Who among cytomegalovirus-seropositive liver transplant recipients is at risk for cytomegalovirus infection?

A vast majority of the transplant recipients are cytomegalovirus (CMV)-seropositive (R+). We sought to assess variables predictive of CMV infection, specifically in R+ liver transplant recipients. Study patients comprised 182 consecutive liver transplant recipients who survived at least 14 days after transplantation. Surveillance testing was used to detect CMV infection. Pre-emptive therapy was employed for the prevention of CMV disease, however, no antiviral prophylaxis was used for CMV infection. CMV infection developed in 32.5% (38 of 117) of R+ patients, 84.6% (33 of 39) of R-/D+, and 3.8% (1 of 26) of R-/D- patients. In R+ patients, Hispanic race (21.6% vs. 7.8%, P = 0.06), donor CMV seropositivity (73.7% vs. 45.6%, P = 0.005), and hepatocellular carcinoma (23.7% vs. 6.3%, P = 0.05) correlated with a higher risk of CMV infection. In a multivariate model, Hispanic race (OR: 3.5, 95% CI: 1.03-11.6, P = 0.045), donor CMV serostatus (OR: 4.0, 95% CI: 1.6-10.2, P = 0.003) and hepatocellular carcinoma (OR: 5.8, 95% CI: 1.6-20.5, P = 0.006) were all significant independent predictors of CMV infection. The aforementioned variables did not portend a higher risk of CMV infection in R-/D+ patients; donor CMV seropositivity overwhelmed all other risk factors in R- patients (P < 0.00001). In conclusion, CMV-seropositive liver transplant recipients at risk for CMV infection can be identified based on readily assessable variables. Preventive strategies may be selectively targeted toward these patients.     

Tibialis posterior dysfunction as a cause of flatfeet in elderly patients

Background: Tibialis posterior is a frequent cause of an acquired flatfoot deformity and the prevalence is not known. If tibialis posterior dysfunction was found to occur frequently, a greater awareness may result leading to earlier patient diagnosis, referral and treatment.Objectives: To validate a screening questionnaire for tibialis posterior dysfunction, and to investigate the prevalence of tibialis posterior dysfunction in a high-risk patient population.Methods: The screening questionnaire was given prospectively to 65 patients (44 females, 21 males; mean age 79.6 years) attending an unrelated care of the elderly appointment. A foot and ankle surgery fellow separately examined all feet for tibialis posterior dysfunction.Results: The survey was 100% sensitive and 98.3 % specific at detecting tibialis posterior dysfunction. Six of the 65 patients (5 females, 1 male) had tibialis posterior dysfunction, and two had bilateral involvement. All six of the patients had longstanding symptoms, all had consulted their doctor and three had seen an orthopaedic surgeon; only one of the six patients had been correctly diagnosed.Conclusions: This study suggests that tibialis posterior dysfunction occurs frequently, but is seldom diagnosed in elderly women. Further epidemiologic studies are needed to determine the true prevalence.     

Serum and peritoneal dialysate thyroid hormone levels in patients on continuous ambulatory peritoneal dialysis

Thyroid function tests were performed on 16 clinically euthyroid patients with end-stage renal failure undergoing regular haemodialysis or continuous ambulatory peritoneal dialysis and compared with 8 healthy subjects. The patient groups were carefully matched, especially regarding relative duration of dialysis (mean of 24 months). Total serum thyroxine, total triiodothyronine, free thyroxine, free triiodothyronine and reverse triiodothyronine were significantly lower in both patient groups than control. The thyrothrophin response to the standard thyrotrophin-releasing hormone test was delayed and blunted. Using a novel concentration technique we measured loss of T4 in peritoneal dialysate effluent and found it to be approximately 10% of daily thyroidal T4 release.