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Adult Patients (adult + patient)
Kinds of Adult Patients Selected AbstractsSuccessful Treatment of an Adult Patient with an Aortopulmonary Window and Severe Unilateral Pulmonary HypertensionCONGENITAL HEART DISEASE, Issue 6 2009Olaf Franzen MD ABSTRACT A 40-year-old woman with an aortopulmonary window combined with a severe stenosis of the right pulmonary artery was successfully treated by surgical closure of the defect and pulmonary artery patch plasty of the pulmonary stenosis. Even though the vasculature of the left lung was severely damaged preoperatively, the resulting pressure in the lung after surgical correction was only mildly elevated. [source] Persistence of Left Supracardinal Vein in an Adult Patient with Heart,Hand Syndrome and Cardiac PacemakerCONGENITAL HEART DISEASE, Issue 3 2008Jan Nemec MD ABSTRACT A patient with a sporadic heart,hand syndrome, which includes thumb hypoplasia, septum primum atrial septal defect, and cleft mitral valve is described. During attempted placement of a pacemaker lead, persistence of left superior and inferior vena cava was found in addition to the right-sided caval veins. This corresponds to persistence of left-sided supracardinal vein present during fetal development. [source] Congenital Left Ventricular Splint in an Adult Patient with Unrepaired Anomalous Left Coronary Artery from the Pulmonary ArteryCONGENITAL HEART DISEASE, Issue 4 2007Adam M. Sabbath MD ABSTRACT A 24-year-old woman presented with a recent increase in dyspnea on exertion and development of presyncope. The patient stated that she has reproducible episodes of dizziness and near fainting when she climbs a flight of stairs and activity is limited to a slow gait. [source] An Alternative Technique for the Atrial Switch Operation for Transposition of the Great Arteries in an Unoperated Adult PatientJOURNAL OF CARDIAC SURGERY, Issue 4 2010Sachin Talwar M.Ch. The relevant literature on late natural survivors with this condition is reviewed and the technical aspects of an alternative technique for accomplishing a successful atrial switch in this situation are discussed. (J Card Surg 2010;25:406-409) [source] Anesthesia for Heart or Single or Double Lung Transplantation in the Adult PatientJOURNAL OF CARDIAC SURGERY, Issue 3 2000Paul M. Chetham M.D. Patients with end-stage cardiac dysfunction have an impaired response to ,-agonist due to receptor downregulation. These patient will have isolated left ventricular dysfunction secondary to ischemic heart disease or present with biventricular failure with or without significant pulmonary hypertension. Increasingly, more patients have undergone prior major cardiac procedures and are at risk for significant perioperative bleeding. Patients undergoing single or double lung are particularly challenging because most of these procedures are performed without the aid of cardiopulmonary bypass. The anesthesiologist must be proficient at the management of one-lung ventilation techniques and have a rational physiologic approach to the management of intraoperative hypoxemia and auto-PEEP. [source] Clinical Evaluation and Treatment of the Adult Patient With Suspected Primary Immunodeficiency Disease: A Case AnalysisJOURNAL OF THE AMERICAN ACADEMY OF NURSE PRACTITIONERS, Issue 4 2004Debbie Ciesielka MSN Purpose To describe immunoglobulin G2 (IgG2) sub-class deficiency in the context of primary immunodeficiency disorders, their pathophys-iology, epidemiology, clinical evaluation, and management. Data Sources Actual case study and extensive review of the scientific and medical literature. Conclusions Consideration should be given to primary immunodeficiency diseases as one possible cause of recurrent upper and lower respiratory tract infections in patients at any age. Early diagnosis and intervention can significantly reduce the burden of these diseases. Implications for Practice Advanced practice nurses need to keep pace with the ever-expanding field of immunity. Knowledge of basic principles of the immune system facilitates a logical approach to the evaluation and management of primary immunodeficiency diseases. [source] Eslicarbazepine Acetate: A Double-blind, Add-on, Placebo-controlled Exploratory Trial in Adult Patients with Partial-onset SeizuresEPILEPSIA, Issue 3 2007Christian Elger Summary:,Objective: To explore the efficacy and safety of eslicarbazepine acetate (BIA 2-093), a new antiepileptic drug, as adjunctive therapy in adult patients with partial epilepsy. Methods: A multicenter, double-blind, randomized, placebo-controlled study was conducted in 143 refractory patients aged 18,65 years with ,4 partial-onset seizures/month. The study consisted of a 12-week treatment period followed by a 1-week tapering off. Patients were randomly assigned to one of three groups: treatment with eslicarbazepine acetate once daily (QD, n = 50), twice daily (BID, n = 46), or placebo (PL, n = 47). The daily dose was titrated from 400 mg to 800 mg and to 1,200 mg at 4-week intervals. The proportion of responders (patients with a ,50% seizure reduction) was the primary end point. Results: The percentage of responders versus baseline showed a statistically significant difference between QD and PL groups (54% vs. 28%; 90% CI =,,, ,14; p = 0.008). The difference between the BID (41%) and PL did not reach statistical significance (90% CI =,,, ,1; p = 0.12). A significantly higher proportion of responders in weeks 5,8 was found in the QD group than in the BID group (58% vs. 33%, respectively, p = 0.022). At the end of the 12-week treatment, the number of seizure-free patients in the QD and BID groups was 24%, which was significantly different from the PL group. The incidence of adverse events was similar between the treatment groups and no drug-related serious adverse events occurred. Conclusion: Eslicarbazepine acetate was efficacious and well tolerated as an adjunctive therapy of refractory epileptic patients. [source] Coblation versus Unipolar Electrocautery Tonsillectomy: A Prospective, Randomized, Single-Blind Study in Adult Patients,THE LARYNGOSCOPE, Issue 8 2006J Pieter Noordzij MD Abstract Objectives: To determine if the coblation tonsillectomy (subcapsular dissection) results in less postoperative pain, equivalent intraoperative blood loss, equivalent postoperative hemorrhage rates, and faster healing compared with tonsillectomy was performed using unipolar electrocautery in adult patients. Study Design: The authors conducted a prospective clinical trial. Methods: Forty-eight patients underwent tonsillectomy and were randomly assigned to have one tonsil removed with coblation and the other with unipolar electrocautery. Outcome measures included time to remove each tonsil, intraoperative blood loss, patient-reported pain, postoperative hemorrhage, and amount of healing 2 weeks after surgery. Results: Mean time to remove a single tonsil with coblation and electrocautery was 8.22 minutes and 6.33 minutes, respectively (P = .011). Mean intraoperative blood loss for each technique was less than 10 mL. Postoperative pain was significantly less with coblation as compared with electrocautery: 18.6% less painful during the first week of recovery. Seventy percent of blinded patients identified the coblation side as less painful during the overall 14-day convalescent period. Postoperative hemorrhage rates (2.1% for coblation and 6.2% for electrocautery) were not significantly different. No difference in tonsillar fossa healing was observed between the two techniques 2 weeks after surgery. During nine of the 48 surgeries, wires on the tip of the coblation handpiece experienced thinning to the point of discontinuity while removing a single tonsil. Conclusions: Coblation subcapsular tonsillectomy was less painful than electrocautery tonsillectomy in this 48-patient group. On average, intraoperative blood loss was less than 10 mL for both techniques. Postoperative hemorrhage rates and the degree of tonsillar fossa healing were similar between the two techniques. The coblation handpiece experienced degradation of vital wires in 18% of cases necessitating the use of a second, new handpiece. [source] Recent Trends in Early Outcome of Adult Patients after Heart Transplantation: A Single-institution Review of 251 Transplants Using Standard Donor Organs,AMERICAN JOURNAL OF TRANSPLANTATION, Issue 6 2002Feng-Chun Tsai Older age, prior transplantation, pulmonary hypertension, and mechanical support are commonly seen in current potential cardiac transplant recipients. Transplants in 436 consecutive adult patients from 1994 to 1999 were reviewed. There were 251 using standard donors in 243 patients (age range 18,69 years). To emphasize recipient risk, 185 patients who received a nonstandard donor were excluded from analysis. The indications for transplant were ischemic heart disease (n = 123, 47%), dilated cardiomyopathy (n = 82, 32%), and others (n = 56, 21%). One hundred and forty-nine (57%) recipients were listed as status I; 5 and 6% were supported with an intra-aortic balloon and an assist device, respectively. The 30-d survival and survival to discharge were 94.7 and 92.7%, respectively; 1-year survival was 89.1%. Causes of early death were graft failure (n = 6), infection (n = 4), stroke (n = 4), multiorgan failure (n = 3) and rejection (n = 2). Predictors were balloon pump use alone (OR = 11.4, p =,0.002), pulmonary vascular resistance > 4 Wood units (OR = 5.7, p =,0.007), pretransplant creatinine > 2.0 mg/dL (OR = 6.9, p =,0.004) and female donor (OR = 8.3, p =,0.002). Recipient age and previous surgery did not affect short-term survival. Heart transplantation in the current era consistently offers excellent early and 1-year survival for well-selected recipients receiving standard donors. Early mortality tends to reflect graft failure while hospital mortality may be more indicative of recipient selection. [source] Violence among schizophrenia out-patients compliant with medication: prevalence and associated factorsACTA PSYCHIATRICA SCANDINAVICA, Issue 3 2009J. Bobes Objective:, Aggressive behaviour has been related to schizophrenia both in in-patient and out-patient samples. In this study, we aimed to assess the prevalence and factors associated with aggressive behaviour in out-patient compliant with their prescribed medication. Method:, Eight hundred and ninety-five patients were interviewed at Community-Based Mental Health Services about aggressive,violent behaviour within the week prior to the study visit. Adult patients diagnosed with schizophrenia and receiving stable pharmacological treatment were enrolled. Presence of aggressive episodes, including type of aggression, severity and frequency, was assessed with the Modified Overt Aggression Scale (MOAS). Violence was defined as a score of 3 or more in any of the MOAS subscores. Results:, Prevalence of recent aggressive behaviour was 5.07%, (95% CI 5.04,5.10), where 47% (43 behaviours 91) reached the violent threshold. Among the 91 violent episodes rated, most episodes were verbal (44%), followed by physical violence towards objects (29%), violence towards others (19%) and self-directed violence (8%). Recent episodes of any severity were more likely among patients with a history of violence and also with relapses within the previous year and with low treatment satisfaction. Conclusion:, Five per cent of the studied cases showed aggressive behaviour in the week prior to assessment, despite having been compliant with their medication. Most aggressive behaviour was verbal rather than physical. [source] Once-weekly epoetin beta therapy in patients with solid tumours and chemotherapy-induced anaemia: a randomized, double-blind, dose-finding studyEUROPEAN JOURNAL OF CANCER CARE, Issue 6 2008P. HERAS md, phd Anaemia is common in patients receiving chemotherapy, causing symptoms that have a major impact on quality of life (QoL). Epoetin beta rapidly increases haemoglobin (Hb) levels and improves QoL in anaemic patients with a variety of tumours. This was a randomized, double-blind, parallel-group, dose-finding study assessing the efficacy and safety of once-weekly epoetin beta in patients with solid tumours receiving chemotherapy. Adult patients with anaemia (Hb < 11 g/dL) were randomized to receive epoetin beta 30 000 IU or 20 000 IU once weekly for 12 weeks. All patients received oral iron supplementation. Haemoglobin levels, transfusion need and QoL [Functional Assesment of Cancer Therapy-fatigue (FACT-F) subscale score] were assessed at regular intervals. Fifty patients were randomized; 30 patients received epoetin beta 30 000 IU once weekly and 20 received 20 000 IU once weekly. Mean (± SD) increase in Hb from baseline to week 12 was 1.75 ± 2.15 g/dL in the 30 000 IU group (P = 0.008 vs. baseline) and 1.04 ± 1.75 g/dL in the 20 000 IU group (non-significant). Haemoglobin response (increase in Hb ,2 g/dL from baseline) was observed in 78.3% of patients receiving epoetin beta 30 000 IU and 66.7% receiving epoetin beta 20 000 IU. Improvements in FACT-F subscale score were significantly (P < 0.001) correlated with increases in Hb level. Transfusion use was low during the study in both groups. Both epoetin beta regiments were well tolerated and there were no dose-dependant adverse events. Epoetin beta 30 000 IU once weekly is an effective and well-tolerated treatment of anaemia in patients with solid tumours. [source] Patient perceptions of the risks and benefits of infliximab for the treatment of inflammatory bowel diseaseINFLAMMATORY BOWEL DISEASES, Issue 1 2008Corey A. Siegel MD Abstract Background: For a patient to make informed, preference based decisions, they must be able to balance the risks and benefits of treatment. The aim of this study was to determine patients' and parents' perceptions of the risks and benefits of infliximab for the treatment of inflammatory bowel disease (IBD). Methods: Adult patients with IBD and parents of patients attending IBD patient education symposiums were asked to complete a questionnaire regarding the risks and benefits of infliximab. Results: One hundred and sixty-five questionnaires were completed. A majority (59%) of respondents expected a remission rate greater than 50% at 1 year and 18% expected a remission rate greater than 70% at 1 year. More than one-third (37%) of respondents answered that infliximab is not associated with a risk of lymphoma and 67% responded that the lymphoma risk is no higher than twice that of the general population. When presented a scenario of a hypothetical new drug for IBD with risks mirroring those estimated for infliximab, 64% of respondents indicated that they would not take the medication, despite its described benefits. Thirty percent of these patients were either currently taking or had previously taken infliximab. Patients actively taking infliximab predicted the highest remission rates for the infliximab (P = 0.05), and parents of patients predicted the lowest (P = 0.01). Parents estimated a higher risk of lymphoma than patients (P = 0.003). Risk and benefit perception was independent of gender and age of patient respondents. Conclusions: Compared to published literature, patients and parents of patients overestimate the benefit of infliximab and underestimate its risks. We conclude that effective methods for communicating risks and benefits to patients need to be developed. (Inflamm Bowel Dis 2007) [source] Trends in hospital-based management of acute asthma from a teaching hospital in South AsiaINTERNATIONAL JOURNAL OF CLINICAL PRACTICE, Issue 8 2005S. F. Hussain Summary The aim of this study is to evaluate the hospital-based management of acute asthma in south Asia and to compare practices over a 10-year period. Adult patients (n = 102) admitted at a teaching hospital with acute asthma were studied. Documentation of precipitating factors, family history and physical signs were inadequate in more than half of patients. Pulse oximetry was documented in 95 (93%) patients, but peak flow monitoring was performed only in 50 (49%) patients. Ten-year trend showed deterioration in history and physical examination skills, under use of peak flow readings, and poor pre-discharge instructions. Some aspects of improved care included frequent use of pulse oximeter, preference of inhaled over systemic bronchodilators and increased use of systemic steroids. Significant deficiencies were identified in hospital-based management of acute asthma. Most aspects of asthma care continued to fall short of asthma guidelines. [source] Patients undergoing total hip arthroplasty: a perioperative pain experienceJOURNAL OF CLINICAL NURSING, Issue 4 2006Margareta Warrén Stomberg PhD Aim., The aim was to evaluate patient's perioperative pain experience after total hip replacement and patients' satisfaction with pain management. Background., Total hip arthroplasty is a common surgical procedure intended to reduce pain and return patients to better function. Realistic expectations about total hip arthroplasty is important for optimal postoperative recovery and the information must be adapted to fit the individual patient. Methods., A descriptive design was used comparing patients outcome data. Pitman's test was used for statistical analyses. Adult patients (n = 112) undergoing surgical hip replacement procedures answered a 17-item questionnaire on the fourth postoperative day. The questionnaire included given alternatives and visual analogue scales (0,100 mm) for the pain assessment. Result., The patients' postoperative pain experience after hip replacement surgery was in average low, 33·1 mm on a 100 mm visual analogue scale. Patient's pain experience was reported to be highest on the first postoperative day for most of the patients. The preoperative pain experience tends to be higher than the postoperative pain experience. Older patients reported less average pain level postoperatively. Satisfaction with pain management was high. Conclusion., The pain experience tends to be higher preoperatively than postoperatively. Patients who reported a higher pain experience postoperatively reported that their pain experience was significant higher than preoperative expected. Relevance to practice., It is important for the postoperative outcome measure that the patients have a realistic expectation of pain experiences after total hip arthroplasty. The nurse is one of the staff members responsible for information to the individual patient. [source] Acute liver failure in Sweden: etiology and outcomeJOURNAL OF INTERNAL MEDICINE, Issue 3 2007G. Wei Abstract. Objective., To determine the causes and outcome of all patients with acute liver failure (ALF) in Sweden 1994,2003 and study the diagnostic accuracy of King's College Hospital (KCH) criteria and the model for end-stage liver disease (MELD) score with transplant-free deaths as a positive outcome. Research design and methods., Adult patients in Sweden with international normalized ratio (INR) of ,1.5 due to severe liver injury with and without encephalopathy at admission between 1994,2003 were included. Results., A total of 279 patients were identified. The most common cause of ALF were acetaminophen toxicity in 42% and other drugs in 15%. In 31 cases (11%) no definite etiology could be established. The KCH criteria had a positive-predictive value (PPV) of 67%, negative-predictive value (NPV) of 84% in the acetaminophen group. Positive-predictive value and negative-predictive value of KCH criteria in the nonacetaminophen group were 54% and 63% respectively. MELD score >30 had a positive-predictive value of 21%, negative-predictive value of 94% in the acetaminophen group. The corresponding figures for the nonacetaminophen group were 64% and 76% respectively. Conclusions., Acetaminophen toxicity was the most common cause in unselected patients with ALF in Sweden. KCH criteria had a high NPV in the acetaminophen group, and in combination with MELD score <30 predicts a good prognosis in acetaminophen patients without transplantation. [source] Symptom Perception and Adherence to Asthma Controller MedicationsJOURNAL OF NURSING SCHOLARSHIP, Issue 3 2006Ruth Ohm Purpose: To explore asthma symptom perception and the relationship between asthma symptom perception and adherence to asthma treatment. Design: Adult patients (N=120) of asthma/allergy specialty clinics, taking Advair® as a controller medication, were enrolled in this cross-sectional descriptive study. Methods: Ninety-seven participants completed 4 weeks of daily diaries to assess subjective symptom perception and measured peak expiratory flow rates (PEFR), both done twice daily. Individual perceptual accuracy scores (PAS) were determined by correlating the subjective symptom perception scores with the PEFRs. Measures included demographic variables, illness identity (personal control and treatment control, consequences, and timeline-cyclical subscales of the IPQ-R), asthma severity (FEV1 percentage) and a single-item indicator of perceived asthma severity. Adherence was measured by the Medication Adherence Report Scale (MARS) and by an Advair® dose count (percentage of doses taken as prescribed). Findings: Independent t tests comparing adherence rates of good versus poor perceivers were not significant, using either the percentage Advair® dose count or the MARS. Multiple regression analyses showed that years with asthma, illness identity, and peak flow variability were all significant explanatory variables for perceptual accuracy. Conclusion: Peak flow variability adds complexity to the relationship between perceptual accuracy and adherence that warrants further investigation. [source] N-terminal pro-brain natriuretic peptide for detection of cardiovascular stress in patients with obstructive sleep apnea syndromeJOURNAL OF SLEEP RESEARCH, Issue 4 2006EDMOND VARTANY Summary Patients with obstructive sleep apnea syndrome (OSAS) have an elevated incidence of cardiovascular events that may be related to an increased ventricular load and hypoxemia caused by apneas and hypopneas. N-terminal pro-brain natriuretic peptide (NTproBNP) appears to be an excellent marker of myocardial stretch and could serve as an indicator of subclinical cardiac stress, thereby identifying a patient population at risk for cardiac effects from OSAS. Adult patients presenting with suspected OSAS and scheduled for nocturnal polysomnography were recruited. Patients with heart or renal failure or severe lung disease were excluded. NTproBNP was measured the evening before and the morning after sleep. Blood pressure (BP) was monitored intermittently throughout the night. Fifteen male and 15 female subjects with a mean ± SD body mass index of 38.2 ± 9.8 were studied. Mean Apnea,Hypopnea Index (AHI) was 38.4 ± 26, with 17 subjects having severe OSAS (AHI > 30). No subject had a significant rise in BP. NTproBNP values overnight decreased in 19 patients and rose in 11 (mean change 3.8 ± 33 pg mL,1), but only one patient had an abnormal morning value. Three patients had an abnormal NTproBNP value prior to sleep, but their levels decreased with sleep. No correlations were detected between the evening baseline or postsleep NTproBNP levels and OSAS. Monitoring pre- and postsleep NTproBNP levels revealed no association with the occurrence or degree of OSAS, making it unlikely that NTproBNP could serve as a marker of cardiac stress in OSAS patients with stable BP and without overt heart failure. [source] Unipolar or bipolar depression?JOURNAL OF THE AMERICAN ACADEMY OF NURSE PRACTITIONERS, Issue 4 2007Improving diagnostic confidence with the adult patient Abstract Purpose: The purpose of this article is to inform advanced practice nurses in primary care about the differential diagnosis of bipolar disorder (BD), when depression is identified in the adult patient. Data sources: Selected research and clinical articles. Conclusions: Adult patients with BD are much more likely to seek treatment for depression than for mania or hypomania. Recognition of BD is improved when the primary care clinician is alerted to the factors indicating bipolarity and utilizes available screening tools. Implications for practice: Misdiagnosis of a bipolar spectrum disorder delays proper treatment and precludes adequate management both pharmacologically and psychotherapeutically. [source] Antibiotic prophylaxis for percutaneous endoscopic gastrostomy for non-malignant conditions: a double-blind prospective randomized controlled trialALIMENTARY PHARMACOLOGY & THERAPEUTICS, Issue 6 2005A. SAADEDDIN Summary Background :,The use of antibiotic prophylaxis prior to percutaneous endoscopic gastrostomy insertion has been encouraged following development of guidelines by a number of professional societies within the past few years. However, not all evidence supports routine prophylaxis, particularly in patients with ,benign' disease indications for percutaneous endoscopic gastrostomy insertion. Aim :,To identify whether prophylactic antibiotic usage is beneficial in patients undergoing percutaneous endoscopic gastrostomy insertion without malignant disease. Methods :,Adult patients without malignant disease who were referred for percutaneous endoscopic gastrostomy insertion at our unit were assessed for participation in this prospective, double-blind, randomized controlled study. Patients were randomized to receive either placebo or 2.2 g co-amoxiclav (or 2 g cefotaxime if penicillin-allergic) at time of percutaneous endoscopic gastrostomy insertion. Clinical endpoints studies were percutaneous endoscopic gastrostomy site or systemic infection and death within 7 days of percutaneous endoscopic gastrostomy insertion. Results :,Ninety-nine patients completed the study (51 antibiotics, 48 placebo). Outcomes in the antibiotic and placebo groups respectively were: percutaneous endoscopic gastrostomy site infection, 11% vs. 47% (P < 0.01); systemic infection, 16% vs. 38% (P < 0.05); and death, 8% vs. 15% (P = 0.5). Conclusions :,Antibiotic prophylaxis prior to percutaneous endoscopic gastrostomy insertion reduces both percutaneous endoscopic gastrostomy site and systemic infections in patients without malignant disease. [source] The underrecognized progressive nature of N370S Gaucher disease and assessment of cancer risk in 403 patients,AMERICAN JOURNAL OF HEMATOLOGY, Issue 4 2009Tamar H. Taddei Mutations in GBA1 gene that encodes lysosomal glucocerebrosidase result in Type 1 Gaucher Disease (GD), the commonest lysosomal storage disorder; the most prevalent disease mutation is N370S. We investigated the heterogeneity and natural course of N370S GD in 403 patients. Demographic, clinical, and genetic characteristics of GD at presentation were examined in a cross-sectional study. In addition, the relative risk (RR) of cancer in patients compared with age-, sex-, and ethnic-group adjusted national rates of cancer was determined. Of the 403 patients, 54% of patients were homozygous (N370S/N370S) and 46% were compound heterozygous for the N370S mutation (N370S/other). The majority of N370S/N370S patients displayed a phenotype characterized by late onset, predominantly skeletal disease, whereas the majority of N370S/other patients displayed early onset, predominantly visceral/hematologic disease, P < 0.0001. There was a striking increase in lifetime risk of multiple myeloma in the entire cohort (RR 25, 95% CI 9.17,54.40), mostly confined to N370S homozygous patients. The risk of other hematologic malignancies (RR 3.45, 95% CI 1.49,6.79), and overall cancer risk (RR 1.80, 95% CI 1.32,2.40) was increased. Homozygous N370S GD leads to adult-onset progressive skeletal disease with relative sparing of the viscera, a strikingly high risk of multiple myeloma, and an increased risk of other cancers. High incidence of gammopathy suggests an important role of the adaptive immune system in the development of GD. Adult patients with GD should be monitored for skeletal disease and cancers including multiple myeloma. Am. J. Hematol., 2009. © 2009 Wiley-Liss, Inc. [source] Delayed Introduction of Reduced-Dose Tacrolimus, and Renal Function in Liver Transplantation: The ,ReSpECT' StudyAMERICAN JOURNAL OF TRANSPLANTATION, Issue 2 2009J. M. Neuberger We report a multicenter, prospective, randomized, open-label trial investigating the effect of lower levels and delayed introduction of tacrolimus on renal function in liver transplant recipients. Adult patients with good renal function undergoing primary liver transplant were randomized to either: group A (standard-dose tacrolimus [target trough levels >10 ng/mL] and corticosteroids; n = 183); group B (mycophenolate mofetil [MMF] 2g/day, reduced-dose tacrolimus [target trough levels ,8 ng/mL], and corticosteroids; n = 170); group C (daclizumab induction, MMF, reduced-dose tacrolimus delayed until the fifth day posttransplant and corticosteroids, n = 172). The primary endpoint was change from baseline in estimated glomerular filtration rate (eGFR) at 52 weeks. The eGFR decreased by 23.61, 21.22 and 13.63 mL/min in groups A, B and C, respectively (A vs C, p = 0.012; A vs B, p = 0.199). Renal dialysis was required less frequently in group C versus group A (4.2% vs. 9.9%; p = 0.037). Biopsy-proven acute rejection rates were 27.6%, 29.2% and 19.0%, respectively. Patient and graft survival was similar. In conclusion, daclizumab induction, MMF, corticosteroids and delayed reduced-dose tacrolimus was associated with less nephrotoxicity than therapy with standard-dose tacrolimus and corticosteroids without compromising efficacy or tolerability. [source] Acceptance of Rapid HIV Screening in a Southeastern Emergency DepartmentACADEMIC EMERGENCY MEDICINE, Issue 11 2009Arin E. Freeman MPH Abstract Objectives:, The objective was to assess the acceptance of an emergency department (ED) human immunodeficiency virus (HIV) screening program based on the Centers for Disease Control and Prevention (CDC) recommendations for routine HIV screening in health care settings. Methods:, Rapid HIV screening was offered on an opt-out basis to patients aged 13 to 64 years presenting to the ED by trained HIV counselors. Patients were excluded if they had a history of HIV, were physically or mentally incapacitated, did not understand their right to opt-out, or did not speak English or Spanish. Statistical analyses, including logistic regression, were performed to assess the associations between the demographics of patients offered testing and their test acceptance or refusal. Results:, From March 2008 to January 2009, a total of 5,080 (91%) of the 5,585 patients offered the HIV test accepted, and 506 (9%) refused. White and married patients were less likely to accept testing than those who were African American and unmarried (p < 0.001). Adult patients were almost twice as likely to accept testing as pediatric patients (odds ratio [OR] = 1.95; 95% confidence interval [CI] = 1.50 to 2.53). As age increased among pediatric patients, testing refusal decreased (OR = 0.71; 95% CI = 0.59 to 0.85), and as age increased among adult patients, testing refusal increased (OR = 1.17; 95% CI = 1.12 to 1.22). Two percent of persons accepting the test were considered high risk. Males were more likely to report high-risk behavior than females (OR = 1.83; 95% CI = 1.23 to 2.72). Conclusions:, The opt-out approach results in high acceptance of routine HIV screening. Widespread adoption of the CDC's recommendations, although feasible, will require significant increases in resources. [source] Golimumab, a new human anti,tumor necrosis factor , antibody, administered intravenously in patients with active rheumatoid arthritis: Forty-eight,week efficacy and safety results of a phase III randomized, double-blind, placebo-controlled study ,ARTHRITIS & RHEUMATISM, Issue 4 2010Joel Kremer Objective To assess the efficacy and safety of intravenous administration of golimumab in patients with rheumatoid arthritis (RA). Methods Adult patients with RA in whom disease activity was persistent despite treatment with methotrexate (MTX) at a dosage of 15,25 mg/week for ,4 weeks were randomized to receive intravenous infusions of placebo plus MTX or intravenous infusions of golimumab at a dose of 2 mg/kg or 4 mg/kg, with or without MTX, every 12 weeks through week 48. Patients with <20% improvement in the swollen and tender joint counts could enter early escape and receive additional active treatment (week 16) or could have their dose regimen adjusted (week 24). The primary end point was the proportion of patients achieving a 50% response according to the American College of Rheumatology improvement criteria (ACR50) at week 14. Results The primary study end point was not met (at week 14, an ACR50 response was observed in 21% of the patients treated with golimumab plus MTX compared with 13% of the patients treated with placebo plus MTX [P = 0.051]). By week 24, significantly more patients treated with golimumab plus MTX had achieved an ACR50 response. Differences in the proportion of patients achieving an ACR50 response between the group receiving golimumab monotherapy and the group receiving placebo plus MTX were not significant at either week 14 (16% versus 13%) or week 24 (10% versus 9%). At week 48, the proportions of patients achieving ACR20 and ACR50 responses were highest among those who had received golimumab 4 mg/kg plus MTX (70% and 48%, respectively). Concomitant treatment with MTX was associated with a lower incidence of antibodies to golimumab. The most commonly reported adverse events through week 48 were infections (48% of patients treated with golimumab with or without MTX and 41% of patients receiving placebo plus MTX). Conclusion The primary end point was not met. However, intravenously administered golimumab plus MTX appears to have benefit in the longer-term reduction of RA signs/symptoms in MTX-resistant patients, with no unexpected safety concerns. [source] Golimumab, a new human tumor necrosis factor , antibody, administered every four weeks as a subcutaneous injection in psoriatic arthritis: Twenty-four,week efficacy and safety results of a randomized, placebo-controlled study,ARTHRITIS & RHEUMATISM, Issue 4 2009Arthur Kavanaugh Objective To assess the efficacy and safety of golimumab in patients with active psoriatic arthritis (PsA). Methods Adult patients with PsA who had at least 3 swollen and 3 tender joints and active psoriasis were randomly assigned to receive subcutaneous injections of placebo (n = 113), golimumab 50 mg (n = 146), or golimumab 100 mg (n = 146) every 4 weeks through week 20. Efficacy assessments through week 24 included the American College of Rheumatology 20% improvement criteria (ACR20), the Psoriasis Area and Severity Index (PASI) in patients in whom at least 3% of the body surface area was affected by psoriasis at baseline, the Short Form 36 Health Survey (SF-36), the disability index of the Health Assessment Questionnaire (HAQ), the Nail Psoriasis Severity Index (NAPSI), the physician's global assessment of psoriatic nail disease, and enthesitis (using the PsA-modified Maastricht Ankylosing Spondylitis Enthesitis Score [MASES] index). Results At week 14, 48% of all patients receiving golimumab, 51% of patients receiving golimumab 50 mg, and 45% of patients receiving golimumab 100 mg achieved an ACR20 response (the primary end point), compared with 9% of patients receiving placebo (P < 0.001 for all comparisons). Among the 74% of patients in whom at least 3% of the body surface area was affected by psoriasis at baseline, 40% of those in the golimumab 50 mg group and 58% of those in the golimumab 100 mg group had at least 75% improvement in the PASI at week 14 (major secondary end point), compared with 3% of placebo-treated patients (P < 0.001 for both doses). Significant improvement was observed for other major secondary end points (the HAQ and the SF-36), the NAPSI, the physician's global assessment of psoriatric nail disease, and the PsA-modified MASES index in each golimumab group compared with placebo. This efficacy was maintained through week 24. Golimumab was generally well tolerated. Conclusion Treatment with golimumab at doses of 50 mg and 100 mg significantly improved active PsA and associated skin and nail psoriasis through week 24. [source] Performance of Severity of Illness Scoring Systems in Emergency Department Patients with InfectionACADEMIC EMERGENCY MEDICINE, Issue 8 2007Michael D. Howell MD ObjectivesTo validate the Mortality in Emergency Department Sepsis (MEDS) score, the Confusion, Urea nitrogen, Respiratory rate, Blood pressure, 65 years of age and older (CURB-65) score, and a modified Rapid Emergency Medicine Score (mREMS) in patients with suspected infection. MethodsThis was a prospective cohort study. Adult patients with clinically suspected infection admitted from December 10, 2003, to September 30, 2004, in an urban emergency department with approximately 50,000 annual visits were eligible. The MEDS and CURB-65 scores were calculated as originally described, but REMS was modified in neurologic scoring because a full Glasgow Coma Scale score was not uniformly available. Discrimination of each score was assessed with the area under the receiver operating characteristics curve (AUC). ResultsOf 2,132 patients, 3.9% (95% confidence interval [CI] = 3.1% to 4.7%) died. Mortality stratified by the MEDS score was as follows: 0,4 points, 0.4% (95% CI = 0.0 to 0.7%); 5,7 points, 3.3% (95% CI = 1.7% to 4.9%); 8,12 points, 6.6% (95% CI = 4.4% to 8.8%); and ,13 points, 31.6% (95% CI = 22.4% to 40.8%). Mortality stratified by CURB-65 was as follows: 0 points, 0% (0 of 457 patients); 1 point, 1.6% (95% CI = 0.6% to 2.6%); 2 points, 4.1% (95% CI = 2.3% to 6.0%); 3 points, 4.9% (95% CI = 2.8% to 6.9%); 4 points, 18.1% (95% CI = 11.9% to 24.3%); and 5 points, 28.0% (95% CI = 10.4% to 45.6%). Mortality stratified by the mREMS was as follows: 0,2 points, 0.6% (95% CI = 0 to 1.2%); 3,5 points, 2.0% (95% CI = 0.8% to 3.1%); 6,8 points, 2.3% (95% CI = 1.1% to 3.5%); 9,11 points, 7.1% (95% CI = 4.2% to 10.1%); 12,14 points, 20.0% (95% CI = 12.5% to 27.5%); and ,15 points, 40.0% (95% CI = 22.5% to 57.5%). The AUCs were 0.85, 0.80, and 0.79 for MEDS, mREMS, and CURB-65, respectively. ConclusionsIn this large cohort of patients with clinically suspected infection, MEDS, mREMS, and CURB-65 all correlated well with 28-day in-hospital mortality. [source] Routine versus Selective Abdominal Computed Tomography Scan in the Evaluation of Right Lower Quadrant Pain: A Randomized Controlled TrialACADEMIC EMERGENCY MEDICINE, Issue 2 2007Christopher C. Lee MD Objectives To determine the role of abdominal computed tomography (CT) imaging in patients with right lower quadrant (RLQ) pain. The authors hypothesized that selective use of abdominal CT would reduce imaging without increasing the rates of negative appendectomy and perforated appendicitis. Methods A prospective randomized clinical trial was conducted in a community teaching emergency department. Adult patients with acute RLQ abdominal pain with suspected acute appendicitis were included. Patients were randomized to mandatory (all patients) or selective (based on clinical evaluation) abdominal CT imaging. The primary outcome was the negative appendectomy rate. Results A total of 152 patients were randomized to selective (n= 80) and mandatory (n= 72) intervention groups. The mean (±SD) age was 34.1 (±3.5) years, and 48% were female. CT imaging was performed in 54 of 80 patients (68%; 95% confidence interval [CI] = 56% to 78%) in the selective group and in 70 of 72 patients (97%; 95% CI = 90% to 100%) in the mandatory group. There was a trend to a decreased rate of negative appendectomy in the mandatory group (1/39 [2.6%]; 95% CI = 0.5% to 13.2%) as compared with the selective group (6/43 [13.9%]; 95% CI = 6.6% to 27.3%), with a difference in prevalence rates of 11.3% (95% CI =,3.5% to 26.3%). There was also a trend to a decreased perforated appendix rate in the mandatory group (4/39 [10.3%]) as compared with the selective group (7/38 [18.4%]), with a difference in prevalence rates of 8.2% (95% CI =,8.0% to 24.4%). Conclusions In this small sample of adult patients with RLQ abdominal pain and suspected acute appendicitis, CT imaging was performed less frequently in the selective group and there was a trend with mandatory CT imaging to reduced rates of negative appendectomy and perforated appendices. [source] Comparison of Laboratory Values Obtained by Phlebotomy versus Saline Lock DevicesACADEMIC EMERGENCY MEDICINE, Issue 1 2007Jill Corbo MD Abstract Objectives To assess the utility of a peripheral saline lock device (SLD) as an alternative to a second venipuncture for obtaining selected blood samples. Methods This prospective study used a comparative design and was conducted in an urban emergency department (ED). Adult patients with an existing SLD in place who required serial phlebotomy were eligible for inclusion in the study. Each subject had blood samples obtained by venipuncture (control) with a Vacutainer adapter according to standard protocols. Within 5 minutes of obtaining the control samples, a sample was obtained from the patients' SLDs; a tourniquet was applied proximal to the intravenous line, a 5-mL waste portion was obtained, and a Vacutainer adapter was placed to draw specimens for testing. Each of the paired samples was analyzed for hematocrit, electrolytes, and cardiac enzymes. The Bland-Altman method was used to analyze the concordance between each pair of measurements. Paired t-tests for each of the eight laboratory tests were used to assess whether the values were statistically different from each other. The 95% limits of agreement around the mean differences were calculated. Differences between SLD aspirates and venipuncture aspirates also were compared with the federal regulatory standards that ensure reliable and accurate laboratory testing. Results Eighty-one patients were eligible for the study; in 73 (90.1%; 95% confidence interval [CI] = 81.5% to 95.6%) of the patients, the SLD could be aspirated for testing. The paired t-tests indicated that there were no statistically significant differences between the mean values of the two methods of testing. Of the 584 paired values analyzed, 35 (6.0%; 95% CI = 4.3% to 8.2%) exceeded the Bland-Altman limits of agreement, and 43 (7.4%; 95% CI = 5.4% to 9.8%) fell outside the acceptable range determined by the federal regulation of clinical laboratories. Of those values that exceeded the acceptable Bland-Altman limits of agreement, none would have resulted in clinical intervention. Conclusions Aspirating blood via an SLD is an acceptable method of obtaining serial laboratory values in a group of stable, consenting adult ED patients. [source] A Prospective Comparison of Ultrasound-guided and Blindly Placed Radial Arterial CathetersACADEMIC EMERGENCY MEDICINE, Issue 12 2006Stephen Shiver MD Abstract Background Arterial cannulation for continuous blood-pressure measurement and frequent arterial-blood sampling commonly are required in critically ill patients. Objectives To compare ultrasound (US)-guided versus traditional palpation placement of arterial lines for time to placement, number of attempts, sites used, and complications. Methods This was a prospective, randomized interventional study at a Level 1 academic urban emergency department with an annual census of 78,000 patients. Patients were randomized to either palpation or US-guided groups. Inclusion criteria were any adult patient who required an arterial line according to the treating attending. Patients who had previous attempts at an arterial line during the visit, or who could not be randomized because of time constraints, were excluded. Enrollment was on a convenience basis, during hours worked by researchers over a six-month period. Patients in either group who had three failed attempts were rescued with the other technique for patient comfort. Statistical analysis included Fisher's exact, Mann-Whitney, and Student's t-tests. Results Sixty patients were enrolled, with 30 patients randomized to each group. Patients randomized to the US group had a shorter time required for arterial line placement (107 vs. 314 seconds; difference, 207 seconds; p = 0.0004), fewer placement attempts (1.2 vs. 2.2; difference, 1; p = 0.001), and fewer sites required for successful line placement (1.1 vs. 1.6; difference, 0.5; p = 0.001), as compared with the palpation group. Conclusions In this study, US guidance for arterial cannulation was successful more frequently and it took less time to establish the arterial line as compared with the palpation method. [source] Live/Real Time Three-Dimensional Transthoracic Echocardiographic Assessment of Bicuspid Aortic Valve MorphologyECHOCARDIOGRAPHY, Issue 4 2009Preeti Singh M.D. We describe the usefulness of three-dimensional transthoracic echocardiography (3D TTE) in the assessment of bicuspid aortic valve morphology in an adult patient with no stenosis but severe aortic regurgitation. [source] Transesophageal and Transpharyngeal Ultrasound Demonstration of Reversed Diastolic Flow in Aortic Arch Branches and Neck Vessels in Severe Aortic RegurgitationECHOCARDIOGRAPHY, Issue 4 2004Deepak Khanna M.D. In the current study, we describe an adult patient with torrential aortic regurgitation due to an aortic dissection flap interfering with aortic cusp motion, in whom a transesophageal echocardiogram with the probe positioned in the upper esophagus and transpharyngeal ultrasound examination demonstrated prominent reversed flow throughout diastole in the left subclavian, left vertebral, left common carotid, and left internal carotid arteries. Another unique finding was the demonstration of aortic valve leaflets held in the fully opened position in diastole by the dissection flap as it prolapsed into the left ventricular outflow tract, dramatically documenting the mechanism of torrential aortic regurgitation in this patient. (ECHOCARDIOGRAPHY, Volume 21, May 2004) [source] | ||||||||||||||||||||||||||||||||||||||||