Effect of erythropoietin on the incidence of acute kidney injury following complex valvular heart surgery: a double blind,randomized clinical trial of efficacy and safety

Introduction

Recombinant human erythropoietin (EPO) is known to provide organ protection against ischemia-reperfusion injury through its pleiotropic properties. The aim of this single-site, randomized, case-controlled, and double-blind study was to investigate the effect of pre-emptive EPO administration on the incidence of postoperative acute kidney injury (AKI) in patients with risk factors for AKI undergoing complex valvular heart surgery.

Methods

We studied ninety-eight patients with preoperative risk factors for AKI. The patients were randomly allocated to either the EPO group (n = 49) or the control group (n = 49). The EPO group received 300 IU/kg of EPO intravenously after anesthetic induction. The control group received an equivalent volume of normal saline. AKI was defined as an increase in serum creatinine >0.3 mg/dl or >50% from baseline. Biomarkers of renal injury were serially measured until five days postoperatively.

Results

Patient characteristics and operative data, including the duration of cardiopulmonary bypass, were similar between the two groups. Incidence of postoperative AKI (32.7% versus 34.7%, P = 0.831) and biomarkers of renal injury including cystatin C and neutrophil gelatinase-associated lipocalin showed no significant differences between the groups. The postoperative increase in interleukin-6 and myeloperoxidase was similar between the groups. None of the patients developed adverse complications related to EPO administration, including thromboembolic events, throughout the study period.

Conclusions

Intravenous administration of 300 IU/kg of EPO did not provide renal protection in patients who are at increased risk of developing AKI after undergoing complex valvular heart surgery.

Trial registration

Clinical Trial.gov, {"type":"clinical-trial","attrs":{"text":"NCT01758861","term_id":"NCT01758861"}}NCT01758861     

Erythropoietin Ameliorates Oxidative Stress and Tissue Injury following Renal Ischemia/Reperfusion in Rat Kidney and Lung

Objective

To study the effect of erythropoietin (EPO) treatment on renal and lung injury following renal ischemia/reperfusion (I/R).

Materials and Methods

Thirty male Wistar rats were assigned to three groups of 10 rats each. The first group was sham-operated, the second was subjected to renal I/R (30 min of ischemia followed by 24 h of reperfusion). The third group was subjected to renal I/R and treated with EPO in two doses: the first dose 1 h prior to ischemia (1,000 U/kg) and the second dose 6 h after ischemia (1,000 U/kg).

Results

The renal and lung tissue injury index, tissue serum blood urea nitrogen and creatinine (Cr) were higher in the renal I/R group compared to the renal I/R + EPO group; the difference was statistically significant (p < 0.05). Kidney and lung tissue glutathione peroxidase and superoxide dismutase levels were higher in the renal I/R + EPO group than the renal I/R group; the difference was also statistically significant (p < 0.05).

Conclusion

The data showed that EPO pretreatment could be effective in reducing renal and lung injury following renal I/R and could improve the cellular antioxidant defense system. Hence EPO pretreatment may be effective for attenuating renal and lung injury after renal I/R-induced injury during surgical procedures, hypotension, renal transplantation and other conditions inducing renal I/R.Key Words: Erythropoietin, Ischemia/reperfusion, Kidney, Lung     

Clinical features and treatment of primary autoimmune hemolytic anemia in childhood

Background and aim

Autoimmune hemolytic anemia (AIHA) is characterized by autoimmune destruction of erythrocytes. In this retrospective study, the clinical, laboratory features and treatment responses of patients with primary AIHA were evaluated.

Survey of Ontario primary care physicians' experiences with opioid prescribing

Objective

To measure physicians’ experiences with opioid-related adverse events and their perceived level of confidence in their opioid prescribing skills and practices.

Design

Mailed survey.

Setting

The province of Ontario.

Participants

A total of 1000 primary care physicians randomly selected from the College of Physicians and Surgeons of Ontario registration database.

Main outcome measures

Opioid-related adverse events and concerns (eg, number of patients, type of opioid, cause of the event or concern); physicians’ confidence, comfort, and satisfaction with opioid prescribing; physicians’ opinions on strategies to optimize their prescribing; and physicians’ perspectives of their interactions with pharmacists and nurses.

Results

The response rate was close to 66%, for a total of 658 participants. Almost all respondents reported prescribing opioids for chronic pain in the past 3 months. Eighty-six percent of respondents reported being confident in their prescribing of opioids, but 42% of respondents indicated that at least 1 patient had experienced an adverse event related to opioids in the past year, usually involving oxycodone, and 16.3% of respondents did not know if their patients had experienced any opioid-related adverse events. The most commonly cited factors leading to adverse events were that the patient took more than prescribed, the prescribed dose was too high, or the patient took alcohol or sedating drugs with the opioids. Most physicians had concerns about the opioid use of 1 or more of their patients; concerns included running out of opioids early, minimal access to pain and addiction treatment, and addiction and overdose. The reported number of physicians’ patients taking opioids was positively associated with their confidence and comfort levels in opioid prescribing and negatively associated with their belief that many patients become addicted to opioids.

Conclusion

Most physicians have encountered opioid-related adverse events. Comprehensive strategies are required to promote safe prescribing of opioids, including guidelines and comprehensive office-system materials.     

Graves Hyperthyroidism After Stopping Immunosuppressive Therapy in Type 1 Diabetic Islet Cell Recipients With Pretransplant TPO Autoantibodies

OBJECTIVE

After an initially successful islet cell transplantation, a number of patients return to C-peptide negativity, and therefore immunosuppressive therapy is discontinued. Some are then found to have developed Graves disease. We examined the risk of Graves disease after immunosuppression.

RESEARCH DESIGN AND METHODS

Immunosuppressive therapy was stopped in 13 type 1 diabetic islet cell recipients who had received one course of antithymocyte globulin and maintenance doses of mycophenolate mofetil and a calcineurin inhibitor. None had a history of thyroid disease.

RESULTS

In four patients, clinical Graves hyperthyroidism was observed within 21 months after discontinuation and 30–71 months after the start of immunosuppressive therapy. All four patients exhibited a pretransplant positivity for thyroid peroxidase (TPO) autoantibodies, while the nine others were TPO negative pre- and posttransplantation.

CONCLUSIONS

Type 1 diabetic recipients of islet cell grafts with pretransplant TPO autoantibody positivity exhibit a high risk for developing Graves hyperthyroidism after immunosuppressive therapy is discontinued for a failing graft.Islet cell transplantation has been shown to reproducibly achieve metabolic correction in nonuremic type 1 diabetic patients (1,2). However, in the years following transplantation, several of them return to C-peptide negativity and thus to a discontinuation of their immunosuppressive therapy (2).     

Differential diagnosis and management of a patient with peripheral vestibular and central nervous system disorders: a case study

Background

Clinical examination and management of patients with meningiomas is primarily dependent upon appropriate diagnosis of tumor type and surgical intervention. Physical therapists should be able to identify patients presenting with signs and symptoms suggestive of potential central nervous system (CNS) disorders and refer the patient appropriately.

Patient characteristics

In this case report, a 52-year-old female was referred to physical therapy after 18 months of unresolved dizziness.

Examination

Oculomotor examination revealed evidence of peripheral vestibular and potential CNS disorders. The physical therapist referred the patient to a physician who ordered magnetic resonance imaging (MRI).

Intervention

The patient received five physical therapy sessions while waiting for the MRI which revealed a meningioma. The meningioma was surgically removed and the patient was subsequently relieved of all symptoms.

Outcomes

Despite the presence of the meningioma, the patient reported improved stability during work-related activities and decreased dizziness as a result of physical therapy intervention pre-operatively.

Discussion

This case report emphasizes the importance of a physical therapists ability to perform and interpret an oculomotor examination in a patient presenting with signs consistent with peripheral vestibular and CNS disorders. It also demonstrates the role of physical therapy in collaboration with physicians in order to provide appropriate patient care management.     

Patient satisfaction with access and continuity of care in a multidisciplinary academic family medicine clinic

Objective

To determine patient satisfaction with care provided at a family medicine teaching clinic.

Design

Mailed survey.

Setting

Victoria Family Medical Centre in London, Ont.

Participants

Stratified random sample of 600 regular patients of the clinic aged 18 years or older; 301 responses were received.

Main outcome measures

Patient satisfaction with overall care, wait times for appointments, contact with physicians, and associated demographic factors. Logistic regression analysis and analysis were used to determine the significance of factors associated with satisfaction.

Results

The response rate was 50%. Overall, 88% of respondents were fairly, very, or completely satisfied with care. Older patients tended to be more satisfied. Patients who were less satisfied had longer wait times for appointments (P < .001) and reduced continuity with specific doctors (P = .004). More satisfied patients also felt connected through other members of the health care team.

Conclusion

Patients were generally satisfied with the care provided at the family medicine teaching clinic. Older patients tended to be more satisfied than younger patients. Points of dissatisfaction were related to wait times for appointments and continuity with patients’ usual doctors. These findings support the adoption of practices that reduce wait times and facilitate continuity with patients’ usual doctors and other regular members of the health care team.     

Deep vein thrombosis among injecting drug users in Sheffield

Aims

To identify the proportion of patients testing positive for deep vein thrombosis (DVT) who are injecting drug users (IDUs), and examine differences in the investigation and management of this group compared with non‐IDUs.

Methods

Analysis of data collected from emergency department records and a review of patient notes.

Results

All patients in this study who were known to inject recreational drugs tested positive for DVT on Doppler ultrasound scan.

Conclusions

IDUs should be considered at high risk of developing DVT and should be investigated accordingly.To identify the proportion of patients testing positive for deep vein thrombosis (DVT) who are injecting drug users (IDUs).To establish if the IDUs are managed as inpatients more or less often than their non‐IDU counterparts.To highlight any differences in the medical management of patients with confirmed DVT in each group (IDUs and non‐IDUs).     

Association of primary care physician sex with cervical cancer and mammography screening

Objective

To assess whether the sex of primary care physicians is associated with differing rates of cervical cancer and mammography screening in a contemporary multicultural context.

Design

Structured medical record review of a retrospectively defined cohort.

Setting

Academic urban primary care clinic in Montreal, Que.

Participants

Seven male physicians and 9 female physicians, and all female patients aged 14 to 69 years registered to one of the physicians (N = 1948).

Main outcome measures

Screening compliance rates as measured by the elapsed time between the last visit and cervical cancer screening for all women in the study. In addition, in women aged 50 to 69 years, elapsed time between the last visit and mammography screening.

Results

Crude rates of Papanicolaou tests for patients of female primary care physicians were higher than for patients of male primary care physicians in all patient age groups. The lowest rates of Pap testing were among the youngest and oldest patients. After adjustment for patient age, first language, and region of birth, as well as physician age, the odds ratio of having a Pap test was 2.24 (95% CI 1.18 to 4.28) for the patients of female physicians, relative to those of male physicians. The adjusted odds ratio for mammography screening was 1.25 (95% CI 0.97 to 1.61) for patients of female physicians.

Conclusion

Male primary care physician sex is associated with lower rates of cervical cancer screening in an urban multicultural context. The study did not detect a physician sex effect in the mammography cohort.     

Estimating patient demographic profiles from practice location

Objective

To test the accuracy of imputing a practice population’s average socioeconomic characteristics (such as average education levels and average income) using census data centred on the location of the practice.

Design

Comparison of census data with survey data collected in primary care offices.

Setting

Ontario.

Participants

A cross-sectional sample of patients from 116 urban practices.

Main outcome measures

Patient data were compared with census data at different levels of aggregation using mean absolute relative error (ARE), median ARE, and Spearman rank correlations.

Results

A total of 4413 patient surveys were collected. Differences between patient profiles and census data were large. Most mean AREs were clustered between 0.70 and 0.80, and median AREs were as high as 1.67. Correlations were low (ρ = 0.02) to moderate (ρ = 0.48). These results held across both levels of aggregation.

Conclusion

The use of imputation techniques based on practice location is inadvisable, given the large differences that were observed.     

Referring patients with chronic noncancer pain to pain clinics: survey of Ontario family physicians

Objective

To examine the factors associated with FPs’ referrals of patients with chronic noncancer pain to a tertiary care pain clinic.

Design

A questionnaire-based survey; data were analyzed using univariate methods.

Setting

A tertiary care pain clinic in Toronto, Ont.

Participants

All FPs who referred patients to the clinic between 2002 and 2005.

Main outcome measures

Variables explored included FPs’ sex, age, and ethnic background, ethnicity of patient groups seen, and FPs’ rationale or barriers influencing referrals to specialized pain clinics.

Results

The response rate was 32% (47 of 148 FPs). There were no statistically significant differences between respondents and non-respondents in sex, age, duration of practice, and university of graduation, or between the variables of interest and the referral patterns of those who did respond. The mean age of respondents was 50 years; 47% of the FPs identified themselves as Canadian; and one-third of the respondents indicated that they referred more than 30 patients to pain clinics each year. The 3 most frequently cited reasons prompting referral to pain clinics were requests for nerve blocks or other injections, desire for the expertise of the program, and concerns about opioids; the 3 most prevalent barriers were long waiting lists, patient preference for other treatments, and distance from the clinic.

Conclusion

Although the results of our survey of FPs identify certain barriers to and reasons for referring patients to pain clinics, the results cannot be generalized owing to the small sample of FPs in our study. Larger studies of randomly selected FPs, who might or might not refer patients to pain clinics, are needed to provide a better understanding of chronic noncancer pain management needs at the primary care level.     

Short-term effects of thoracic spinal manipulations and message conveyed by clinicians to patients with musculoskeletal shoulder symptoms: a randomized clinical trial

Study design:

Randomized clinical trial.

Objectives:

To evaluate the effects of high-velocity, low-amplitude thrust manipulations (HVLATMs) and various messages on patients with musculoskeletal shoulder symptoms.

Background:

Previous studies indicated that HVLATM directed at the thoracic spine and ribs resulted in improvements of shoulder range of motion, pain, and disability in patients with musculoskeletal shoulder symptoms. These studies did not explore if the outcome was dependent on thrust location, clinician communication with the patient, or if there were any lasting effects.

Methods:

A consecutive sample of 100 patients with shoulder pain was randomized into four groups. Patients received one intervention session including: six thoracic HVLATM (spine versus scapula), a message about HVLATM (neutral versus positive), and standardized home exercises. Outcome measures included shoulder Numeric Pain Rating Scale (NPRS), NPRS with impingement testing, and Shoulder Pain and Disability Index (SPADI). Measurements were recorded prior to intervention, immediately following intervention, and at short-term follow-up. Kruskal–Wallis statistics were used for between-group comparisons and Wilcoxon signed ranks for within-group comparisons.

Results:

Eighty-eight patients (22 per group) completed the study. Statistically significant differences were found for within-group comparisons for most time points assessed. No statistical differences were found for between-group comparisons.

Conclusion:

Patients improved following the interventions. Neither the type of HVLATM nor the message conveyed to the patients had a significant effect on the patients’ improvements.

Level of evidence:

1b     

Case report: Inflammatory myofibroblastic tumor of pancreatic origin in a patient with down syndrome: The role of diagnostic ultrasound

Introduction

Inflammatory myofibroblastic tumor (IMT) is a benign solid tumor of uncertain etiology.

Materials and methods

We report a case of a 4-year-old Down syndrome affected child, who had a pancreatic mass identified by ultrasonography (US) and confirmed by computed tomography (CT).

Results

Monitoring of IMT was performed by serial US studies, and at follow-up after 4 years there was no relapse.

Discussion

As radical removal of the lesion was not possible, the patient was successfully treated with nonsteroidal anti-inflammatory drugs (NSAIDs). It was decided to monitor the lesion by serial US in order to reduce the number of CT examinations and thereby avoid excessive exposure to ionizing radiation. It is widely reported in the literature that repeated CT scans are associated with increased exposure to radiation which may cause cancer, a fact which should not be overlooked in children.     

Disposition of emergency department patients with psychiatric comorbidity: results from the 2004 National Hospital Ambulatory Medical Care Survey

Background

Few emergency department (ED) studies have examined how psychiatric comorbidity relates to hospitalisation decisions.

Methods

We assessed the relationship of psychiatric comorbidity to hospitalisation decisions among ED patients in the 2004 National Hospital Ambulatory Medical Care Survey.

Results

Patients with psychiatric comorbidity were five times more likely to be hospitalised than patients with a single psychiatric diagnosis. The most frequent psychiatric comorbidities involved substance use disorders (SUDs).

Conclusions

Psychiatric disorders are underdiagnosed among ED patients. We believe that this underdiagnosis may be partly responsible for the high hospitalisation rates of ED patients with SUDs     

Impact of Anemia on In-Hospital, One-Month and One-Year Mortality in Patients with Acute Coronary Syndrome from the Middle East

Aim

The aim of this study was to evaluate the impact of admission anemia on in-hospital, one-month, and one-year mortality in patients from the Middle East with acute coronary syndrome (ACS).

Methods

Data were analyzed from 7922 consecutive patients admitted to hospitals throughout six Middle-Eastern countries with the final diagnosis of ACS, as part of Gulf RACE II (Registry of Acute Coronary Events II). Anemia at admission was defined according to the World Health Organization definition (<13 g/dL in men and <12 g/dL in women). Analyses were conducted using univariate and multivariate statistical techniques.

Results

The median age of the cohort was 56 (48–65) years, with the majority being male (79%). Anemia at admission was present in 2241 patients (28%). Patients with anemia were more likely to have in-hospital complications including heart failure, recurrent ischemia, re-infarction, cardiogenic shock, stroke, and major bleed. Even after adjustment, anemia was still associated with mortality at in-hospital (odds ratio [OR]=1.71, 95% confidence interval [CI], 1.34–2.17; P<0.001), at one-month (OR=1.34, 95% CI, 1.06–1.71; P=0.016), and at one-year (OR=1.22, 95% CI, 1.01–1.49; P=0.049) post-admission with ACS.

Conclusions

Admission anemia in patients with ACS from six Middle-Eastern countries was strongly associated with mortality at in-hospital, one-month, and at one-year. Hence, admission anemia must be considered in the initial risk assessment of ACS patients along with other risk scores.     

Treatment of herpes zoster

OBJECTIVE

To review the evidence regarding treatment of herpes zoster (HZ) in the short-term, focusing on the prevention of postherpetic neuralgia (PHN).

QUALITY OF EVIDENCE

The evidence relating to treatment of HZ is derived mainly from randomized controlled trials (level I evidence).

MAIN MESSAGE

Antiviral drugs might have some effect on the severity of acute pain and on the duration of skin lesions. Corticosteroids also alleviate acute pain. Oral antiviral medication reduces the risk of eye complications in patients with ophthalmic HZ. There is no convincing evidence that antiviral medication reduces the risk of PHN. Some studies, however, have shown that famciclovir and valacyclovir shorten the duration of PHN. The effectiveness of amitriptyline or cutaneous and percutaneous interventions in preventing PHN has not been proven.

CONCLUSION

Oral antiviral drugs should be prescribed to elderly HZ patients with high risk of PHN. Moreover, these drugs should be prescribed to all patients at the first signs of ophthalmic HZ, irrespective of age or severity of symptoms.     

Treatment and follow-up of anxiety and depression in clinical-scenario patients: Survey of Saskatchewan family physicians

Objective

To explore family physicians’ recommendations for treatment of, and number of weeks to first follow-up visit for, clinical-scenario patients presenting with symptoms of either a major depressive episode (MDE) or generalized anxiety disorder (GAD), as well as physicians’ perceived barriers to optimal care for these patients.

Design

Cross-sectional survey.

Setting

Saskatchewan.

Participants

A total of 331 family physicians practising in Saskatchewan as of December 2007.

Main outcome measures

Type of treatment and number of weeks to first follow-up visit recommended for clinical-scenario patients, as well as family physicians’ barriers to providing optimal care.

Results

The response rate was 49.7% (331 of 666 surveys returned). Most physicians recommended treatment of the GAD-scenario patient (93.7%) and the MDE-scenario patient (90.1%). Most physicians recommended immediate (65.6%) rather than delayed (28.1%) treatment of the GAD-scenario patient, and immediate (55.6%) rather than delayed (34.5%) treatment of the MDE-scenario patient. Pharmacotherapy alone (26.3%) was the most commonly recommended immediate treatment of the GAD-scenario patient; combination pharmacotherapy and counseling (15.8%) was the most commonly recommended immediate treatment of the MDE-scenario patient. Most physicians recommended that the first follow-up visit occur within 2 weeks for the GAD (79.4%) and the MDE (82.5%) clinical-scenario patients. Physicians were more likely to identify themselves rather than patients and the health care system as barriers to providing optimal care to the GAD (39.4%) and the MDE (39.8%) clinical-scenario patients.

Conclusion

Most family physicians recommend immediate treatment and early follow-up for patients presenting with symptoms of GAD or MDE. Physician-related barriers outweigh patient and health system barriers to providing optimal care to patients with common psychiatric disorders.