Metabolic alkalosis in skilled nursing patients

Renal failure is common among the long-term care (LTC) elderly. Little is known about the acid/base status of these patients. The aim of this study is to evaluate the relationship between the acid base status and renal function in a representative group of skilled nursing patients and relate it to their feeding status. LTC elderly patients, in stable clinical condition, 50 on naso-gastric tube (NGT) feeding, 40 orally fed (OF), were recruited to this study. As controls, we studied a group of 30 elderly independent, ambulatory patients admitted to the acute geriatric departments of the hospital for different causes which were not related to their acid-base status. Venous blood was taken for the routine tests and blood gases. In the LTC study groups a 24-h urine collection was examined for biochemical parameters and calculations of all clearances. Glomerular filtration rate (GFR) was estimated by the Cockroft and Goult and MDRD formulas. Renal function was similar in the two main study groups. Daily secretion of sodium and chloride were 50% lower in the NGT fed patients (p<0.001). The LTC elderly patients had significantly higher venous pH values, with no differences in pCO(2) or HCO(3). An alkalotic state (pH>7.45) was found in 13.6% of them (18% in the NGT and 6.5% in the OF) while none of the independent elderly had such values (p<0.05). Similarly, HCO(3)>34 was found in 12% of the LTC elderly versus none in the independents (p=0.06). Values of pO(2) and O(2) saturation were significantly higher in the nursing elderly and mainly those fed by NGT. Hemoglobin levels had a significantly negative correlation with the pH (r=-0.3, p<0.002). In conclusion, unexpected metabolic alkalosis was found in a group of skilled nursing patients, more prominent in those fed by NGT. This finding warrants the inclusion of routine pH determination in patients whenever pharmacokinetic considerations are essential.     

Delayed and repeated cardiac tamponade following microleak in RCA successfully treated with intra arterial sterile glue injection

Postinterventional pericardial leaks mostly occur intraprocedure or immediately postprocedure and call for an aggressive management right then. Also, once controlled for 24–48 hr, the leaks usually seal themselves spontaneously. We herein describe an unusual case of delayed and continued pericardial leak over 10 days as a result of micro perforation of RCA from the distal wire tip and which was successfully managed by intracoronary injection of sterile synthetic glue, which to the best of our knowledge is the first report of its kind. © 2009 Wiley‐Liss, Inc.     

Add-on cases in the endoscopy unit: Factors that affect volume

BACKGROUND

Although most procedures in the endoscopy clinic are elective, emergency add-on cases in hospital-based endoscopy clinics are common, frequently consuming a great deal of time and resources relative to elective endoscopy procedures.

OBJECTIVE

To determine which specific factors correlate with the high volume of add-on emergency cases in a tertiary care, hospital-based endoscopy unit.

METHODS

A retrospective chart review of all gastrointestinal add-on, and electively booked cases of esophagastroduodenoscopy (EGD), colonoscopy (C) and flexible sigmoidoscopy (FS) procedures from September 2006, to May 2007 was conducted. The day of the week, month, type of procedure and physician were recorded. Emergency add-on procedures performed during the weekends were not assessed. These cases were then compared with elective cases during a similar time frame to determine differences in the aspects of add-on cases versus those that were elective.

RESULTS

Seven hundred twenty-one add-on cases were reviewed (mean patient age 57.4 years; 46% women) and compared with 736 elective cases (mean age 56 years; 49% women; P not significant). Of the add-on cases, 377 (52%) were EGD, 216 C (30%) and 105 (15%) were FS, with 23 combined procedures (3.2%) versus 202 (27%) EGD, 442 (60%) C and 74 (10%) FS in the elective group. Add-on cases were more likely to be EGDs than elective cases (OR 2.7; 95% CI 1.8 to 4.3; P<0.0001) and less likely to be Cs (OR 0.24; 95% CI 0.15 to 0.38; P<0.0001). There were significantly more add-on cases on Mondays (OR 1.7; 95% CI 1.0 to 2.28; P>0.03). Conversely, there were significantly fewer procedures added on Fridays (OR 0.31; 95% CI 0.16 to 0.57; P=0.0001). There were statistically fewer add-on cases in September compared with the other months that were evaluated (OR 0.31; 95% CI 0.11 to 0.78; P=0.0006).

CONCLUSION

With the present system of performing only emergency cases on the weekend, Monday tends to have more add-on cases. Consistent with the fact that upper gastrointestinal bleeding is the most common emergency condition, EGD is more common in add-on cases than with elective cases. Although speculative, the reasons for Friday having fewer add-on cases may be the result of a change of physician on call that day; consequently, most cases may be performed earlier in the week. For unknown reasons, fewer cases tend to be added on in September than in the other months evaluated. These data demonstrate that even in the same institution with similar patients, variability in the number of add-on cases likely is a result of many additional factors governing add-on cases, which require appropriate resource planning to ensure adequate allocation of services to ensure ideal patient care.     

Effect of Dysphasia and Dysphagia on Inpatient Mortality and Hospital Length of Stay: A Database Study

OBJECTIVES: To examine the effect of dysphasia and dysphagia on stroke outcome. DESIGN: Retrospective database study. SETTING: Norfolk, United Kingdom. PARTICIPANTS: Two thousand nine hundred eighty‐three men and women with stroke admitted to the hospital between 1997 and 2001. MEASUREMENTS: Inpatient mortality and likelihood of longer length of hospital stay, defined as longer than median length of stay (LOS). Dysphagia was defined as difficulty swallowing any liquid (including saliva) or solid material. Dysphasia was defined as speech disorders in which there was impairment of the power of expression by speech, writing, or signs or impairment of the power of comprehension of spoken or written language. An experienced team assessed dysphagia and dysphasia using explicit criteria. RESULTS: Two thousand nine hundred eighty‐three patients (1,330 (44.6%) male), median age 78 (range 17–105), were included, of whom 77.7% had ischemic, 10.5% had hemorrhagic, and 11.8% had undetermined stroke types. Dysphasia was present in 41.2% (1,230) and dysphagia in 50.5% (1,506), and 27.7% (827) had both conditions. Having either or both conditions was associated with greater mortality and longer LOS (P<.001 for all). Using multiple logistic regression models controlling for age, sex, premorbid Rankin score, previous disabling stroke, and stroke type, corresponding odds ratios for death and longer LOS were 2.2 (95% confidence interval (CI)=1.8–2.7) and 1.4 (95% CI=1.2–1.6) for dysphasia; 12.5 (95% CI=8.9–17.3) and 3.9 (95% CI=3.3–4.6) for dysphagia, 5.5 (95% CI=3.7–8.2), 1.9 (95% CI=1.6–2.3) for either, and 13.8 (95% CI=9.4–20.4) and 3.7 (95% CI=3.1–4.6) if they had both, versus having no dysphasia, no dysphagia, or none of these conditions, respectively. CONCLUSION: Patients with dysphagia have worse outcome in terms of inpatient mortality and length of hospital stay than those with dysphasia. When both conditions are present, the presence of dysphagia appears to determine the likelihood of poor outcome. Whether this effect is related just to stroke severity or results from problems related directly to dysphagia is unclear.     

Aspergillus fumigatus extract differentially regulates antigen-specific CD4+ and CD8+ T cell responses to promote host immunity

Invasive aspergillosis is a major cause of morbidity and mortality in the severely immunocompromised. The paucity of information about the mechanisms by which Aspergillus-derived factors regulate antigen-specific T cell responses in vivo poses a significant hurdle for devising effective immunization strategies to treat or prevent aspergillosis. By monitoring adoptively transferred T cell receptor transgenic, naive CD4+ (OT-II) and CD8+ (OT-I) T cells specific for distinct peptides of a nominal antigen, chicken ovalbumin (OVA), we demonstrate that sensitization with Aspergillus fumigatus (Af) extract plus OVA protein considerably enhances OT-I and OT-II T cell activation, which results in clonal expansion, primarily as a result of increased proliferation. The sensitization provided by Af extract promotes OT-I expansion accompanied by differentiation into interferon-gamma-producing cytotoxic cells. It is surprising that no effector differentiation of the induced OT-II response was observed. Moreover, the Af extract-induced OT-I and OT-II T cell expansion was transient, as considerable contraction in the numbers of detectable OT-I and OT-II T cells was evidenced by Day 10. In agreement with these observations, sensitization with Af extract plus OVA marginally promoted host immunity against an OVA-expressing thymoma (E.G7) challenge, and the protection was enhanced by resensitization with Af extract and OVA. Our results demonstrate the ability of Af extract to differentially regulate antigen-specific CD4+ and CD8+ T cell responses, resulting in limited augmentation of host immunity. This information suggests that strategies to target CD4+ T cell effector maturation may promote host immunity to Aspergillus and unexpectedly demonstrates the use for Af extract as a CD8+ T cell adjuvant.     

Benefits of an implant platform modification technique to reduce crestal bone resorption

PURPOSE: The alveolar bone resorption that occurs around a 2-piece implant following abutment attachment is a well-documented observation. Several investigators propose that crestal bone loss is a response to the invasion of the biologic width by secondary bacterial colonization and micromovements at the implant-abutment interface. This study proposes the creation of a difference between the diameter of the implant platform and diameter of the abutment (implant platform modification), shifting the implant-abutment interface medially to minimize invasion of the biologic width. MATERIAL AND METHODS: We present a series of 30 control cases and 30 study cases using the platform-modification technique. Interproximal bone resorption on the medial and distal of each implant was assessed using digital radiography at 1, 4, and 6 months after abutment attachment. RESULTS: The mean value of bone resorption observed in the mesial measurement for the control group was 2.53 mm, whereas for those patients included in the study group, it was 0.76 mm. The mean value of bone resorption observed in the distal measurement for patients in the control group was 2.56 mm, whereas for those included in the study group, it was 0.77 mm. CONCLUSIONS: All patients in the study group had a significant reduction of bone loss in comparison to the control group (P < 0.0005).     

Leg muscles differ in spatial activation patterns with differing levels of voluntary plantarflexion activity in humans

BACKGROUND/AIMS: The purpose of this study was to investigate the differential activity between and within individual muscles commonly grouped as plantarflexors. Much of the previous information gathered on plantarflexor activity has been attained using electromyographic recordings. In this study, we used magnetic resonance imaging which allowed us to look at spatial differences in activation. METHODS: Twenty-two human subjects exercised under four different conditions - combinations of loads of 25 or 65% of maximum voluntary contraction (MVC) and the direction of plantarflexion at a sagittal and off-sagittal angle. Before and after each exercise condition, T2-weighted magnetic resonance images were collected. Regions of interest were drawn around the lateral gastrocnemius (LG), medial gastrocnemius (MG), soleus (SOL), peroneus longus (PER) and tibialis anterior (TA) muscles and analyzed for differences. RESULTS: Significant increases in T2 relaxation times during 25% MVC conditions were found for PER and, during the 65% MVC, for all four muscles considered plantarflexors (LG, MG, SOL, PER). No significant differences were found between sagittal and off-sagittal conditions. Within LG and MG, greater increases in T2 times with exercise were found in proximal regions compared with distal regions. CONCLUSION: These results are consistent with suggestions that individual members of muscle groups are capable of differential activity and that for at least some muscles, such differential activity may exist within subvolumes of individual muscles.     

Differentiating Acute Hepatitis B from the First Episode of Symptomatic Exacerbation of Chronic Hepatitis B

In countries with intermediate or high endemicity for chronic hepatitis B virus (HBV) infection, exacerbations of chronic hepatitis B (CHB) are common. We studied the clinical, biochemical, and virologic characteristics of patients first presenting clinically with features of acute icteric hepatitis B, to identify features that might differentiate between acute viral hepatitis B (AVHB) from first episode of exacerbation of chronic hepatitis (ECHB). We retrospectively analyzed 79 patients (mean age 35.4 ± 14 years; M:F = 60:19) who first presented clinically as AVHB, within 4 weeks of onset of symptoms. Patients who on follow-up cleared HBsAg and/or did not develop any clinical, radiologic, or histologic evidence of chronic liver disease (CLD) were categorized as AVHB (group 1). Patients who had persistence of HBsAg and developed clinical, biochemical, radiologic, or histologic evidence of chronic liver disease were categorized as ECHB (group 2). Forty-nine patients were in group 1 and 30 in group 2. The 2 groups were comparable with respect to prodrome, onset of jaundice, serum bilirubin, ALT, prothrombin time prolongation, serum albumin, and A/G ratio. Among group 1 patients, 78% had IgM anti-HBc positive in titers > 1:1000; in group 2, there were negative or positive in titers < 1:1000 in 70% patients (P < .001). Forty-seven of 49 (95.9%) patients in group 1 had HBV-DNA levels < 0.5 pg/mL, whereas 26 of 30 (86.73%) patients in group 2 had levels > 0.5 pg/mL (P ≤ .001). Quantitative HBV DNA and IgM anti-HBc titers at initial presentation can differentiate patients with a true episode of acute hepatitis B from patients with first episode of symptomatic exacerbation of chronic hepatitis B. Clinical and biochemical features do not help in differentiating the two.