL/kg lean body mass (LBM)×min⁻¹ and 6.5mL/kg LBM×min⁻¹, respectively; P<.001). The levels of activity during leisure time and work/household were significantly associated with this reduced level of aerobic fitness. However, the variables of the fear avoidance model were not.

Conclusions

Most patients with CLBP-associated disability have a lower level of aerobic fitness, but this is not associated with fear avoidance.     

Is Dynamic Cervical Shortening During Symptomatic Contractions Predictive of Preterm Delivery in Patients With a Normal Baseline Cervical Length?

Objective. The purpose of this study was to determine whether dynamic cervical change in symptomatic patients with a normal baseline cervical length (CL; ≥30 mm) is predictive of preterm delivery (PTD). Methods. A prospective observational study was performed in 120 symptomatic patients between 23 and 34 weeks' gestation. Patients underwent standardized CL sonography with contraction monitoring, and CL measurements were recorded each minute for approximately 10 minutes. Initial and minimum CLs as well as the presence of dynamic change were assessed for prediction of PTD. Results. Forty‐seven patients (39.2%) had dynamic cervical change and delivered at a mean gestational age ± SD of 37.1 ± 2.7 weeks compared to 38.7 ± 1.5 weeks for those without dynamic change (P < .01). A larger proportion of those with dynamic change delivered before 37 weeks (43% versus 15%; P < .01) and before 35 weeks (19% versus 0%; P < .01). Multivariable logistic regression analysis showed that dynamic cervical change was predictive of PTD, but not independently of the minimum CL. Statistical analyses were completed using the Student t test, χ² test, Fisher exact test, Wilcoxon rank sum test. and logistic regression as appropriate. Conclusions. Although symptomatic patients with a normal baseline CL who have dynamic shortening generally deliver at term, they appear to be at increased risk of PTD.     

Can Mental Imagery Functional Magnetic Resonance Imaging Predict Recovery in Patients With Disorders of Consciousness?

Objective

To determine the potential prognostic value of using functional magnetic resonance imaging (fMRI) to identify patients with disorders of consciousness, who show potential for recovery.

Design

Observational study.

Setting

Unit for acute rehabilitation care.

Participants

Patients (N=22) in a vegetative state (VS; n=10) and minimally conscious state (MCS; n=12) during the first 200 days after the initial incident.

Interventions

Not applicable.

Main Outcome Measure

Further course on the Coma Recovery Scale-Revised.

Results

Participants performed a mental imagery fMRI paradigm. They were asked to alternately imagine playing tennis and navigating through their home. In 14 of the 22 examined patients (VS, n=5; MCS, n=9), a significant activation of the regions of interest (ROIs) of the mental imagery paradigm could be found. All 5 patients with activation of a significant blood oxygen level dependent signal, who were in a VS at the time of the fMRI examination, reached at least an MCS at the end of the observation period. In contrast, 5 participants in a VS who failed to show activation in ROIs, did not (sensitivity 100%, specificity 100%). Six of 9 patients in an MCS with activation in ROIs emerged from an MCS. Of 3 patients in an MCS who did not show activation, 2 patients stayed in an MCS and 1 patient emerged from the MCS (sensitivity 85%, specificity 40%).

Conclusions

The fMRI paradigm mental imagery displays a high concordance with the further clinical course of patients in a VS. All 5 patients in a VS who showed significant activation of ROIs had a favorable further course until the end of the observation period. We therefore propose the term “functional minimally conscious state” for these patients. They may benefit from rehabilitation treatment. In cases where no significant activation was seen, the method has no prognostic value. Prediction of the clinical course of patients in an MCS by fMRI was considerably less accurate than in patients in a VS.     

Can Functional Capacity Tests Predict Future Work Capacity in Patients With Whiplash-Associated Disorders?

ObjectiveTo determine whether functional capacity evaluation (FCE) tests predict future work capacity (WC) of patients with whiplash-associated disorders (WADs) grades I and II who did not regain full WC 6 to 12 weeks after injury.DesignProspective cohort study.SettingRehabilitation center.ParticipantsWorkers (N=267) listed on workers' compensation with grade I or II WADs 6 to 12 weeks after injury.InterventionsPatients performed 8 work-related FCE tests.Main Outcome MeasuresWC (0–100%) measured at baseline and 1, 3, 6, and 12 months after testing. Correlation coefficients between FCE tests and WC were calculated. A linear mixed-model analysis was used to assess the association between FCE and future WC.ResultsMean ± SD WC increased over time from 20.8%±27.6% at baseline to 32.3%±38.4%, 51.3%±42.8%, 65.6%±42.2%, and 83.2%±35.0% at the 1-, 3-, 6-, and 12-month follow-ups, respectively. Correlation coefficients between FCE tests and WC ranged from r=.06 (lifting low at 12-mo follow-up) to r=.39 (walking speed at 3mo). Strength of the correlations decreased over time. FCE tests did not predict WC at follow-up. The predictors of WC were ln (time) (β=23.74), mother language (β=5.49), WC at baseline (β=1.01), and self-reported disability (β=−.20). Two interaction terms, ln (time) × WC (β=−.19) and ln (time) × self-reported disability (β=−.21), were significant predictors of WC.ConclusionsFCE tests performed within 6 to 12 weeks after WADs injury grades I and II are associated with WC at baseline but do not predict future WC, whereas time course, mother language, WC at baseline, and self-reported disability do predict future WC. Additionally, the interaction between time course WC at baseline and self-reported disability predicted future WC.     

How Reproducible Is Home-Based 24-Hour Ambulatory Monitoring of Motor Activity in Patients With Multiple Sclerosis?

Rietberg MB, van Wegen EE, Uitdehaag BM, de Vet HC, Kwakkel G. How reproducible is home-based 24-hour ambulatory monitoring of motor activity in patients with multiple sclerosis?

Objective

To determine the reproducibility of 24-hour monitoring of motor activity in patients with multiple sclerosis (MS).

Design

Test-retest design; 6 research assistants visited the participants twice within 1 week in the home situation.

Setting

General community.

Participants

A convenience sample of ambulatory patients (N=43; mean age ± SD, 48.7±7.0y; 30 women; median Expanded Disability Status Scale scores, 3.5; interquartile range, 2.5) were recruited from the outpatient clinic of a university medical center.

Interventions

Not applicable.

Main Outcome Measures

Dynamic activity and static activity parameters were recorded by using a portable data logger and classified continuously for 24 hours. Reproducibility was determined by calculating intraclass correlation coefficients (ICCs) for test-retest reliability and by applying the Bland-Altman method for agreement between the 2 measurements. The smallest detectable change (SDC) was calculated based on the standard error of measurement.

Results

Test-retest reliability expressed by the ICC_agreement was .72 for dynamic activity, .74 for transitions, .77 for walking, .71 for static activity, .67 for sitting, .62 for standing, and .55 for lying. Bland and Altman analysis indicated no systematic differences between the first and second assessment for dynamic and static activity. Measurement error expressed by the SDC was 1.23 for dynamic activity, 66 for transitions, .99 for walking, 1.52 for static activity, 4.68 for lying, 3.95 for sitting, and 3.34 for standing.

Conclusions

The current study shows that with 24-hour monitoring, a reproducible estimate of physical activity can be obtained in ambulatory patients with MS.     

Effect of Functional Status on Survival in Patients With Stroke: Is Independent Ambulation a Key Determinant?

Chiu H-T, Wang Y-H, Jeng J-S, Chen B-B, Pan S-L. Effect of functional status on survival in patients with stroke: is independent ambulation a key determinant?ObjectiveTo investigate the effect of functional status, measured using the Modified Rankin Scale (MRS), at 3 months after stroke on survival in patients with stroke.DesignCohort study.SettingReferral medical center.ParticipantsPatients with stroke (N=1032).InterventionsNot applicable.Main Outcome MeasureSurvival after stroke.ResultsThe Kaplan-Meier survival curves stratified by the 3-month MRS score showed 2 clear groups of patients with 3-month MRS scores of 0 to 3 (able to walk without assistance) and 4 or 5 (unable to walk without assistance). Accordingly, we grouped the patients into a high function (HF) group (3-month MRS≦3) and a low function (LF) group (3-month MRS≧4). Multiple Cox regression analysis showed that the LF group had significantly poorer survival (adjusted hazard ratio=4.69; 95% confidence interval [CI], 2.89–7.60; P<.001) than the HF group. Other significant risk factors of higher mortality were older age, history of diabetes mellitus, and heart disease.ConclusionsThis study showed a significant influence of the 3-month MRS score on stroke survival. Moreover, independent ambulation may be a major determinant of a favorable survival prognosis. This finding suggests a potential role of rehabilitation in promoting stroke survival by maximizing ambulation function.     

Comparative Effectiveness of Traditional Chinese Medicine and Psychosocial Care in the Treatment of Temporomandibular Disorders–Associated Chronic Facial Pain

This dual-site study sought to identify the appropriate role for traditional Chinese medicine (TCM; acupuncture and herbs) in conjunction with a validated psychosocial self-care (SC) intervention for treating chronic temporomandibular disorders (TMD)-associated pain. Participants with Research Diagnostic Criteria for Temporomandibular Disorders–confirmed TMD (n = 168) entered a stepped-care protocol that began with a basic TMD class. At weeks 2 and 10, patients receiving SC whose worst facial pain was above predetermined levels were reallocated by minimization to SC or TCM with experienced practitioners. Characteristic facial pain (CFP: mean of worst pain, average pain when having pain, and current pain; each visual analog scale [VAS] 0–10) was the primary outcome. Social activity interference (VAS 0–10) was a secondary outcome. Patients were monitored for safety. TCM provided significantly greater short-term (8-week) relief than SC (CFP reduction difference, −.60 [standard deviation of the estimate .26], P = .020) and greater reduction in interference with social activities (−.81 [standard deviation of the estimate .33], P = .016). In 2 of 5 treatment trajectory groups, more than two thirds of participants demonstrated clinically meaningful responses (≥30% improvement) in pain interference over 16 weeks. This study provides evidence that TMD patients referred for TCM in a community-based model will receive safe treatment that is likely to provide some short-term pain relief and improved quality of life. Similar designs may also apply to evaluations of other kinds of chronic pain. (ClinicalTrials.gov number NCT00856167).     

Is Splenectomy Necessary for Immune Thrombocytopenic Purpura? The Role of Rituximab in Patients With Corticosteroid Resistance in a Single-Center Experience

Background

Corticosteroid therapy followed by splenectomy for immune thrombocytopenic purpura (ITP) is the standard practice. Rituximab is mostly used in patients with chronic refractory ITP who have failed multiple previous treatments, including splenectomy.

Objective

We explored the potential role of rituximab as an early therapeutic option for patients with corticosteroid-resistant ITP who preferred to avoid splenectomy in favor of other treatment.

Methods

Twenty-five patients with corticosteroid-resistant ITP were treated with rituximab between May 1, 2009, and June 30, 2012, at a single center. Rituximab was administered at 100 mg/m² on days 7, 14, 21, and 28. The response to rituximab therapy and adverse effects were observed.

Results

Complete remission was achieved in 19 patients (76%), partial remission in 3 patients (12%), and minimal response in none of the patients; 1 patient was considered a treatment failure (4%). Two patients (8%) were lost to follow-up. Twenty-two patients (88%) achieved a platelet count >50×10⁹/L. The median time from administration of the first rituximab dose to partial remission was 2 months (range, 0.7–3 months) for all the patients. Response classified as sustained was achieved in 21 patients (84%). No serious adverse effects were observed during rituximab therapy.

Conclusions

Rituximab therapy is effective and safe for patients with corticosteroid-resistant ITP before splenectomy, resulting in high complete remission and overall response rates. A multicenter study with a larger sample should be performed to further explore the role of rituximab therapy.     

Is Fatigue Associated With Short-Term Health-Related Quality of Life in Stroke?

Tang WK, Lu JY, Chen YK, Mok VC, Ungvari GS, Wong KS. Is fatigue associated with short-term health-related quality of life in stroke?

Objective

To evaluate the relation between poststroke fatigue and short-term health-related quality of life (HRQOL) in Chinese patients with first or recurrent stroke.

Design

Cross-sectional survey.

Setting

Acute stroke unit of a general hospital.

Participants

A total of 458 patients with acute ischemic stroke admitted to the acute stroke unit of a university-affiliated regional hospital in Hong Kong.

Interventions

Not applicable.

Main Outcome Measures

HRQOL was assessed with the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36) at 3 months after the subjects' index stroke. Fatigue was evaluated by using the Fatigue Severity Scale (FSS). The correlation between the FSS and SF-36 scores was examined and adjusted for potential confounders, including age, sex, marital status, previous stroke, social support, global cognitive functions, neurologic deficits, and depressive symptoms.

Results

Univariate analysis revealed that fatigue was a significant correlate of all SF-36 domain scores. The magnitude of correlation was highest for the vitality domain (r=−.605, Bonferroni corrected P<.05) and lowest for the physical functioning domain (r=−.202, Bonferroni corrected P<.05). Canonic correlation analysis indicated that FSS was strongly related to the HRQOL with a loading of −.678. Increasing fatigue was associated with a lower HRQOL. The association between FSS and HRQOL remained significant in the subsequent multivariate regression analysis, having adjusted for possible confounders.

Conclusions

These findings suggest that fatigue has an impact on short-term HRQOL in Chinese stroke patients. The early identification and treatment of fatigue may improve HRQOL of stroke patients.     

Can Surface Neuromuscular Electrical Stimulation of the Wrist and Hand Combined With Routine Therapy Facilitate Recovery of Arm Function in Patients With Stroke?

Rosewilliam S, Malhotra S, Roffe C, Jones P, Pandyan AD. Can surface neuromuscular electrical stimulation of the wrist and hand combined with routine therapy facilitate recovery of arm function in patients with stroke?ObjectiveTo investigate whether treatment with surface neuromuscular electrical stimulation to the wrist extensors improves recovery of arm function in severely disabled patients with stroke.DesignSingle blinded randomized controlled trial.SettingAcute stroke unit and stroke rehabilitation wards of a university hospital.ParticipantsPatients with no upper limb function (Action Research Arm Test [ARAT] score 0) (N=90; mean age ± SD, 74±11y; 49% men) were recruited to the study within 6 weeks of stroke. Only 67 participants were alive at the end of the study and data from 66 of these people were analyzed.InterventionsParticipants were randomized to surface neuromuscular electrical stimulation using surface electrical stimulators for 30 minutes, twice in a working day for 6 weeks in addition to standardized upper limb therapy or just standardized upper limb therapy.Main Outcome MeasureThe primary outcome measure was the ARAT score. Assessments were made at baseline and at 6, 12, 24, and 36 weeks after recruitment.ResultsThere were statistically significant improvements in measures of wrist extensor (mean difference 0.5; 95% confidence interval [CI], 0.0–1.0) and grip strength (mean difference 0.9; 95% CI, 0.1–1.7) over the treatment period. Arm function (ARAT score) was not significantly different between the groups over the treatment period at 6 weeks (mean difference 1.9; 95% CI, ?2.9 to 6.8) or over the study period at 36 weeks (mean difference 6.4; 95% CI, ?1.8 to 14.7), and the rate of recovery was not significantly different (mean difference 0.7; 95% CI, ?0.2 to 1.6).ConclusionsIn patients with severe stroke, with no functional arm movement, electrical stimulation of wrist extensors improves muscle strength for wrist extension and grip, and larger studies are required to study its influence on arm function.     

Is serology helpful in the diagnosis of malaria?

Malaria is arguably the most important parasitic disease of man, and falciparum malaria the most dangerous. More than 1·6 billion of the world's population live in malaria endemic areas¹. The increased availability of international air travel has made some endemic areas popular tourist resorts. In addition, immigrants to developed countries whose immunity has waned over the years may acquire malaria when they make a return visit to their country of origin². As a result there are up to 2000 new cases of malaria reported each year in the United Kingdom, which represents more than half of all cases imported into Europe^1,2. This has meant that malaria is no longer a rare or exotic disease, but one which every clinical laboratory will meet regularly and be required to diagnose. The examination of stained thick and thin blood films for the presence of malaria parasites is the mainstay of laboratory diagnosis. It combines a sensitivity and specificity unmatched by currently available serological techniques. Thus for the present and the immediate future conventional parasitological techniques will remain the investigation of choice. However, serology does have a part to play. This article will briefly outline human serological responses to malaria parasites which are useful for diagnosis, the techniques available, and the indications for their use in the clinical laboratory.     

Clinical Efficacy and Tolerability of Ezetimibe in Combination With Atorvastatin in Japanese Patients With Hypercholesterolemia—Ezetimibe Phase IV Randomized Controlled Trial in Patients With Hypercholesterolemia

ObjectiveThe purpose of this study was to compare the efficacy and tolerability of combination therapy of ezetimibe and atorvastatin in patients with high LDL cholesterol that had not reached the lipid management target value with 10 mg atorvastatin monotherapy, against increasing the dose to 20 mg atorvastatin or switching to 2.5 mg rosuvastatin.Design, setting, and participantsThis was an open-label, randomized, multicenter, 3-parallel-group comparison trial at 23 community hospitals and clinics in Japan (enrollment period March 2009 to May 2010) in 125 patients with high LDL cholesterol.InterventionsA total of 125 Japanese patients with high LDL cholesterol level were randomized to 1 of the following 3 treatment groups: the ezetimibe (10 mg/d) and atorvastatin (10 mg/d) group, the atorvastatin (20 mg/d) group, or the rosuvastatin (2.5 mg/d) group for 12 weeks after treatment with 10 mg atorvastatin alone for 4 weeks.Main outcome measurePercent change in LDL cholesterol level from baseline (4 weeks after treatment with 10 mg atorvastatin alone) until study completion.ResultsThe percent change in LDL cholesterol level from baseline until study completion was statistically greater for the combination of 10 mg ezetimibe + 10 mg atorvastatin compared with increasing atorvastatin to 20 mg (?25.8% vs ?15.1%; P < 0.0001). A similar result was observed for ezetimibe + atorvastatin compared with switching to 2.5 mgt rosuvastatin (?25.8% vs 0.8%; P < 0.0001). The proportion of patients who reached the target LDL cholesterol value with the combination of ezetimibe + atorvastatin was significantly higher than increasing atorvastatin and switching to rosuvastatin (78.7%, 41.3%, and 3.1%, respectively). Although 5 serious adverse experiences bearing no relation to the study medications were reported, there were no adverse reactions.ConclusionsThe combination of 10 mg ezetimibe +10 mg atorvastatin was more effective than increasing atorvastatin to 20 mg or switching to 2.5 mg rosuvastatin in patients with hypercholesterolemia whose LDL cholesterol levels had not reached the recommended target value with 10 mg atorvastatin monotherapy for 4 weeks. Ezetimibe coadministration with atorvastatin was well tolerated. ClinicalTrials.gov identifier: NCT00871351.     

Evidence of Reduced β-Cell Function in Asian Indians With Mild Dysglycemia

OBJECTIVE

To examine β-cell function across a spectrum of glycemia among Asian Indians, a population experiencing type 2 diabetes development at young ages despite low BMI.

RESEARCH DESIGN AND METHODS

One-thousand two-hundred sixty-four individuals without known diabetes in the Diabetes Community Lifestyle Improvement Program in Chennai, India, had a 75-g oral glucose tolerance test, with glucose and insulin measured at 0, 30, and 120 min. Type 2 diabetes, isolated impaired fasting glucose (iIFG), isolated impaired glucose tolerance (iIGT), combined impaired fasting glucose and impaired glucose tolerance, and normal glucose tolerance (NGT) were defined by American Diabetes Association guidelines. Measures included insulin resistance and sensitivity (homeostasis model assessment of insulin resistance [HOMA-IR], modified Matsuda Index, 1/fasting insulin) and β-cell function (oral disposition index = [Δinsulin_0–30/Δglucose_0–30] × [1/fasting insulin]).

RESULTS

Mean age was 44.2 years (SD, 9.3) and BMI 27.4 kg/m² (SD, 3.8); 341 individuals had NGT, 672 had iIFG, IGT, or IFG plus IGT, and 251 had diabetes. Patterns of insulin resistance or sensitivity were similar across glycemic categories. With mild dysglycemia, the absolute differences in age- and sex-adjusted oral disposition index (NGT vs. iIFG, 38%; NGT vs. iIGT, 32%) were greater than the differences in HOMA-IR (NGT vs. iIFG, 25%; NGT vs. iIGT, 23%; each P < 0.0001). Compared with NGT and adjusted for age, sex, BMI, waist circumference, and family history, the odds of mild dysglycemia were more significant per SD of oral disposition index (iIFG: odds ratio [OR], 0.36; 95% CI, 0.23–0.55; iIGT: OR, 0.37; 95% CI, 0.24–0.56) than per SD of HOMA-IR (iIFG: OR, 1.69; 95% CI, 1.23–2.33; iIGT: OR, 1.53; 95% CI, 1.11–2.11).

CONCLUSIONS

Asian Indians with mild dysglycemia have reduced β-cell function, regardless of age, adiposity, insulin sensitivity, or family history. Strategies in diabetes prevention should minimize loss of β-cell function.Type 2 diabetes mellitus is a global problem, with 80% of all cases worldwide occurring in low- and middle-income countries (1). However, despite the increasing prevalence of type 2 diabetes, the etiology of the disease remains incompletely understood. Previously invoked as the driving feature of diabetes, increased insulin resistance can trigger increased insulin production to maintain normoglycemia and, over time, can strain β cells to the point at which insulin production is no longer adequate (2–4), i.e., β-cell “exhaustion.” Characteristics associated with insulin resistance, particularly older age, obesity, and physical inactivity, are strong risk factors for diabetes (5).Yet, poor β-cell function also may have more of a primary role in diabetes development. The inadequate β-cell response to physiologic needs for insulin not only may be an acquired feature (e.g., as a result of insulin resistance) but also, at least in some individuals, may be an inherent feature. β-Cell dysfunction has been detected early in the pathogenesis of the disease (6), with recent cross-sectional and longitudinal studies detecting dysfunction in people with prediabetes or even normoglycemia (7–10). Supported by recent genetic discoveries (11), these studies suggest that some individuals have an underlying susceptibility to poor β-cell function (12) and that β-cell dysfunction may be an early driving metabolic feature of diabetes development.Most studies of diabetes pathogenesis have been conducted in populations of European descent; however, more people have diabetes in other populations worldwide. Asian Indians, in particular, experience high rates of type 2 diabetes (13) at younger ages and lower BMI values (14) compared with other populations. They have high basal insulin levels (15) that are not entirely explained by obesity or adverse fat distribution (16), which are commonly cited factors related to insulin resistance. Considering these characteristics, Asian Indians may be an ideal population to utilize for developing a better understanding of the relative roles of β-cell function and insulin resistance in the pathogenesis of type 2 diabetes. Previous studies that have examined the etiology of diabetes in Asian Indians have produced conflicting findings. Altered β-cell function has been associated with impaired glucose tolerance (IGT) (17), has not been associated with IGT (18,19), and has been associated with impaired fasting glucose (IFG) but not IGT (20). Furthermore, β-cell function has not always been evaluated rigorously in Asian Indians (i.e., expressed relative to the insulin resistance of each individual) (21). We investigated the associations between the pathophysiologic mechanisms of insulin resistance and β-cell function with glycemic status in a large cohort (n = 1,264) of Asian Indians in Chennai, India.     

Is Dialysis Modality a Factor in the Survival of Patients Initiating Dialysis After Kidney Transplant Failure?

♦ Background: Kidney transplant failure (TF) is among the leading causes of dialysis initiation. Whether survival is similar for patients treated with peritoneal dialysis (PD) and with hemodialysis (HD) after TF is unclear and may inform decisions concerning dialysis modality selection.♦ Methods: Between 1995 and 2007, 16 113 adult dialysis patients identified from the US Renal Data System initiated dialysis after TF. A multivariable Cox proportional hazards model was used to evaluate the impact of initial dialysis modality (1 865 PD, 14 248 HD) on early (1-year) and overall mortality in an intention-to-treat approach.♦ Results: Compared with HD patients, PD patients were younger (46.1 years vs 49.4 years, p < 0.0001) with fewer comorbidities such as diabetes mellitus (23.1% vs 25.7%, p < 0.0001). After adjustment, survival among PD patients was greater within the first year after dialysis initiation [adjusted hazard ratio (AHR): 0.85; 95% confidence interval (CI): 0.74 to 0.97], but lower after 2 years (AHR: 1.15; 95% CI: 1.02 to 1.29). During the entire period of observation, survival in both groups was similar (AHR for PD compared with HD: 1.09; 95% CI: 1.0 to 1.20). In a sensitivity analysis restricted to a cohort of 1865 propensity-matched pairs of HD and PD patients, results were similar (AHR: 1.03; 95% CI: 0.93 to 1.14). Subgroups of patients with a body mass index exceeding 30 kg/m² [AHR: 1.26; 95% CI: 1.05 to 1.52) and with a baseline estimated glomerular filtration rate (eGFR) less than 5 mL/min/1.73 m² (AHR: 1.45; 95% CI: 1.05 to 1.98) experienced inferior overall survival when treated with PD.♦ Conclusions: Compared with HD, PD is associated with an early survival advantage, inferior late survival, and similar overall survival in patients initiating dialysis after TF. Those data suggest that increased initial use of PD among patients returning to dialysis after TF may be associated with improved outcomes, except among patients with a higher BMI and those who initiate dialysis at lower levels of eGFR. The reasons behind the inferior late survival seen in PD patients are unclear and require further study.     

Incomplete Bladder Emptying in Patients With Stroke: Is Detrusor External Sphincter Dyssynergia a Potential Cause?

Meng NH, Lo SF, Chou LW, Yang PY, Chang CH, Chou EC. Incomplete bladder emptying in patients with stroke: is detrusor external sphincter dyssynergia a potential cause?

Objectives

To delineate the frequency, clinical risk factors, and urodynamic mechanisms of incomplete bladder emptying (IBE) among patients with recent stroke.

Design

Retrospective study.

Setting

Inpatient setting in the rehabilitation ward of a university hospital.

Participants

All patients with acute stroke admitted for rehabilitation between January and December 2005, excluding those with a history of lower-urinary tract symptoms and urologic diseases. Eighty-two patients (42 women and 40 men; mean age, 65.5y) were included.

Interventions

Not applicable.

Main Outcome Measures

We measured postvoid residual (PVRs) by catheterization or by using an ultrasonic bladder scanner. Twenty-five patients (30.5%) had IBE with PVRs greater than 100mL on 2 consecutive days. Patients with IBE were evaluated by a urologist and subsequently underwent urodynamic studies.

Results

The presence of IBE was significantly associated with urinary tract infection (P<.001) and aphasia (P=.046). The presence of IBE was not related to sex, stroke location, nature of stroke (hemorrhagic or ischemic), history of diabetes mellitus, or previous stroke. Urodynamic studies done on 22 patients with IBE revealed acontractile detrusor in 8 patients (36%) and detrusor underactivity in 3 (14%). Eleven patients (50%) had detrusor-external sphincter dyssynergia (DESD) combined with normative detrusor function (5 patients) or detrusor hyperactivity (6 patients); all but 1 of these patients had a supratentorial lesion. The presence of DESD was associated with a longer onset-to-evaluation interval (P=.008) and spasticity of the stroke-affected lower limb (P=.002). Diabetes mellitus was associated with the presence of acontractile detrusor or detrusor underactivity (P=.03).

Conclusions

IBE is common among patients with stroke and is caused by decreased detrusor contractility or DESD. Spasticity of the external urethral sphincter is a possible pathophysiologic mechanism of DESD.     

Diagnosis of Carpal Tunnel Syndrome in Patients Without Diabetes With Hemodialysis Using Ultrasonography: Is It a Useful Adjunctive Tool?

Objective(1) To examine the ultrasonography (US) characteristics in patients with hemodialysis-related carpal tunnel syndrome (H-CTS) and (2) to evaluate the accuracy of a proposed US parameter-dynamic ratio of median nerve-to-hamate hook distance (RMHD) in diagnosis of H-CTS.DesignA case-control study.SettingA tertiary medical center and a secondary hospital from November 2017 to March 2021.ParticipantsConsecutive patients (N=207) without diabetes under hemodialysis were recruited and divided into a hemodialysis without carpel tunnel syndrome (CTS) (H-Control) group and an H-CTS group. Age-matched volunteers (N=89) without diabetes or upper extremity disorders were enrolled as the control group.InterventionUS examinations by 2 operators blinded to the patient's clinical information.Main Outcome MeasuresUS parameters including cross-sectional area of the median nerve at the carpal tunnel inlet (CSA-I) and outlet (CSA-O), the flattening ratio of the median nerve at the inlet (FR-I) and outlet (FR-O), and RMHD.ResultsHandedness and arteriovenous fistula showed no associations with CSA-I/O and FR-I/O. Compared with the control group (n=69), the CSA-I was significantly larger in the H-Control group (n=63) and H-CTS group (n=76) (P<.001, both). There were no significant differences in the FR-I/-O among the 3 groups. For the second aim, in the H-CTS group (n=38), there was a significantly lower RMHD compared with both the control (n=20) and H-Control groups (n=30) (0.1%±2.2% vs 3.5±2.3% and 3.8±1.7%, P<.001, both). An RMHD cutoff value of <2.7% yielded a specificity of 80.0%, a sensitivity of 94.7%, and an overall accuracy of 88.2% in the diagnosis of H-CTS.ConclusionsNeither CSA-I/-O or FR-I/-O have a role in the diagnosis of H-CTS. RMHD might be a useful US parameter in the diagnosis of CTS in patients without diabetes undergoing hemodialysis.