Cyclosporine-associated end-stage nephropathy after cardiac transplantation: incidence and progression

BACKGROUND

The salutary immunosuppressive effects of cyclosporine in extending cardiac allograft survival may be curtailed by its nephrotoxic effects. We reviewed our first 9 years of experience with cyclosporine after cardiac transplantation, to evaluate the incidence and progression of cyclosporine-associated end-stage renal failure necessitating chronic hemodialysis.

METHODS

Retrospective computer-based file review and personal interview when possible.

RESULTS

The population at risk was comprised of all adult cardiac recipients surviving at least 3 years (n=293). Of these, 19 (6.5%) developed end-stage renal failure requiring chronic hemodialysis. There were 17 men and 2 women (mean age of 45 +/- 11 years). The mean creatinine clearance for the study group decreased by 38% (P<0.001 vs. before transplant) by 6 months after transplantation and by 48% by 3 years postoperatively (P<0.001 vs. before transplant). The mean serum creatinine rose by 80% (P< 0.001 vs. before transplant) by 6 months after transplantation and by 125% by 3 years postoperatively (P<0.001 vs. before transplant). Time elapsed from transplantation to hemodialysis ranged from 3.7 to 9.5 years (mean 6.4 +/- 2). Actuarial 1- year survival after onset of hemodialysis was 75%.

CONCLUSIONS

Although cyclosporine remains the central immunosuppressive agent for cardiac allograft recipients, its use leads to a greater than one-third decrease in creatinine clearance by 6 months after transplantation and progression to end-stage renal failure, requiring hemodialysis in 6.5% of cardiac transplant recipients. Moreover, these patients are at increased risk of death compared with other cardiac allograft recipients. This data warrants the search of alternative or adjunctive agents that would allow decreased dosing or reduced nephrotoxicity of cyclosporine, while maintaining equivalent survival.

Self-hypnosis reduces anxiety following coronary artery bypass surgery. A prospective, randomized trial

OBJECTIVE

The role of complementary medicine techniques has generated increasing interest in today's society. The purpose of our study was to evaluate the effects of one technique, self-hypnosis, and its role in coronary artery bypass surgery. We hypotesize that self-hypnosis relaxation techniques will have a positive effect on the patient's mental and physical condition following coronary artery bypass surgery.

EXPERIMENTAL DESIGN

A prospective, randomized trial was conducted. Patients were followed beginning one day prior to surgery until the time of discharge from the hospital.

SETTING

The study was conducted at Columbia Presbyterian Medical Center, a large tertiary care teaching institution.

PATIENTS

All patients undergoing first-time elective coronary artery bypass surgery were eligible. A total of 32 patients were randomized into two groups.

INTERVENTIONS

The study group was taught self-hypnosis relaxation techniques preoperatively, with no therapy in the control group.

MEASURES

Outcome variables studied included anesthetic requirements, operative parameters, postoperative pain medication requirements, quality of life, hospital stay, major morbidity and mortality.

RESULTS

Patients who were taught self-hypnosis relaxation techniques were significantly more relaxed postoperatively compared to the control group (p=0.032). Pain medication requirements were also significantly less in patients practising the self-hypnosis relaxation techniques that those who were noncompliant (p=0.046). No differences were noted in intraoperative parameters, morbidity or mortality.

CONCLUSION

This study demonstrates the beneficial effects self-hypnosis relaxation techniques on patients undergoing coronary artery bypass surgery. It also provides a framework to study complementary techniques and the limitations encountered.

Cancer genetics--survey of primary care physicians' attitudes and practices

BACKGROUND

Genetic testing for susceptibility to cancer often involves complex medical, ethical, legal, and psychological issues that present a challenge for physicians in clinical practice.

METHODS

This study is based on survey data from 101 primary care physicians throughout Texas, measuring their interest in and attitudes about cancer genetics.

RESULTS

The majority of physicians surveyed reported that they would consider genetic screening for at least one of seven genetic disorders that predispose to cancer, and almost 20% had made one or more referrals for genetic evaluation and DNA testing. Overall, they wanted to see a variety of continuing education programs and educational materials on DNA testing for cancer susceptibility developed. Although most of the physicians accurately perceived a number of major obstacles to referring patients for genetic testing, barriers such as difficulty in interpreting test results, potential for false-positive and false-negative results, and concern about patients'reactions to test results were reported less frequently.

CONCLUSIONS

The results support other evidence for a need to provide continuing education to physicians about genetic testing for susceptibility to cancer.

Screening behaviors and long-term compliance with mammography guidelines in a breast cancer screening program

INTRODUCTION

Screening for breast cancer is generally underused. In an effort to remove common barriers to screening, a free breast cancer screening and education program was created for the employees of a large hospital, incorporating mammography, clinical breast examination (CBE), and breast self-examination (BSE).

METHODS

The present study was conducted to evaluate the screening behaviors and long-term compliance of asymptomatic women over age 50 who participated in the program. Data were obtained from questionnaires administered at the time of enrollment (time 1) and annual reenrollment, as well as from radiology records. (Time 2 represents the most recent data.) Long-term compliance with mammography guidelines was measured by calculating a compliance quotient (CQ) for each participant.

RESULTS

From time 1 to time 2, subjects significantly increased their use of mammography, CBE, and BSE. At time 2, 89.5% of women had ever received a mammogram, 42.7% had gotten one in the last year, nearly all women (94.6%) had received at least one CBE, 58.0% reported annual CBE, and 44.6% of women practiced monthly BSE. CQ was higher among women who remained in the program longer, were still active in the program at the time of the study, and used screening prior to enrollment. It was also higher in Caucasians and women with a family history of breast cancer.

CONCLUSIONS

These results show that a worksite program that eliminates common barriers to screening can significantly increase use of early detection practices. It also demonstrates one method of quantifying long-term compliance with mammography guidelines.

Is aprotinin indicated for reoperative valvular surgery?

BACKGROUND AND AIMS OF THE STUDY

While the hemostatic effect of aprotinin for patients undergoing reoperative coronary bypass is well established, it remains unclear whether these effects extend to patients undergoing reoperative valvular surgery.

METHODS

We examined our experience with 85 consecutive patients undergoing isolated reoperative valvular surgery with and without use of perioperative aprotinin in order to investigate differences in perioperative blood use, blood loss, bleeding complications, mortality and incidence of myocardial injury.

RESULTS

Aprotinin recipients benefited from a significant reduction in bleeding complications, and a decrease in perioperative and in-hospital mortalities as compared with untreated patients. Anaphylactic reactions and clinically significant thromboembolic events were not observed. There was no difference in the incidence of renal dysfunction or myocardial injury among aprotinin-treated and untreated groups.

CONCLUSIONS

Our results indicate that aprotinin therapy can be safely administered to patients undergoing reoperative valvular surgery. No increased incidence of anaphylactic reactions, renal dysfunction or perioperative myocardial injury was noted. The observed reductions in bleeding complications and perioperative and in-hospital mortality strongly warrant the evaluation of aprotinin for reoperative valvular surgery in a prospective fashion.

Screening for breast and prostate cancer: a survey of Texas primary care physicians

Screening for breast and prostate cancer is underutilized, and according to previous studies, physicians often fail to comply with recommended screening guidelines. We surveyed Texas physicians to determine their screening behaviors and their compliance with National recommendations. For women aged 40 through 49 years, 75.5% of respondents recommend mammography every 1 to 2 years, and 8.4% suggest it annually. For women 50 years and older, 16.1% of clinicians screen every 1 to 2 years, and 81.4% recommend annual mammography. Thus, 71.7% of physicians match or exceed the American Cancer Society guidelines for screening mammography in women 40 years and older. Texas physicians also report a high rate of prostate cancer screening, with more than 90% of respondents offering testing by age 60 years. The screening method preferred by 72.0% of clinicians combines digital rectal examination and the prostate-specific antigen blood test. Overall, the screening practices reported by this sample of Texas physicians compare very favorably with those reported by other groups.

Extended indications for lung volume reduction surgery in advanced emphysema

BACKGROUND

Lung volume reduction surgery has shown early promise as a palliative therapy in severe emphysema. Selection of potential candidates has been based on certain functional and anatomic criteria, and a variety of operative contraindications have been proposed.

METHODS

Over 15 months, we performed lung volume reduction surgery in 85 patients selected on the basis of severe hyperinflation with air trapping, diaphragmatic dysfunction, and disease heterogeneity. Patients were not excluded on the basis of severe hypercapnia, steroid dependence, profound pulmonary dysfunction, or inability to complete preoperative rehabilitation.

RESULTS

We observed significant improvements in pulmonary function, exercise capacity, and dyspnea, with an acceptable 30-day perioperative mortality of 7% and actuarial survival of 90% and 83% at 6 and 12 months, respectively. In each "high-risk" group, perioperative mortality, actuarial survival to 1 year, and functional results were equivalent, and in some cases superior, to those in the corresponding "low-risk" patients.

CONCLUSIONS

Severe hypercapnia, steroid dependence, profound pulmonary dysfunction, and inability to complete preoperative rehabilitation do not preclude successful lung volume reduction surgery and should not be regarded as absolute exclusionary criteria.

Low thromboembolic risk without anticoagulation using advanced-design left ventricular assist devices

BACKGROUND

A major limitation of cardiac assist devices has been the high incidence of thromboembolic events and their requirement for systemic anticoagulation. The Thermo Cardiosystems HeartMate 1000 IP left ventricular assist device (LVAD) employs a design that may reduce thromboembolic risk and obviate the need for systemic anticoagulation.

METHODS

Two hundred twenty-three patients with nonreversible heart failure were supported with the HeartMate LVAD as a bridge to heart transplantation. All patients were monitored prospectively for thromboembolic events. Anticoagulation regimens and occurrence of subclinical thromboembolic events, including those seen by transcranial Doppler examinations in selected patients, were also recorded.

RESULTS

Total time of LVAD support use was 531.2 patient-months. Twenty-three patients (10%) received warfarin postoperatively for 42.4 patient-months (8.2% of total support time). Six patients (2.7%) had thromboembolic events, representing 0.011 events per patient-month of device use.

CONCLUSIONS

The thromboembolic complication rate associated with this LVAD is acceptably low despite the minimal anticoagulation employed in this series, allowing consideration of long-term device use for the treatment of heart failure.

Duration of left ventricular assist device support affects transplant survival

BACKGROUND

Left ventricular assist devices have become an important tool in the successful treatment of heart failure as bridges to transplantation. The optimal duration of device support before heart transplantation is debated. We report the effect of left ventricular device support duration on survival after heart transplantation.

METHODS

All patients bridged to heart transplantation with the ThermoCardiosystems Heartmate 1,000 IP left ventricular assist device between January 1, 1986, and October 15, 1994, were included in our study. Parameters studied included duration of support, measures of end-organ function, and complications while supported with the device. Patients supported < 30 days were compared with patients supported > 30 days before undergoing transplantation.

RESULTS

Patients supported for < 30 days had a threefold increased perioperative mortality compared with patients supported > 30 days (p = 0.031). Laboratory values of end-organ function were similar before left ventricular device insertion in both groups, although at the time of transplantation patients supported < 30 days had a significantly elevated bilirubin level compared with patients supported > 30 days (p < 0.001). Patients supported > 30 days had significantly more infections than the < 30 days group (p = 0.0345).

CONCLUSIONS

Patients supported for > 30 days with left ventricular assist devices have improved post-transplant perioperative survival because of normalization of end-organ function and improved physiologic status secondary to aggressive physical rehabilitation. Patients should be supported for > 30 days in combination with physical rehabilitation, to improve early survival after heart transplantation.

Development of an intraluminal device for the treatment of aortic regurgitation: prototype and in vitro testing system

OBJECTIVES

Development of an intraluminal device to reduce aortic regurgitation could provide a strategy intermediate between medical treatment and aortic valve replacement. An initial prototype and a testing system have been designed.

METHODS

Aortic valves obtained from heart transplant recipients were explanted and assessed in a mock circulatory loop with resistive and capacitive elements, including pressure-flow characteristics, similar to those of a normal arterial system. Normal heart function was simulated by a pulsatile ventricular-assist device. Pressure on each side of the valve and flow through the valve were recorded, allowing the calculation of regurgitant fractions and transvalvular gradients. Six solid geometrically differing obturators were tested.

RESULTS

All six designs resulted in significant reduction in aortic regurgitation (p < 0.0001), ranging from 15% to 38% improvement compared with control values. Small increases in transvalvular gradients (from 0 to 7 mm Hg) were also noted.

DISCUSSION

Initial results suggest that an intraluminally placed obturator can reduce aortic regurgitation without creating clinically significant transvalvular gradients. These initial in vitro experiments demonstrate the feasibility of an intraluminal device for the treatment of aortic valve disease, and further investigation is warranted.

MHC-restriction, cytokine profile, and immunoregulatory effects of human T cells specific for TCR V beta CDR2 peptides: comparison with myelin basic protein-specific T cells

HLA-DR2+ patients with multiple sclerosis (MS) that respond to vaccination with TCR V beta 5.2-38-58 peptides have increased frequencies of TCR peptide-specific T cells, reduced frequencies of myelin basic protein (MBP)-specific T cells, and a better clinical course than non-responders. To evaluate possible network regulation of MBP responses by TCR peptide-specific T cells, we compared properties of both cell types. Both MBP- and TCR peptide-specific T cell clones were CD4+ and predominantly HLA-DR restricted. HLA-DR2, which is in linkage disequilibrium in MS patients, preferentially restricted TCR peptide-specific clones as well as MBP-specific responses in HLA-DR2 and DR2,3+ donors. Within the DR2 haplotype, however, both DR beta 1*1501 and DR beta 5*0101 alleles could restrict T cell responses to V beta CDR2 peptides, whereas responses to MBP were restricted only by DR beta 5*0101. TCR peptide-specific clones expressed message for Th2 cytokines, including IL-4, IL-5, IL-6, IL-10, and TGF-beta, whereas MBP-specific T cell clones expressed the Th1 cytokines IFN-gamma and IL-2. Consistent with the Th2-like cytokine profile, TCR peptide-specific T cell clones expressed higher levels of CD30 than MBP-specific T cells. Culture supernatants from TCR peptide-specific T cell clones, but not from MBP- or Herpes simplex virus-specific T cells, inhibited both proliferation responses and cytokine message production of MBP-specific T cells. These results demonstrate distinct properties of MBP and TCR peptide-specific T cells, and indicate that both target and bystander Th1 cells can be inhibited by Th2 cytokines secreted by activated TCR peptide-specific T cells. These data support the rationale for TCR peptide vaccination to regulate pathogenic responses mediated by oligoclonal T cells in human autoimmune diseases.

Outpatient left ventricular assist device support: a destination rather than a bridge

BACKGROUND

To evaluate the feasibility and efficacy of outpatient left ventricular assist devices as a bridge to transplantation, we reviewed the initial clinical experience with this modality at our institution.

METHODS

During January 1993 to November 1995, 12 male and 2 female patients with an average age of 47 +/- 17 years were supported for an average of 117 +/- 24 days with the Thermo Cardiosystems VE wearable left ventricular assist device. Seven patients were discharged home an average of 35 +/- 4 days after implantation.

RESULTS

No device failures occurred, although 29 controller malfunctions were identified during 1,640 total support days. All patients were able to safely maintain their devices. Outflow graft bleeding and driveline infection were responsible for two readmissions. No long-term anticoagulation treatment was used; one small thromboembolic episode occurred, but without significant long-term sequelae.

CONCLUSIONS

None of the 7 patients released from the hospital died, and all were able to successfully maintain their devices at home. Hospital discharge of patients supported with left ventricular assist devices has allowed long-term evaluation of this technology, and the findings should prompt study of their use as a long-term alternative treatment to medical management for congestive heart failure.

V beta CDR3 motifs associated with BP recognition are enriched in OX-40+ spinal cord T cells of Lewis rats with EAE

Spinal cord (SC) T cells were isolated at the onset of actively induced experimental autoimmune encephalomyelitis (EAE) and sorted for the presence of the OX-40 activation marker. Previously, we reported an enhanced bias in V beta 8.2 expression as well as enhanced proliferative responses to basic protein antigens among the OX-40+ SC T cells. Here we demonstrate that CDR3 motifs associated with EAE are present at a significantly higher frequency in V beta 8.2 sequences of OX-40+ SC T cells (16/17) compared with those of OX-40- SC T cells (5/17). Thus, the OX-40 antigen may be useful as a marker to isolate and characterize autoantigen-specific T cells from the site of inflammation in T-cell-mediated autoimmune diseases.

Pitfalls in interpreting prostate specific antigen velocity

PURPOSE

The concept of prostate specific antigen (PSA) velocity as an improved marker for prostate cancer detection is intriguing. However, before this concept is applied to individual patients several confounding parameters must be addressed. We determined the variability of serum PSA levels in men without prostate cancer.

MATERIALS AND METHODS

We reviewed data from a prostate cancer screening program, and determined inter-assay and individual variability of the serum PSA values for a 2-year followup period in 265 men clinically free of prostate cancer.

RESULTS

Our average inter-assay coefficient of variation was 7.5%. Therefore, we considered only PSA changes exceeding +/- 15% as significant. Fluctuations in serum PSA occurred in 78% of the men during the observation period, and 12.5% had at least a single PSA increase exceeding 0.75 ng/ml. per year. Fluctuations were noted throughout the entire range of serum PSA levels but became progressively larger with an increasing mean PSA.

CONCLUSIONS

The inter-assay variability must be considered when interpreting PSA velocity. Individual fluctuations in serum PSA dictate an observation period of at least 2 years before PSA velocity is considered abnormal.

Multivariate analysis of factors affecting waiting time to heart transplantation

BACKGROUND

The growing clinical success of cardiac transplantation has resulted in a dramatic increase in the number of patients referred and subsequently listed for cardiac transplantation. Paradoxically, in the presence of a limited donor organ pool, such expansion has increased both the waiting time for transplantation and the number of patients dying while on the waiting list.

METHODS

We performed univariate and multivariate analyses of the waiting times of 301 patients listed for transplantation using a Cox proportional hazards model to evaluate the simultaneous effect of multiple variables on the waiting time of heart transplant candidates. Variables considered included age, sex, race, blood type, weight at listing, United Network for Organ Sharing (UNOS) status at listing, UNOS status at transplantation, and proportion of time on the waiting list as UNOS status 1.

RESULTS

The mean waiting time for patients ultimately having transplantation was 170.2 +/- 206.0 days; the median waiting time was 103.5 days. Age, sex, weight, blood type, and percent of time as UNOS status 1 all had a significant impact on waiting time in the univariate analysis. By multivariate analysis, proportion of time as UNOS status 1, lower weight at listing, and blood type AB were all highly associated as predictors of a shorter waiting time. Weight at listing represented a continuous variable whose risk ratio for a shorter waiting time correlated in such a way that the risk of a longer waiting time increased 2.3 per 22.5-kg (50-pound) increase in weight. Blood types A and B, although associated with a shorter waiting time, correlated less strongly than the other three variables.

CONCLUSIONS

Our findings from this multivariate analysis demonstrate that UNOS status, blood type, and weight were the variables that most strongly affected overall waiting time for transplantation. It is our hope to define more accurately a group of patients with both a high likelihood of a long waiting time and a prohibitive risk of death while on the waiting list, who therefore may benefit from surgical alternatives to transplantation.

Selective depletion of myelin-reactive T cells with the anti-OX-40 antibody ameliorates autoimmune encephalomyelitis

The OX-40 protein was selectively upregulated on encephalitogenic myelin basic protein (MBP)-specific T cells at the site of inflammation during the onset of experimental autoimmune encephalomyelitis (EAE). An OX-40 immunotoxin was used to target and eliminate MBP-specific T cells within the central nervous system without affecting peripheral T cells. When injected in vivo, the OX-40 immunotoxin bound exclusively to myelin-reactive T cells isolated from the CNS, which resulted in amelioration of EAE. Expression of the human OX-40 antigen was also found in peripheral blood of patients with acute graft-versus-host disease and the synovia of patients with rheumatoid arthritis during active disease. The unique expression of the OX-40 molecule may provide a novel therapeutic strategy for eliminating autoreactive CD4+T cells that does not require prior knowledge of the pathogenic autoantigen.

Demographic, psychosocial, and objective risk factors related to perceived risk of skin cancer

BACKGROUND AND METHODS

The present study examined the ways in which demographic, psychosocial, and objective risk factors were related to perceived risk of skin cancer among 384 hospital employees who participated in a screening program. It was hypothesized that pyschosocial risk factors would account for a significant portion of the variance in risk perception beyond that accounted for by the other risk factors.

RESULTS

The risk factors accounted for approximately 44% of the variance in risk perception. Psychosocial risk factors accounted for a statistically significant portion of the variance in risk perception beyond that accounted for by other risk factors. Worry, family history of skin cancer, and race/ethnicity were most strongly related to perceived risk.

CONCLUSIONS

Results are discussed in terms of the need for educational programs that emphasize the relationship between level of risk and skin cancer and provide specific information regarding steps that can be taken to prevent skin cancer.

OX-40 antibody enhances for autoantigen specific V beta 8.2+ T cells within the spinal cord of Lewis rats with autoimmune encephalomyelitis

The V beta 8.2 T cell receptor (TCR) component is the predominant V beta gene product associated with antigen specific CD4+ T cell response to the major encephalitogenic epitope of myelin basic protein (MBP) in Lewis rats. Lewis rats were actively immunized with MBP in complete Freund's adjuvant and the V beta 8.2 positive and negative cells were analyzed for IFN-gamma mRNA production and OX-40 cell surface expression during the onset of EAE. The V beta 8.2+ T cells isolated from the spinal cord produced the majority of mRNA for IFN-gamma and also showed a marked enhancement for OX-40 expression compared to V beta 8.2+ T cells isolated from the lymph nodes. Only a fraction of IL-2 receptor positive T cells examined ex vivo from the inflammatory compartments co-expressed the OX-40 antigen. These results suggested that OX-40 cell surface expression could be used to identify and isolate the most recently activated T cells ex vivo. OX-40+ T cells isolated from the spinal cord were highly enriched for the V beta 8.2 T cell receptor component compared to OX-40- or unsorted spinal cord lymphocytes. OX-40+ T cells isolated from the spinal cord had an enhanced response to MBP, whereas OX-40+ cells isolated from the lymph nodes responded to both MBP and purified protein derivative. These data suggest that activated T cells can be isolated and characterized with the OX-40 antibody which only respond to the antigens present at the local site. The data also imply that isolation of OX-40+ T cells will be useful in identifying V beta biases and autoantigen specific cells within inflamed tissues even when the antigen specificity is unknown.

Safety and efficacy of aprotinin under conditions of deep hypothermia and circulatory arrest

Aprotinin has been successfully used to reduce blood loss and blood product requirements in patients undergoing primary and reoperative cardiac operations. Its safety and efficacy during profound hypothermia and circulatory arrest have been questioned, however. A retrospective review compared 24 patients who received aprotinin during complex aortic procedures under profound hypothermia and circulatory arrest with 24 age-matched patients undergoing similar procedures without aprotinin. Activated clotting time was maintained at longer than 500 seconds (kaolin activating agent) or longer than 750 seconds (celite). We observed no statistically significant difference in the incidence of neurologic events (p not significant) or myocardial infarctions (p not significant), and there was a trend toward reduced in-hospital mortality rate in aprotinin-treated patients. A higher incidence of postoperative renal dysfunction was encountered in aprotinin-treated patients. Aprotinin recipients had a significant reduction in requirements for postoperative homologous erythrocytes (p = 0.01). We conclude that aprotinin may be safely and effectively used in patients undergoing deep hypothermia and circulatory arrest.

De novo solid malignancies after cardiac transplantation

BACKGROUND

As long-term survival after cardiac transplantation improves, neoplastic complications are increasingly being discovered. Although lymphoproliferative disorders predominate, the incidence and clinical spectrum of solid tumors in a uniform population of heart transplant recipients remains uncertain.

METHODS

We reviewed our experience with 712 patients who underwent cardiac transplantation. Clinical charts were reviewed and telephone interviews were conducted, when possible.

RESULTS

De novo solid malignancies were identified in 3.3% of patients at risk (21 of 633 patients). Twenty patients were male; mean age was 51.5 +/- 8.6 years. Most patients reported a significant smoking history. Pulmonary, urologic, and Kaposi's sarcoma were the most common malignancies identified. Mean interval from transplantation to diagnosis was 35 months. Six patients were diagnosed within 6 months of transplantation. One-year and 5-year survival after transplantation were 90% and 49%, respectively. One-year and 3-year survival after cancer diagnosis were 60% and 52%, respectively.

CONCLUSIONS

De novo solid malignancy after transplantation occurred with about half the frequency of lymphoproliferative disorders. A striking male predominance was noted. The interval from transplantation to the appearance of cancer is variable, and no clustering was identified. A significant smoking history warrants aggressive search for occult malignancy during pretransplantation evaluation of potential heart recipients.

Dehydration. Evaluation and management in older adults. Council on Scientific Affairs, American Medical Association

OBJECTIVE

To review published literature regarding dehydration in older individuals and formulate a consensus on the evaluation and treatment of this unrecognized cause of hospitalizations, morbidity, and mortality.

DATA SOURCES AND STUDY SELECTION

The literature concerning dehydration in the elderly population from MEDLINE was reviewed from 1976 through 1995. Search terms included dehydration, elderly, evaluation, hospitalization, and treatment. Particular emphasis was placed on articles describing original research leading to the development of new information on the evaluation and treatment of dehydration and review articles relating to the epidemiology, detection, treatment and health outcomes of this syndrome common in the geriatric population, including frail, institutionalized individuals.

DATA EXTRACTION

Data contributing to a broad scientific understanding of dehydration were initially grouped according to topic areas of the physiology of normal aging, illness-associated clinical reports of dehydration in the elderly population, and diagnostic and therapeutic interventions. The authors developed a consensus based on the weight of evidence presented and the authors' experience in the field.

CONCLUSIONS

Early diagnosis is sometimes difficult because the classical physical signs of dehydration may be absent or misleading in an older patient. Many different etiologies place the elderly at particular risk. In patients identified as being at risk for possible dehydration, an interdisciplinary care plan with regard to prevention of clinically significant dehydration is critical if maximum benefit is to result.

Screening scale predicts patients successfully receiving long-term implantable left ventricular assist devices

BACKGROUND

Although use of long-term implantable left ventricular assist devices (LVAD) is becoming more popular, further reduction of the mortality rate accompanying device insertion through improved patient selection would make this alternative even more appealing. We sought to develop a scoring system that was based on criteria obtainable at the time of evaluation and predictive of successful early outcome and simple to apply.

METHODS AND RESULTS

Patients (n = 56) undergoing LVAD insertion between 1990 and 1994 were screened for easily obtainable preoperative risk factors. To test the association between survival and each risk factor, a chi 2 analysis was performed, and relative risks were estimated. Oliguria, ventilator dependence, elevated central venous pressure, elevated prothrombin time, and reoperation stats had low probability values and high estimated relative risks. On the basis of these relations, a risk factor-selection scale (RFSS) (range, 0 to 10) was developed by computing appropriate weights for each risk factor. The distribution of patients for each scale score reveal that with RFSS > or = 5, most device recipients will die (P < .001). The average RFSS (+/- SD) of survivors (n = 42) was 2.45 +/- 1.73 compared with 5.43 +/- 2.85 in nonsurvivors (n = 14) (P < .0001). Univariate logistical regression was also significant (score statistic, 16.2; df = 1; P = .001).

CONCLUSIONS

The RFSS is simple, easy to apply, and statistically valid. Physicians could use the scale as a starting point in discussing the suitability for LVAD implantation in a specific patient and as a basis for comparing patient outcomes.

Caring for survivors of the Chernobyl disaster. What the clinician should know

The health status of approximately 1 million immigrants in the United States and Israel may have been adversely affected by radiation exposure as a result of the Chernobyl nuclear power plant disaster and cleanup efforts. Many of these immigrants suffer from significant psychological distress, fearing that they have a radiation-induced illness. Based on a review of the literature and our experience from the US National Chernobyl Registry Coordinating Center, we recommend that medical management of these immigrants include routine physical examination, with particular attention to the thyroid gland. Adults should receive regular cancer screening as well as routine blood chemistry tests, thyroid function tests, complete blood cell count, and urinalysis. Children should be examined regularly, with attention to the thyroid and overall body growth. It is reasonable for children to undergo thyroid studies, a complete blood cell count, or neuropsychiatric testing if there is clinical suspicion of a disorder. Given the long latency period for disease induction by radiation exposure, it is still too early to fully assess and draw conclusions concerning the possible health effects of the Chernobyl disaster, and long-term follow-up of all potentially affected individuals is important.