Association of environmental tobacco smoke at work and forced expiratory lung function among never smoking asthmatics and non-asthmatics

Inconsistencies across studies on the association of environmental tobacco smoke (ETS) and pulmonary function may be dlarified addressing potentially susceptible subgroups. We determined the association of ETS exposure at work with FVC, FEV1, and FEF 25–75% in life-time never smokers (N=3534) of the SAPALDIA random population sample (age 18–60). We considered sex, bronchial reactivity, and asthma status as a priori indicators to identify susceptible riskgroups. The multivariate regression models adjusted for height, age, education, dustlaerosol exposure, region, and ETS at home. Overall, ETS was not significantly associated with FVC (0.7%; ?0.4 to +1.8), FEV1 (?0.1%; 95% Cl:?1.3 to +1.1) or FEF 25–75% (?1.9%;?4.2 to +0.5). Effects were observed among asthmatics (n=325), FEV1 (?4.8%; 0 to?9.2); FEF 25–75% (?12.4%; ?3.7 to ?20.4); FVC; (?1.7%; +2.1 to ?5.5), particularly in asthmatic women (n=183): FVC ?4.4% (?9.6 to +1.1); FEV1: ?8.7% (?14.5 to ?2.5); FEF 25–75%; ?20.8% (?32 to ?7.6), where duration of ETS exposure at work was associated with lung function (FEV 1–6% per hour of ETS exposure at work (p=0.01); FEF 25–75%: ?3.4%/h (p<0.05). In non-asthmatic women (n=1963) and in men no significant effect was observed. The size of the observed effect among susceptible subgroups has to be considered clinically relevant. However, due to inherent limitations of this cross-sectional analysis, selection or information biases may not be fully controlled. For example, asthmatic women reported higher ETS exposure at work than asthmatic men. Given the public health importance to identify susceptible subgroups, these results ought to be replicated.     

Management of 350 aneurysmal subarachnoid hemorrhages in 22 Italian neurosurgical centers

OBJECTIVE: To collect information on clinical practice and current management strategies in 22 Italian neurosurgical hospitals for patients with aneurysmal subarachnoid hemorrhage. DESIGN AND SETTING: Observational 6-month study for prospective data collection. PATIENTS: 350 cases of aneurysmal subarachnoid hemorrhage. MEASUREMENTS AND RESULTS: Each center enrolled from 4-36 patients. Neurological deterioration (24%) was more frequent in patients with higher Fisher classification, and with pretreatment rebleeding and it was associated with an unfavorable outcome (46%, 36/78, vs. 33%, 83/251). Aneurysms were mainly secured by clipping (55%, 191/350). An endovascular approach was utilized in 35% (121/350). The more frequent medical complications were fever, recorded in one-half of cases, pneumonia (18%), sodium disturbances (hyponatremia 22%, hypernatremia 17%), cardiopulmonary events as neurogenic pulmonary edema (4%) and myocardial ischemia (5%). Intracranial hypertension was experienced in one-third of the patients, followed by hydrocephalus (29%) and vasospasm (30%). Cerebral ischemia was found in an about one-quarter of the cohort. To identify the independent predictors of outcome we developed a model in which the dichotomized Glasgow Outcome Scale was tested as function of extracranial and intracranial complications. Only high intracranial pressure and deterioration in neurological status were independent factors related to unfavorable outcome. CONCLUSIONS: Our data confirm that in every step of care there is extreme heterogeneity among centers. These patients are complex, with comorbidities, immediate risk of rebleeding, and delayed risk of intracranial and medical complications. Following SAH early treatment and careful intensive care management requires the careful coordination of the various clinical specialties.     

Consensus Meeting on Microdialysis in Neurointensive Care

Background Microdialysis is used in many European neurointensive care units to monitor brain chemistry in patients suffering subarachnoid hemorrhage (SAH) or traumatic brain injury (TBI).Discussion We present a consensus agreement achieved at a meeting in Stockholm by a group of experienced users of microdialysis in neurointensive care, defining the use of microdialysis, placement of catheters, unreliable values, chemical markers, and clinical use in SAH and in TBI.Conclusions As microdialysis is maturing into a clinically useful technique for early detection of cerebral ischemia and secondary brain damage, there is a need to following such definition regarding when and how to use microdialysis after SAH and TBI.     

The Interplay of Socioeconomic Status,Distance to Center,and Interdonor Service Area Travel on Kidney Transplant Access and Outcomes

Background and objectives: Variation in kidney transplant access across the United States may motivate relocation of patients with ability to travel to better-supplied areas.Design, setting, participants, & measurements: We examined national transplant registry and U.S. Census data for kidney transplant candidates listed in 1999 to 2009 with a reported residential zip code (n = 203,267). Cox''s regression was used to assess associations of socioeconomic status (SES), distance from residence to transplant center, and relocation to a different donation service area (DSA) with transplant access and outcomes.Results: Patients in the highest SES quartile had increased access to transplant compared with those with lowest SES, driven strongly by 76% higher likelihood of living donor transplantation (adjusted hazard ratio [aHR] 1.76, 95% confidence interval [CI] 1.70 to 1.83). Waitlist death was reduced in high compared with low SES candidates (aHR 0.86, 95% CI 0.84 to 0.89). High SES patients also experienced lower mortality after living and deceased donor transplant. Patients living farther from the transplant center had reduced access to deceased donor transplant and increased risk of post-transplant death. Inter-DSA travel was associated with a dramatic increase in deceased donor transplant access (HR 1.94, 95% CI 1.88 to 2.00) and was predicted by high SES, white race, and longer deceased-donor allograft waiting time in initial DSA.Conclusions: Ongoing disparities exist in kidney transplantation access and outcomes on the basis of geography and SES despite near-universal insurance coverage under Medicare. Inter-DSA travel improves access and is more common among high SES candidates.It has been nearly a decade since the Department of Health and Human Services issued the Final Rule regarding the operations of the Organ Procurement and Transplantation Network (OPTN), which directs the transplant community to reduce disparity in access to transplantation, to allocate organs over as wide of a geographic area possible, and to ensure that organs are allocated on the basis of medical necessity (1). Reflecting such directives, the kidney allocation algorithm has been adjusted to reduce the importance of HLA matching to improve access to transplantation for racial and ethnic minorities (2). However, with the exception of the recent revisions to the heart transplant allocation system (3), there have been no successful revisions to the current geographic boundaries of organ allocation.Current deceased donor allocation policy is based on a system in which kidneys are initially offered to transplant centers in the local geographic area of recovery (donation service area [DSA]) before sharing within 1 of 11 geographic United Network for Organ Sharing (UNOS) regions, which each include ≥1 DSAs. As a result of substantial differences in the ratio of organs recovered to waiting candidates, there is dramatic variation in average waiting times across the UNOS regions, ranging from <2 years to nearly 7 years (4–7).The role of socioeconomic status (SES) in determining access to transplantation services is complex because SES affects care throughout the transplant process (8,9). Patients with low SES often delay seeking medical care and lack access to specialty services, leading to delays in transplant referral, evaluation, and listing (10,11). Despite near-universal eligibility for Medicare coverage on the basis of ESRD provisions, insurance status continues to influence outcome and access to transplantation. For example, kidney transplant candidates with Medicare-only health insurance were recently shown to have a 78% lower likelihood of being pre-emptively listed for transplant compared with privately insured patients, thereby increasing waiting list morbidity and reducing post-transplant graft survival (12). Conversely, patients with college (odds ratio 1.20, P < 0.001) or postgraduate education (odd ratio 1.65, P < 0.001) were significantly more likely to be listed before dialysis.The study presented here examined the associations of SES, distance from an individual''s residence to the transplant center (quantified as travel time), and choosing to travel to a different DSA with kidney transplant access and outcomes in the United States. Specifically, we examined the differential effects of these sociodemographic factors among listed candidates and recipients of live and deceased donor organs. We sought to understand the potential contributions of SES, geographic differences in place of residence, and individual relocation behaviors to current disparities in transplant access and outcomes.     

Fatal disseminated toxoplasmosis during primary HIV infection

Toxoplasmosis is a well recognized manifestation of AIDS, but the disseminated disease is a rare condition and it has not been associated to HIV seroconversion to our knowledge. We describe a fatal episode of disseminated T. gondii acute infection with massive organ involvement during primary HIV infection. The serological data demonstrate primary T. gondii infection. The avidity index for HIV antibodies supports recent HIV-1 infection.