Novel Biomarkers of Acute Kidney Injury After Contrast Coronary Angiography

Acute kidney injury (AKI), defined as a rise in serum creatinine of greater than 25% from baseline measured at 48 hours after renal insult, may follow iodinated contrast coronary angiography. Termed contrast-induced nephropathy, it can result in considerable morbidity and mortality. Measurement of serum creatinine as a functional biomarker of glomerular filtration rate is widely used for detection of AKI, but it lacks sensitivity for the early diagnosis of AKI (typically rising 24 hours after functional loss) and, as a solely functional marker of glomerular filtration rate, is unable to differentiate among the various causes of AKI. These intrinsic limitations to creatinine measurement and the recognition that improved clinical outcomes are linked to a more timely diagnosis of AKI, has led investigators to search for novel biomarkers of "early" kidney injury. Several studies have investigated the utility of renal injury biomarkers in a variety of clinical settings including angiography/percutaneous coronary intervention, coronary artery bypass graft surgery, sepsis in intensive care patients, and pediatric cardiac surgery. In this article, we discuss the use of iodinated contrast for coronary procedures and the risk factors for contrast-induced nephropathy, followed by a review the potential diagnostic utility of several novel biomarkers of early AKI in the clinical settings of coronary angiography/percutaneous coronary intervention. In particular, we discuss neutrophil gelatinase associated lipocalin in depth. If validated, such biomarkers would facilitate earlier AKI diagnosis and improve clinical outcomes.

In situ viscosity measurement of confined liquids

Viscosity heterogeneity in a thin glycerol film (170 nm) at high pressure was observed with fluorescence lifetime measurements.

First determination of the weak charge of the proton

The Q(weak) experiment has measured the parity-violating asymmetry in ep elastic scattering at Q(2)=0.025(GeV/c)(2), employing 145 μA of 89% longitudinally polarized electrons on a 34.4 cm long liquid hydrogen target at Jefferson Lab. The results of the experiment's commissioning run, constituting approximately 4% of the data collected in the experiment, are reported here. From these initial results, the measured asymmetry is A(ep)=-279±35 (stat) ± 31 (syst) ppb, which is the smallest and most precise asymmetry ever measured in ep scattering. The small Q(2) of this experiment has made possible the first determination of the weak charge of the proton Q(W)(p) by incorporating earlier parity-violating electron scattering (PVES) data at higher Q(2) to constrain hadronic corrections. The value of Q(W)(p) obtained in this way is Q(W)(p)(PVES)=0.064±0.012, which is in good agreement with the standard model prediction of Q(W)(p)(SM)=0.0710±0.0007. When this result is further combined with the Cs atomic parity violation (APV) measurement, significant constraints on the weak charges of the up and down quarks can also be extracted. That PVES+APV analysis reveals the neutron's weak charge to be Q(W)(n)(PVES+APV)=-0.975±0.010.

The direct cost of acute hip fracture care in care home residents in the UK

Data on the true acute care costs of hip fractures for patients admitted from care homes are limited. Detailed costing analysis was undertaken for 100 patients. Median cost was £9,429 [<euro>10,896], increasing to £14,435 [<euro>16,681], for those requiring an upgrade from residential to nursing home care. Seventy-six percent of costs were attributable to hospital bed days, and therefore, interventions targeted at reducing hospital stay may be cost effective.

INTRODUCTION

Previous studies have estimated the costs associated with hip fracture, although these vary widely, and for patients admitted from care homes, who represent a significant fracture burden, there are limited data. The primary aim of this study was to perform a detailed assessment of the direct medical costs incurred and secondly compare this to the actual remuneration received by the hospital.

METHODS

One hundred patients presenting from a care home in 2006 were randomly selected and a detailed case-note costing analysis was undertaken. This cost was then compared to the actual remuneration received by the hospital.

RESULTS

Median cost per patient episode was £9,429 [<euro>10,896] (all patients) range £4,292-162,324 [<euro>4,960-187,582] (subdivided into hospital bed day costs £7,129 [<euro>8,238], operative costs £1,323 [<euro>1,529] and investigation costs £977 [<euro>1,129]). Twenty-two percent of the patients admitted from a residential home required upgrading to a nursing home. In this group, the median length of stay was 31 days (mean 38, range 10-88) median cost £14,435 [<euro>16,681]. Average remuneration received equated to £6,222 [<euro>7,190] per patient. This represents a mean loss in income, compared to actual calculated costs of £3,207 [<euro>3,706] per patient.

CONCLUSION

The median cost was £9,429 [<euro>10,896], increasing to £14,435 [<euro>16,681], for those requiring an upgrade from residential to nursing home care at discharge. Significant cost differences were seen comparing the actual cost to remuneration received. Interventions targeted at reducing length of stay may be cost effective.

An assessment of the long-term health outcome of renal transplant recipients in Ireland

BACKGROUND

Renal transplantation remains the preferred method of renal replacement therapy in terms of patient survival, quality of life and cost. However, patients have a high risk of complications ranging from rejection episodes, infection and cancer, amongst others.

AIMS AND METHODS

In this study, we sought to determine the long-term health outcomes and preventive health measures undertaken for the 1,536 living renal transplant patients in Ireland using a self-reported questionnaire. Outcomes were divided into categories, namely, general health information, allograft-related information, immunosuppression-related complications and preventive health measures.

RESULTS

The results demonstrate a high rate of cardiovascular, neoplastic and infectious complications in our transplant patients. Moreover, preventive health measures are often not undertaken by patients and lifestyle choices can be poor.

CONCLUSIONS

This study highlights the work needed by the transplantation community to improve patient education, adjust immunosuppression where necessary and aggressively manage patient risk factors.

Pre-race dietary carbohydrate intake can independently influence sub-elite marathon running performance

We examined whether selected anthropometric and nutritional factors influenced field-based marathon running performance. An internet-based data collection tool allowed competitors in the 2009 London Marathon (n=257, mean ± SD age: 39 ± 8 years, finish time: 273.8 ± 59.5 min) to record a range of anthropometric, training and nutritional predictors. Multivariate statistical methods were used to quantify the change in running speed mediated by a unit change in each predictor via the 95% confidence interval for each covariate-controlled regression slope ( B). Gender ( B=1.22 to 1.95 km/h), body mass index ( B=-0.14 to -0.27 km/h), training distance ( B=0.01 to 0.04 km/h) and the amount of carbohydrate consumed the day before the race ( B=0.08 to 0.26 km/h) were significant predictors, collectively accounting for 56% of the inter-individual variability in running speed (P<0.0005). Further covariate-adjusted analysis revealed that those competitors who consumed carbohydrate the day before the race at a quantity of >7 g/kg body mass had significantly faster overall race speeds (P=0.01) and maintained their running speed during the race to a greater extent than with those who consumed <7 g/kg body mass (P=0.02). We conclude that, in addition to gender, body size and training, pre-race day carbohydrate intake can significantly and independently influence marathon running performance.

Encapsulating peritoneal sclerosis: experience of a tertiary referral center

AIM

Encapsulating peritoneal sclerosis (EPS) is arguably the most serious complication of chronic peritoneal dialysis (PD) therapy with extremely high mortality rates. We aimed to establish the rates of EPS and factors associated with its development in a single center.

METHODS

We retrospectively reviewed the records of all our PD patients from 1 January 1989 until 31 December 2008. All suspected cases were confirmed at laparotomy. Multifactorial models adjusted for potentially confounding variables such as age and sex.

RESULTS

Eleven cases of EPS were identified giving a prevalence rate of 1.98%. Median duration on PD was substantially longer in affected versus unaffected patients (42.5 months versus 13.8 months; p = 0.0002). EPS patients had experienced a mean of 3.54 previous cases of peritonitis (1 infection per year versus 0.71 per year in unaffected patients; p = 0.075). Six patients died (54.5%) due to intra-abdominal sepsis including all five who presented with small bowel obstruction. Three patients had an omentectomy and adhesiolysis performed with a successful outcome.

CONCLUSION

Our study reinforces the link between duration on PD and EPS. While mortality was high in our cohort, emerging surgical techniques demonstrate a favorable outcome that can be achieved even in severely affected cases.

Postparotidectomy facial nerve paralysis: peripheral versus proximal identification

OBJECTIVES

Facial nerve palsy is a distressing complication of parotid surgery. We determined to analyse parotid surgery outcomes in a district general hospital in order to identify our own risk factors leading to increased incidence of facial nerve palsy. Primarily, we aimed to determine the efficacy of peripheral versus proximal facial nerve identification in preventing facial nerve damage.

METHODS

This was a retrospective study of hospital records. The records of sixty-four patients aged between 32 and 84 years who had attended our Otolaryngology department over a six-year period were analysed, with notes made of operative procedure, identification of the facial nerve and post-operative facial nerve palsy. The Neurosign400 facial nerve monitor was used and the degree of facial nerve paralysis was assessed using the House Brackmann (HB) classification of facial nerve paralysis.

RESULTS

Sixty-four patients underwent parotidectomy. Thirty-two patients had the peripheral branch of the facial nerve identified while another thirty-two patients had proximal nerve identification. Six patients had HB 2 facial nerve palsy, but all completely recovered within six months. Four out of the six patients had peripheral identification of the facial nerve.

CONCLUSIONS

Although peripheral versus proximal identification of the facial nerve was associated with greater incidence of temporary facial nerve paralysis, all the patients recovered within six months. This study may indicate that exposing a peripheral branch of the facial nerve with the help of Neurosign400 is a useful way of performing parotidectomy where proximal identification of a nerve is not possible.

Radiographic appearance of cardiogenic pulmonary oedema in 23 cats

OBJECTIVE

To describe the radiographic appearance of pulmonary oedema in cats with cardiac failure.

METHODS

Thoracic radiographs of 23 cats presented to a first opinion practice with signs of cardiac failure were reviewed. All cats had tachypnoea and/or dyspnoea and enlarged left atrium on echocardiography.

RESULTS

Pulmonary oedema was characterised radiographically by an increased opacity associated with a range of patterns and variable distribution. All cats had evidence of a reticular or granular interstitial pattern. This occurred in combination with alveolar pattern in 19 (83 per cent) cats, including six with air bronchograms, with increased diameter of pulmonary vessels in 16 (71 per cent) cats and with bronchial pattern in 14 (61 per cent) cats. The distribution of pulmonary oedema was considered to be diffuse/non-uniform in 14 (61 per cent) cats, diffuse/uniform in four (17 per cent) cats, multi-focal in four (17 per cent) cats and focal in the remaining one (4 per cent). Nine (39 per cent) cats were considered to have a regional distribution of oedema, including five (22 per cent) with a ventral distribution, three (13 per cent) with a caudal distribution and one (4 per cent) cat with a hilar distribution. The distribution of pulmonary opacities was bilaterally symmetrical in five (22 per cent) cats.

CLINICAL SIGNIFICANCE

The variable appearance of feline pulmonary oedema is likely to complicate its radiographic diagnosis.

Ethnic differences in interleukin 6 (IL-6) and IL6 receptor genes in spontaneous preterm birth and effects on amniotic fluid protein levels

Preterm birth (PTB) is a significant neonatal health problem that is more common in African-Americans (AA) than in European-Americans (EA). Part of this disparity is likely to result from the differing genetic architectures of EA and AA. To begin assessing the role of these differences, patterns of genetic variation in two previously proposed candidate genes, encoding interleukin 6 (IL6) and its receptor (IL6R), were analyzed in mothers and fetuses from 496 EA birth-events (149 cases and 347 controls) and 397 birth-events in AA (76 cases and 321 controls). IL-6 levels in amniotic fluid (AF) samples were determined in a subset of these pregnancies. Case-control comparisons revealed a single SNP in IL6R associated with PTB (p=0.04 for allelic and p=0.05 for genotype association). In addition, all of the SNPs studied showed significant frequency differences between AA and EA in at least one comparison, significantly in excess of that expected from general population databases. Higher IL-6 concentrations were associated with the IL6 SNP -661 in EA preterm samples (p=0.0056), and this result seems to be driven by microbial invasion of the amniotic cavity, indicating a gene by infection interaction. These findings indicate that, as a function of IL6 genotype, EA and AA women respond differently to infection with respect to their expression of IL-6. Our data support differential genetic control of levels of IL-6 in amniotic fluid between EA and AA.

International livestock markets and the impact of animal disease

Escalating and pervasive outbreaks of animal diseases are posing considerable challenges to livestock producers, industries, and policy-makers around the globe in a context of steadily rising demand for locally produced and imported livestock products. This paper reviews the factors and trends underpinning the growth in meat trade over the past decade and assesses the impact of animal diseases on international markets. The factors shaping the transmission of the impact of animal disease to global markets and back into domestic markets are identified and the potential global market impact of further animal disease outbreaks evaluated.

Opportunities for performance improvement in relation to medication administration during pediatric stabilization

OBJECTIVES

To identify and characterize areas for improvement in the clinical performance of nurses in relation to medication administration.

METHOD

Nurses participated in a simulated pediatric stabilization event which was videotaped. Their clinical performance was evaluated at each of the following steps: (1) communicating and confirming the dose of medication; (2) converting the dose; (3) selecting the correct medications; (4) properly preparing the medication formulation; and (5) measuring medication doses. The time required to convert and draw up the medications was also evaluated.

RESULTS

A total of 150 medication orders for five medications were given by the physician. Only 55% of the orders were verbally repeated back by the nurses. Of the 120 orders in which the doses were converted from milligrams to milliliters by nurses, 17 (14.2%) were converted incorrectly and the maximum dose deviation reached 400%. Selection of the wrong medication occurred in 11 of the 150 orders. Dextrose (which requires dilution before being administered to children) was not diluted in 17% of the medication orders and in 12% it was diluted improperly. About 40% of the orders for ceftriaxone (which requires reconstitution) were not properly reconstituted. In 49 (32.7%) of the 150 medication orders that were drawn up in a syringe, the amount measured was not consistent with the stated dose. For some medications, a prolonged time was required by nurses to convert the doses and draw up the medications.

CONCLUSIONS

By observing the clinical performance of nurses in a simulated videotaped pediatric stabilization event, we have identified some important areas in need of improvement in each step of the medication administration process. These findings indicate a need for improved education, training, and use of clinical aids or adjuncts for pediatric emergency nurses.

Scapular kinematics during supraspinatus rehabilitation exercise: a comparison of full-can versus empty-can techniques

BACKGROUND

Supraspinatus strengthening is an important component of shoulder rehabilitation. Previous work has determined that the full-can and empty-can exercises elicit the greatest amount of supraspinatus activity. However, scapular kinematics has not been considered when prescribing supraspinatus exercises.

HYPOTHESIS

Scapular downward rotation, internal rotation, and anterior tipping during the empty-can exercise are increased when compared with the full-can exercise.

STUDY DESIGN

Descriptive laboratory study.

METHODS

Twenty participants performed full-can and empty-can exercises while an electromagnetic tracking system was used to collect three-dimensional scapular kinematic data. Scapular angles at 30 degrees, 60 degrees, and 90 degrees of the ascending and descending phases of humeral elevation were compared using 2-way repeated measures analysis of variance.

RESULTS

There was more scapular anterior tipping and internal rotation during the empty-can exercise at all sampled humeral elevation angles except at 30 degrees of the descending phase for anterior/posterior tipping (P < .05).

CONCLUSION

Scapular anterior tipping and internal rotation are increased during the empty-can exercise, whereas scapular upward rotation was not different between exercises.

CLINICAL RELEVANCE

Increased scapular internal rotation and anterior tipping decrease the volume of the supraspinatus outlet during the empty-can exercise. When maintenance of the subacromial space is important, use of the full-can exercise seems most appropriate for selective strengthening of the supraspinatus muscle.

Penetration of levofloxacin into skin tissue after oral administration of multiple 750 mg once-daily doses

OBJECTIVE

To probe the pharmacokinetic basis for the use of levofloxacin for complicated skin and skin-structure infections (SSSIs) at a once-daily dosage of 750 mg by investigating its penetration into skin tissue.

METHOD

Ten healthy volunteers were administered three oral, once-daily 750 mg doses of levofloxacin, and levofloxacin concentrations were subsequently measured over time (0.5-24 h) in skin-punch biopsy tissue and plasma.

RESULTS

Skin tissue concentrations consistently exceeded those in plasma at every time point, with tissue/plasma ratios of 1.37 +/- 0.81 for peak concentration and 1.97 +/- 0.35 for area under the concentration versus time curve. Three of the ten subjects reported treatment-emergent adverse events (AEs) that were considered unrelated to treatment. An 11th subject who had enrolled in the study withdrew after AEs of mild severity that were possibly related to the study drug.

CONCLUSION

The results support the clinical usage of levofloxacin 750 mg once-daily for complicated SSSIs.