Ultrasonography is not more reliable than anthropometry for assessing visceral fat in obese children

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT

Visceral fat accumulation is a risk factor for obesity-related complications. Waist circumference is used in clinical practice to assess visceral adiposity.

WHAT THIS STUDY ADDS

Ultrasound is not superior to waist circumference for assessing visceral obesity in obese children. The optimal site for measuring waist circumference in obese children is at the smallest body circumference between xiphisternum and umbilicus.

OBJECTIVE

Visceral fat accumulation is a well-established risk factor for obesity-related complications. In children, it has not been determined whether ultrasonography is superior to waist measurement for assessing visceral fat. Moreover, the optimal site for waist measurement has not been determined.

DESIGN

In a prospective cohort of 92 severely obese children and adolescents (age 13.9 ± 2.2 years, body mass index z-score 3.29 ± 0.33), we evaluated the performance of ultrasonography and two different methods of waist circumference measurement, using magnetic resonance imaging as the reference standard.

RESULTS

Waist circumference, defined as the smallest body circumference between xiphisternum and umbilicus had the strongest correlation with visceral fat quantity (r = 0.69 all, r = 0.68 girls, r = 0.64 boys). It was not outperformed by ultrasonography (r = 0.60 all, r = 0.62 girls, r = 0.50 boys) and correlated significantly better than the World Health Organization standard for waist measurement, midway between lower margin of the last rib and the crest of the ilium, (r = 0.51 all, r = 0.39 girls, r = 0.46 boys).

CONCLUSIONS

Waist circumference measurement, defined as the smallest body circumference between xiphisternum and umbilicus, is the preferred non-invasive technique for daily clinical practice to assess visceral fat accumulation in severely obese children and adolescents. There is no place for ultrasonography for the quantification of visceral fat in this group.

Development and growth in very preterm infants in relation to NIDCAP in a Dutch NICU: two years of follow-up

AIM

To study development and growth in relation to newborn individualized developmental and assessment program (NIDCAP) for infants born with a gestational age of less than 30 weeks.

METHODS

Developmental outcome of surviving infants, 25 in the NIDCAP group and 24 in the conventional care group, in a prospective phase-lag cohort study performed in a Dutch level III neonatal intensive care unit (NICU) was compared. Main outcome measure was the Bayley scales of infant development-II (BSID-II) at 24 months corrected age. Secondary outcomes were neurobehavioral and developmental outcome and growth at term, 6, 12 and 24 months.

RESULTS

Accounting for group differences and known outcome predictors no significant differences were seen between both care groups in BSID-II at 24 months. At term age NIDCAP infants scored statistically significant lower on neurobehavioral competence; motor system (median [IQR] 4.8 [2.9-5.0] vs. 5.2 [4.3-5.7], p = 0.021) and autonomic stability (median [IQR] 5.7 [4.8-6.7] vs. 7.0 [6.0-7.7], p = 0.001). No differences were seen in other developmental outcomes. After adjustment for background differences, growth parameters were comparable between groups during the first 24 months of life.

CONCLUSION

At present, the strength of conclusions to be drawn about the effect of NIDCAP on developmental outcome or growth at 24 months of age is restricted. Further studies employing standardized assessment approaches including choice of measurement instruments and time points are needed.

ACE mediates ventilator-induced lung injury in rats via angiotensin II but not bradykinin

Ventilator-induced lung injury is characterised by inflammation and apoptosis, but the underlying mechanisms are poorly understood. The present study proposed a role for angiotensin-converting enzyme (ACE) via angiotensin II (Ang II) and/or bradykinin in acute lung injury. The authors assessed whether ACE and, if so, Ang II and/or bradykinin are implicated in inflammation and apoptosis by mechanical ventilation. Rats were ventilated for 4 h with low- or high-pressure amplitudes in the absence or presence of the ACE inhibitor captopril. Nonventilated animals served as controls. ACE activity, Ang II and bradykinin levels, as well as inflammatory parameters (total protein, macrophage inflammatory protein-2 and interleukin-6) were determined. Apoptosis was assessed by the number of activated caspase-3 and TUNEL (terminal deoxynucleotidyltransferase-mediated deoxyuridine triphosphate nick-end labelling)-positive cells. Bronchoalveolar lavage fluid ACE activity, levels of total protein, inflammatory parameters and the number of apoptotic cells were increased in the high-pressure amplitude group as compared with the control group. Blocking ACE activity by captopril attenuated inflammation and apoptosis in the latter group. Similar results were obtained by blocking Ang II receptors, but blocking bradykinin receptors did not attenuate the anti-inflammatory and anti-apoptotic effects of captopril. The current authors conclude that inflammation and apoptosis in ventilator-induced lung injury is, at least in part, due to angiotensin-converting enzyme-mediated angiotensin II production.

Individualized developmental care in a Dutch NICU: short-term clinical outcome

AIM

To compare the short-term clinical outcomes of Newborn Individualized Developmental Care and Assessment Program (NIDCAP) and conventional care.

METHODS

A prospective phase-lag cohort study was performed in a Dutch tertiary level neonatal intensive care unit (NICU). Infants born before 30 weeks of gestational age (GA) were included, 26 in the conventional and 25 in the NIDCAP group. Outcomes were respiratory status, cerebral ultrasound findings, growth and length of NICU stay.

RESULTS

At study entry, NIDCAP infants had a lower birth weight (mean [SD]: 1043 [191] vs. 1154 [174] g, p = 0.044), were more often small for GA (8 vs. 2, p = 0.038), had smaller head circumferences (mean [SD]: 25.1 [1.3] vs. 26.1 [1.8] cm, p = 0.041) and were less often multiples (6 vs. 14, p = 0.029) than conventional care infants. During NICU stay, more infants in the NIDCAP group developed pneumonia (9 vs. 3, p = 0.040) due to nosocomial infections. After adjustment for these differences, a decreased risk for more severe cerebral damage in favour of NIDCAP was seen (Odds ratio: 0.12, 95% CI: 0.03-0.46, p = 0.002). No differences were observed for the other outcomes.

CONCLUSIONS

We conclude with precaution that in this phase-lag cohort study NIDCAP may have resulted in less severe cerebral damage, but was not associated with other clinical outcomes. In light of these findings, NIDCAP deserves further exploration.

Low mannose-binding lectin (MBL) levels in neonates with pneumonia and sepsis

We investigated whether deficiency of mannose-binding lectin (MBL), a component of innate immunity, is associated with neonatal pneumonia and sepsis during the first 72 h, i.e. early onset, and during the first month after birth. In 88 neonatal intensive care patients (71 premature), MBL2 genotype and MBL plasma levels at birth were determined prospectively by Taqman analysis and enzyme-linked immunosorbent assay, respectively. Thirty-five neonates (40%) had low, i.e. </= 0.7 microg/ml, MBL plasma levels at birth. Median (interquartile range) MBL plasma levels in 32 no early-onset sepsis (EOS) cases, 44 possible EOS cases and 11 EOS cases were 1.57 (0.57-2.67) microg/ml, 1.05 (0.41-1.70) microg/ml and 0.20 (0.10-0.77) microg/ml, respectively (P < 0.01). During the first month, 28 neonates (32%) had no infection, 49 (55%) had suspected infection, five (6%) had pneumonia and six (7%) had culture-proven sepsis. Low MBL levels at birth were associated both with an increased risk of developing pneumonia (OR: 12.0; 95% CI: 1.1-126.1; P = 0.04) and culture-proven sepsis (OR: 15.0; 95% CI: 1.5-151.3; P = 0.02). These results were confirmed by genetic analysis of MBL deficiency. Low MBL levels at birth are associated with an increased risk of early-onset sepsis, culture-proven sepsis and pneumonia during the first month of life.

High prevalence of mannose-binding lectin (MBL) deficiency in premature neonates

Mannose-binding lectin (MBL) is a component of innate immunity and thus particularly important in neonates in whom adaptive immunity is not yet completely developed. Promoter polymorphisms and structural exon-1 mutations in the MBL2 gene cause reduced or deficient MBL plasma concentrations. The aim of our study was to determine the prevalence of MBL deficiency in neonates admitted to the neonatal intensive care unit (NICU). Eighty-five NICU patients (69 premature) were included in the study. We measured MBL concentrations in umbilical cord and neonatal blood within 24 h after birth by ELISA technique. MBL2 genotypes (n = 67) were determined by Taqman analysis. MBL concentrations were measured longitudinally during three weeks in 26 premature neonates. The association between pre- and intra-partum clinical data and MBL concentrations was investigated. At birth, 29 (42%) premature and six (38%) term neonates had MBL plasma concentrations < or = 0.7 microg/ml which was regarded as deficient. Twenty-one (38%) premature and four (36%) term neonates had variant MBL2 haplotypes, corresponding to exon-1 mutations and the LXPA haplotype. MBL concentrations increased over time in neonates with wild-type MBL2 haplotypes, but not in neonates with variant haplotypes. Low MBL plasma concentrations were related to lower gestational age and variant MBL2 haplotypes. Umbilical cord and neonatal MBL plasma concentrations appeared to be similar. In conclusion, almost half of our NICU patients, especially the premature ones, were MBL-deficient at birth. These infants may be at increased risk of neonatal infections. MBL concentration can reliably be measured in umbilical cord blood and it is positively correlated with gestational and postnatal age.

Levamisole in steroid-sensitive nephrotic syndrome of childhood: the lost paradise?

Among the different drugs used for sparing steroids in steroid-sensitive nephrotic syndrome (SSNS) with frequent relapses and steroid dependency, levamisole is the least toxic and the least expensive. However, it is neither approved for this indication nor widely used in Europe. This may be explained by the difficulty in obtaining levamisole in some countries and the lack of good quality evidence for its effectiveness. Evidence is limited to three clinical trials that all suffered from methodological limitations. Statistical synthesis of these trials showed that levamisole reduces the risk of a relapse during treatment (relative risk 0.60, 95% confidence interval 0.45-0.79). From the available information, no conclusions can be drawn on the steroid-sparing effect, the long-term efficacy, and safety, as well as possible differences in efficacy in different subgroups of SSNS patients. The confirmation of a favorable effect of levamisole on the reduction of the frequency of relapses and on sparing steroids in an adequately powered, double-blind, placebo-controlled, randomized, multi-center clinical trial will promote consensus on the place of levamisole in the treatment of SSNS of childhood. Follow-up should be at least 1 year to evaluate long-term efficacy and side effects. If the results of such a clinical trial confirm the beneficial effects of levamisole in nephrotic syndrome, this may allow registration for this indication and interest companies other than Jansen-Cilag, which only recently has decided to stop its production.

A critical assessment of items on the Pediatric Crohn's Disease Activity Index

OBJECTIVES

Questions have been raised about the discriminative value of the three laboratory items (hematocrit, erythrocyte sedimentation rate, and albumin) and three physical items (height, perirectal disease, and extraintestinal manifestations) included in the Pediatric Crohn's Disease Activity Index (PCDAI). The aim of this study was to analyze the value of these six "criticized" items to the discriminative properties of the PCDAI.

METHODS

Data from 71 children with Crohn's disease visiting an outpatient clinic were analyzed. Physician global assessment of disease activity was used as the gold standard. A "basic index" was calculated by subtracting the score of the six criticized items from the score of the PCDAI calculated in the standard fashion. Multivariate logistic regression procedures identified which items significantly contributed to the "basic index". Receiver operating characteristic curves were produced comparing the standard PCDAI score to the "basic index" and a new "clinical index" which included only the criticized items truly contributing to the discriminatory ability of the "basic index".

RESULTS

Logistic regression models identified only perirectal disease as contributing to the discriminative abilities of the basic index. The clinical index therefore consists of the three history items (abdominal pain, number of liquid stools, and general well-being), three physical examination items (weight loss, abdominal examination, and perirectal disease) and no laboratory tests. The clinical index had an area under the curve not significantly inferior to that of the original PCDAI (0.93 [95% confidence interval, 0.89-0.99] vs. 0.96 [95% confidence interval, 0.92-0.99]).

CONCLUSIONS

A clinical index consisting of three history items and three physical examination items has an accuracy equal to the standard PCDAI in distinguishing children with disease in remission from those with a relapse.

A comparison of neuropsychological effects of thalamotomy and thalamic stimulation

OBJECTIVE

The neuropsychological effects of thalamotomy and thalamic stimulation in patients with severe drug-resistant tremor due to PD, essential tremor (ET), or MS were compared in a randomized trial.

METHODS

Complete neuropsychological evaluations at baseline and 6 months after surgery were obtained in 62 patients who underwent thalamotomy (n = 32: 21 PD, 6 ET, 5 MS) or thalamic stimulation (n = 30: 19 PD, 7 ET, 4 MS).

RESULTS

Six months after thalamotomy, a decline was seen in the scores of the Stroop Color-Word Test, with the exception of the interference score. In the thalamic stimulation group, no significant changes were found on any of the cognitive tests. Age, diagnosis, disease severity, and baseline cognitive status were not correlated to cognitive changes. A difference in score changes between right- and left-sided surgery was found in verbal fluency and Stroop Test scores after both thalamotomy and thalamic stimulation.

CONCLUSIONS

Both thalamotomy and thalamic stimulation are associated with a minimal overall risk of cognitive deterioration. Verbal fluency decreased after both left-sided thalamotomy and thalamic stimulation.

Validation of the KDQOL-SF: a dialysis-targeted health measure

BACKGROUND

In evaluations of dialysis therapy, an assessment of health-related quality of life (HRQOL) is often important. The aim of this study was to determine the basic psychometric properties, reliability and validity of the short form of the KDQOL i.e. the KDQOL-SF, a dialysis-targeted instrument, and to assess its ability to detect changes over time.

METHODS

In a prospective cohort study (Netherlands Cooperative Study on the Adequacy of Dialysis, NECOSAD), all new adult ESRD patients in 32 different Dutch centers were consecutively enrolled. Demographic, clinical and HRQOL data were obtained 3 and 12 months after the start of chronic dialysis therapy.

RESULTS

The reliability of the KDQOL-SF was supported by test results that were above the recommended minimal values. Validity of KDQOL-SF was confirmed by the hypothesized positive correlations of the overall health rating and renal function, and by the negative correlations between the number of comorbidities and dialysis dose. Moreover, dialysis-targeted dimensions were more sensitive in detecting relevant differences pertaining to kidney diseases than generic dimensions. The KDQOL-SF was able to detect clinical changes over time.

CONCLUSIONS

The psychometric properties of the KDQOL-SF were good, and the different dialysis-targeted dimensions were informative with a high reliability and validity. These results support the application of the KDQOL-SF in studies evaluating dialysis therapy.

A comparison of quality of life of patients on automated and continuous ambulatory peritoneal dialysis

OBJECTIVE

Data on health-related quality of life (HRQOL) of automated peritoneal dialysis (APD) patients are scarce. The objectives of this study were (1) to explore HRQOL of APD patients and compare it with HRQOL of continuous ambulatory peritoneal dialysis (CAPD) patients and a general population sample, and (2) to study the relationship between HROOL assessment outcomes and background variables.

DESIGN

Home interviews of APD and CAPD patients. HRQOL, social-demographic, clinical, and treatment-related background data were collected at the interview and from patient charts. Multiple regression analysis and logistic regression analysis were used to study the relationship of HRQOL assessment outcomes with background variables.

SETTING

Sixteen Dutch dialysis centers.

PATIENTS

Convenience sample of 37 APD patients and 59 CAPD patients matched for total time on dialysis.

MAIN OUTCOME MEASURES

Four HRQOL instruments: Short-Form 36, EuroQol EQ-5D, Standard Gamble, and Time Trade Off.

RESULTS

Physical functioning of both APD and CAPD patients was impaired compared with the general population; mental functioning was not different. In multivariate analyses, the mental health of APD patients was found to be better than that of CAPD patients. In addition, APD patients were less anxious and depressed than CAPD patients. With respect to physical aspects of HRQOL and role-functioning, no differences were observed between APD and CAPD patients. Other variables to explain HRQOL assessment outcomes were age, the number of comorbid diseases, and primary kidney disease.

CONCLUSIONS

HRQOL of APD patients is at least equal to HRQOL of CAPD patients.

What happens to patients starting dialysis in the Netherlands?

BACKGROUND

despite improvements in dialysis technology, publications around 1990 showed increasing mortality rates in dialysis patients. The Dialysis Group of the Netherlands initiated the Netherlands Cooperative Study on the Adequacy of Dialysis (NECOSAD) to investigate the association of patient and therapy characteristics with outcome.

METHODS

250 patients were included in this prospective multicentre study 3 months after the start of dialysis. We used Cox regression to predict mortality and technique failure and repeated measures analysis of variance to study the time course of continuous parameters.

RESULTS

there were considerable differences in patient populations among dialysis centres. Patient survival was 76% at 2 years. Technique survival was higher in haemodialysis. Hospitalisation decreased from 25 days between 3 and 12 months to 19 days per patient year in the third year. Residual renal function decreased at a similar rate in both modalities, but blood pressure tended to increase in females receiving peritoneal dialysis. Outcome was predominantly dependent on patient characteristics.

CONCLUSIONS

In the light of the increasing age of patients starting dialysis, increasing mortality can be expected. Furthermore, if outcome is to play a role in the quality assessment of dialysis centres, it is essential to know the characteristics of their patient populations.

A comparison of continuous thalamic stimulation and thalamotomy for suppression of severe tremor

BACKGROUND

Deep-brain stimulation through an electrode implanted in the thalamus was developed as an alternative to thalamotomy for the treatment of drug-resistant tremor. Stimulation is thought to be as effective as thalamotomy but to have fewer complications. We examined the effects of these two procedures on the functional abilities of patients with drug-resistant tremor due to Parkinson's disease, essential tremor, or multiple sclerosis.

METHODS

Sixty-eight patients (45 with Parkinson's disease, 13 with essential tremor, and 10 with multiple sclerosis) were randomly assigned to undergo thalamotomy or thalamic stimulation. The primary outcome measure was the change in functional abilities six months after surgery, as measured by the Frenchay Activities Index. Scores for this index can range from 0 to 60, with higher scores indicating better function. Secondary outcome measures were the severity of tremor, the number of adverse effects, and patients' assessment of the outcome.

RESULTS

Functional status improved more in the thalamic-stimulation group than in the thalamotomy group, as indicated by increases in the score for the Frenchay Activities Index (from 31.4 to 36.3 and from 32.0 to 32.5, respectively; difference between groups, 4.4 points; 95 percent confidence interval, 2.0 to 6.9). After adjustment for base-line characteristics, multivariate analysis also showed that the thalamic-stimulation group had greater improvement (difference between groups, 5.1 points; 95 percent confidence interval, 2.3 to 7.9). Tremor was suppressed completely or almost completely in 27 of 34 patients in the thalamotomy group and in 30 of 33 patients in the thalamic-stimulation group. One patient in the thalamic-stimulation group died perioperatively after an intracerebral hemorrhage. With the exception of this incident, thalamic stimulation was associated with significantly fewer adverse effects than thalamotomy. Functional status was reported as improved by 8 patients in the thalamotomy group, as compared with 18 patients in the thalamic-stimulation group (P=0.01).

CONCLUSIONS

Thalamic stimulation and thalamotomy are equally effective for the suppression of drug-resistant tremor, but thalamic stimulation has fewer adverse effects and results in a greater improvement in function.

Quality of life in predialysis end-stage renal disease patients at the initiation of dialysis therapy. The NECOSAD Study Group

OBJECTIVE

To assess health-related quality of life (QL) in a group of Dutch predialysis end-stage renal disease (ESRD) patients prior to the initiation of dialysis, and to compare QL between patients with different intended initial dialysis treatments.

DESIGN

In a prospective cohort study, demographic, clinical, and QL data were obtained from Dutch adult patients who were consecutively enrolled from 27 different centers 0 - 4 weeks prior to the beginning of their chronic dialysis treatment.

PATIENTS

Of the 301 patients who completed the QL questionnaires (of a possible 337 enrolled patients), 152 intended to start with hemodialysis (pre-HD) and 149 patients with peritoneal dialysis (pre-PD).

MAIN OUTCOME MEASURE

Perceived QL of pre-HD and pre-PD patients. Quality of life was assessed with two generic health assessment instruments: the SF-36 and the EuroQol.

RESULTS

After correction for group differences, pre-HD patients scored consistently, but not significantly, lower for all separate dimensions of the SF-36 and the overall health score of the EuroQol compared to pre-PD patients. However, analyzing the dimensions of the SF-36 together, adjusted for case-mix, pre-HD patients scored significantly lower than pre-PD patients. Mean difference was 6.5 points (p = 0.04).

CONCLUSION

Multivariate adjustment for known case-mix differences at the start of dialysis therapy was not sufficient to adjust for all patient selection effects on QL. Consequently, published QL comparisons between HD and PD in nonrandomized cohort studies should be interpreted with caution. Assessment of QL just before start of dialysis therapy and subsequent adjustment for baseline values may be the only valid alternative for randomized studies.

Predictors of poor outcome in chronic dialysis patients: The Netherlands Cooperative Study on the Adequacy of Dialysis. The NECOSAD Study Group

In a prospective cohort study, we constructed a composite index of poor outcome that incorporates survival, morbidity, and quality of life (QL). We identified baseline patient and treatment characteristics that predicted poor outcome 1 year after the start of chronic dialysis. Outcome was classified as poor if a patient had died or if at least two of the following criteria were present: (1) 30 days or greater of hospitalization per year, (2) serum albumin level of 30 g/L or less or a malnutrition index score of 11 or greater, (3) a 36-item Medical Outcomes Study (MOS)-Short Form Health Survey Questionnaire (SF-36) physical summary QL score of 2 or more SDs less than the general population mean score, and (4) an SF-36 mental summary QL score of 2 or more SDs less than the general population mean score. Multivariate logistic regression analysis was used to identify independent predictors of poor outcome. Of 250 included patients, 189 were assessable with respect to poor outcome. Of these patients, 47 (25%) were classified as poor. A baseline presence of comorbidity, serum albumin level of 30 g/L or less, physical or mental QL score 2 or more SDs less than the general population mean score, and, to a lesser extent, residual glomerular filtration rate of 2.5 mL/min/1.73 m(2) or less were independently associated with a greater risk for poor outcome. A post hoc analysis indicated a mean arterial blood pressure greater than 107 mm Hg was predictive of poor outcome in patients undergoing peritoneal dialysis. In conclusion, our prognostic model provides a useful tool to identify chronic dialysis patients at risk for poor health status. Strategies aimed at preserving residual renal function, controlling blood pressure, monitoring QL, and consequently giving psychosocial support may reduce the risk for poor outcome.

Dialysis in The Netherlands: the clinical condition of new patients put into a European perspective. NECOSAD Study Group. Netherlands Cooperative Study on the Adequacy of Dialysis phase 1

BACKGROUND

The unadjusted annual mortality rate among prevalent Dutch dialysis patients increased from 1981 to 1992. Part of this increase may be attributed to the ageing of the dialysis population, but hardly any data were available on other important prognostic features of new Dutch dialysis patients, such as co-morbidity and other aspects of their clinical condition. The aim of the present study was to obtain these data and to put them into a European perspective.

METHODS

Two hundred and fifty consecutive new patients were included in this prospective multi-centre study. Data were collected 3 months after start of dialysis. Multivariate linear regression analysis was used to explain the variability of parameters of nutritional state and blood pressure.

RESULTS

Mean age was 57 years, co-morbid conditions were present in 51%, diabetes mellitus in 18%, and cardiovascular disease in 28%. Decreased protein intake was related to diminished residual renal function. Our patients did not have more co-morbidity than Dutch patients participating in a European study some years earlier. Comparison with other studies was complicated by the use of different definitions of co-morbidity and of selected patient populations.

CONCLUSIONS

Despite the fact that Dutch dialysis patients have become older and the incidence of diabetic nephropathy has increased, no conclusions could be drawn on a concomitant increase in co-morbidity. This patient group may serve as a reference population to study future changes in patient case-mix within the Netherlands. Furthermore, the use of common international definitions of co-morbidity is needed to be able to make comparisons of survival data.

Quality of life over time in dialysis: the Netherlands Cooperative Study on the Adequacy of Dialysis. NECOSAD Study Group

BACKGROUND

Information on the longitudinal quality of life (QL) of patients treated by different dialysis modalities is lacking. Therefore, we performed a prospective cohort study on the QL over time in hemodialysis (HD) and peritoneal dialysis (PD) patients.

METHODS

New chronic dialysis patients from 13 Dutch dialysis centers were consecutively included. The patients' self-assessment of QL was measured with the SF-36 form at 3, 6, 12, and 18 months after the start of dialysis treatment.

RESULTS

Out of 230 patients who completed the QL questionnaire at least once, 139 patients stayed on their initial dialysis modality, 26 patients switched dialysis modality, 35 patients were transplanted, 28 patients died, and two patients had a recovery of renal function. The QL of patients who died during the study period was considerably worse at baseline and worsened at a faster rate than in the other patient groups. In patients who stayed on their initial dialysis modality, the physical QL decreased over time, whereas the mental QL tended to remain stable. After an adjustment for the initial value of QL and comorbidity, a consistently favorable effect of HD on physical QL over time was found compared with PD, whereas mental QL values remained similar. Parameters of adequacy of dialysis were not associated with QL over time.

CONCLUSION

This prospective cohort study shows that physical QL over time in HD patients is better than in PD patients.

Physical symptoms and quality of life in patients on chronic dialysis: results of The Netherlands Cooperative Study on Adequacy of Dialysis (NECOSAD)

BACKGROUND

So far, little attention has been paid to the value of dialysis adequacy for patients' quality of life (QL). Therefore we studied the impact of demographic, clinical, and dialysis characteristics on physical symptoms and perceived QL.

METHODS

The study population consisted of 120 incident chronic haemodialysis (HD) and 106 peritoneal dialysis (PD) patients, starting dialysis treatment in 13 Dutch centres. Data were collected 3 months after the start of dialysis. Nine physical symptoms were assessed with a self-administered questionnaire. Patient's self-assessment of QL was measured with the 36-item MOS Short Form (SF-36).

RESULTS

The most common symptoms in HD and PD were fatigue (respectively 82 and 87%) and itching (73 and 68%). In HD only a medium to high comorbidity--age risk index was associated with greater symptom burden. In PD also a lower percentage lean body mass, a lower rGFR, and past episodes of underhydration were associated with greater symptom burden. The explained variance by these variables was only 12% in HD and 21% in PD. However, greater symptom burden explained a substantial additional amount of impaired physical and mental QL on top of demographics and clinical status. Dialysis variables were associated neither with symptoms nor with QL.

CONCLUSION

Symptom burden can be explained to a limited extent by demographic and clinical variables and not by dialysis characteristics. Addition of symptom burden to the other variables makes it possible to explain one-third of perceived QL. This underlines the importance of symptom reduction in order to improve patient's QL.

Mortality and technique failure in patients starting chronic peritoneal dialysis: results of The Netherlands Cooperative Study on the Adequacy of Dialysis. NECOSAD Study Group

BACKGROUND

Recent studies have shown an association between small solute clearance and patient survival. Thus far, little attention has been paid to the potential effects of fluid overload. The aim of this study was to determine the relative importance of baseline patient and treatment characteristics to mortality and technique failure in patients starting peritoneal dialysis.

METHODS

One hundred and eighteen consecutive new patients were included in this prospective multicenter cohort study. Cox proportional hazards regression was used to predict mortality and technique failure.

RESULTS

There were 33 deaths and 44 technique failures. The two-year patient survival was 77%, and the two-year technique survival was 64%. Age, systolic blood pressure, and the absolute quantity of small solutes removed at baseline were independent predictors of mortality. A one-year increase in age was associated with a relative risk (RR) of death of 1.05 (95% CI, 1.01 to 1.09) and a 10 mm Hg rise in systolic blood pressure, with a RR of 1.42 (95% CI, 1.17 to 1.73). The removal of 1 mmol/week/1.73 m2 of urinary and dialysate creatinine was associated with a RR of death of 0.95 (95% CI, 0.92 to 0.98) and 0.93 (95% CI, 0.89 to 0.98). The removal of urea had a similar association with the RR of death. Predictors for technique failure were urine volume, peritoneal ultrafiltration, and systolic blood pressure.

CONCLUSIONS

Dialysate solute removal was an independent predictor of mortality. The association between systolic blood pressure and mortality shows that the maintenance of fluid balance and the removal of small solutes deserve equal attention.

The prognosis of esophageal carcinoma staged irresectable (T4) by endosonography

BACKGROUND

Endosonography is an accurate preoperative staging technique for esophageal carcinoma. We retrospectively investigated a cohort of patients with carcinoma of the esophagus or gastric cardia that was endosonographically staged to be irresectable and studied whether their survival was influenced by the treatment received.

STUDY DESIGN

Between April 1992 and July 1995, 654 patients were referred for endosonographic staging. We retrospectively searched our database for patients staged T4 and collected followup. Kaplan-Meier survival and Cox proportional hazards model were used to study the effect of treatment and various other factors on survival.

RESULTS

Fifty-one patients (median age, 62 years; range, 44-87; 37 male) were staged T4 by endosonography. Followup was collected of all patients. Explorative surgery was chosen in 24 patients (47%), and the tumor was resected in 13 patients. Median survival in the surgical group was 9.67 months (95% confidence interval [CI] 6.03, 13.31) and 7.06 months (95% CI: 5.68, 8.44) in the nonsurgical group (not significant). Patients with infiltration in the respiratory tract had a 2.5 times higher risk of death than patients without (adjusted hazard ratio: 2.54; 95% CI: 1.30, 4.96).

CONCLUSIONS

Patients staged irresectable by endosonography (T4 stage) have a very poor prognosis, regardless of further therapy. Survival of this group of patients was not influenced by surgery.

Quality of life in patients on chronic dialysis: self-assessment 3 months after the start of treatment. The Necosad Study Group

The aim of the present multicenter study was to assess quality of life of Dutch dialysis patients 3 months after the start of chronic dialysis treatment. The quality of life was compared with the quality of life of a general population sample, and the impact of demographic, clinical, renal function, and dialysis characteristics on patients' quality of life was studied. New end-stage renal disease (ESRD) patients who were started on chronic hemodialysis or peritoneal dialysis in 13 dialysis centers in The Netherlands were consecutively included. Patients' self-assessment of quality of life was measured by the SF-36, a 36-item Short Form Health Survey Questionnaire encompassing eight dimensions: physical functioning, social functioning, role-functioning physical, role-functioning emotional, mental health, vitality, bodily pain, and general health perceptions. One hundred twenty hemodialysis and 106 peritoneal dialysis patients completed the SF-36. Quality of life of hemodialysis and peritoneal dialysis patients was substantially impaired in comparison to the general population sample, particularly with respect to role-functioning physical and general health perceptions. Mean role-functioning physical and general health perceptions scores of the hemodialysis patients corresponded with the lowest scoring 8% and 12%, respectively, of the reference group. Mean role-functioning physical and general health perceptions scores of the peritoneal dialysis patients corresponded with the lowest scoring 10% and 12%, respectively, of the reference group. Hemodialysis patients showed lower levels of quality of life than peritoneal dialysis patients on physical functioning, role-functioning emotional, mental health, and pain. However, on the multivariate level, we could only demonstrate an impact of dialysis modality on mental health. A higher number of comorbid conditions, a lower hemoglobin level, and a lower residual renal function were independently related to poorer quality of life. The variability of the SF-36 scores explained by selected demographic, clinical, renal function, and dialysis characteristics was highest for physical functioning (29.7%). Explained variability of the other SF-36 dimensions ranged from 6.9% for general health perceptions to 15.4% for vitality. We conclude that quality of life of new ESRD patients is substantially impaired. Comorbid conditions, hemoglobin, and residual renal function could explain poor quality of life only to a limited extent. Further research exploring determinants and indices of quality of life in ESRD patients is warranted. From a clinical perspective, we may conclude that quality of life should be considered in the monitoring of dialysis patients.

Extreme obesity: sociodemographic, familial and behavioural correlates in The Netherlands

STUDY OBJECTIVE

To investigate the relationship between sociodemographic, behavioural, and family characteristics and the body mass index (BMI) (weight (kg)/height (m2)) of extremely obese people.

DESIGN

Self reported sociodemographic, behavioural, and familial characteristics and weight and height were obtained by postal questionnaire.

PARTICIPANTS AND SETTING

Adult, obese Dutch people who, on their own initiative, contacted our hospital for information on obesity treatment were sent a questionnaire. A total of 244 of 690 subjects had returned the questionnaire within the stated period of 80 days. Due to missing data 19 subjects could not be included in this analysis, leaving 191 women and 34 men.

MAIN RESULTS

In women the BMI seemed to be significantly inversely associated with the level of education of the partner, the number of cups of coffee consumed, and number of cigarettes smoked a day. In addition, the BMI of women was positively related to BMI of their mothers. Together these variables explained 18.0% of the total variation in BMI. In men none of the selected variables was associated with their BMI.

CONCLUSION

As the selected variables explained almost one fifth of the total variation in BMI, the impact of sociodemographic, familial, and behavioural factors should have more recognition in strategies aimed at reducing obesity.

Percutaneous endoscopic gastrostomy in patients with amyotrophic lateral sclerosis and impaired pulmonary function

Amyotrophic lateral sclerosis is a rapidly progressive disease of unknown etiology resulting in tetraparalysis, dysarthria, dysphagia, and ultimately death from respiratory insufficiency. In the course of the disease, recurrent episodes of aspiration, pneumonia, dehydration, and malnutrition may necessitate nasoenteral tube placement, an inconvenient and unattractive arrangement in patients with dribbling and impaired swallowing. A percutaneous endoscopic gastrostomy seemed a better, though potentially hazardous, alternative in view of the often severely restricted pulmonary function of these patients. Therefore, we prospectively investigated the use of percutaneous endoscopic gastrostomy in 68 consecutive patients with amyotrophic lateral sclerosis. Minimum required pulmonary function was defined as forced vital capacity (FVC) of 1 L or more and CO2 gas exchange capability as pCO2 of 45 mm Hg or less. The methodology of insertion was adapted to facilitate the early removal of gastric air. Fifty-five patients (median FVC, 1.7 L; pCO2, 40 mm Hg) were eligible for the gastrostomy procedure, and 13 patients (median FVC, 0.8 L; pCO2, 47 mm Hg) were not. Despite the fact that modification of the method of insertion rendered the procedure more difficult, the success rate was 89% (49/55); it was 96% (49/51) when failures related to distorted anatomy were excluded. The procedure-related mortality rate was 1.8% and the 24-hour in-hospital mortality rate was 3.6%, mainly related to respiratory insufficiency. The 30-day out-of-hospital mortality rate was 11.5%. Major complications (3.6%) consisted of a spontaneously draining cutaneous abscess in 2 cases. Peristomal redness was present in 6 cases, and 5 patients required analgesics for wound pain.(ABSTRACT TRUNCATED AT 250 WORDS)

Feeding tubes in endoscopic and clinical practice: the longer the better?

In an attempt to combine successful distal feeding tube positioning and a more prolonged stay without interfering with tube patency and feeding regimens, commercially available 105-cm polyurethane feeding tubes were compared with experimental tubes 125 cm and 145 cm long. The technique for endoscopic positioning at the bedside of the patient was standardized. Forty-five patients who required intraduodenal or intrajejunal enteral feeding in the intensive care unit were randomly assigned to one of the three tube-length groups. Even the 105-cm short feeding tubes were able to be introduced beyond the duodenojejunal junction, although insufficient tube length remained for tube fixation at the nose. The longer variants, however, were positioned significantly (p < 0.01) deeper in the intestine, with enough spare tube length for slack formation in the stomach and fixation at the nose. Tubes were electively removed in 29% of the patients. Irrespective of tube length, premature removal by the patient (in 36%) or by the nurse (in 11%) was rather high. Tube blockage was irremediable in 9%. Feeding tubes survived on average 10.6 days in all three tube-length groups, despite the fact that many drugs were administered by tube as well. The successful, easy, and fast endoscopic positioning of feeding tubes far into the intestine and at the patient's bedside may further expand the possibility for enteral feeding. Moreover, polyurethane materials are well tolerated, and increasing the tube length does not interfere with tube patency or feeding plans.

Effect of a lipid-rich fraction from boiled coffee on serum cholesterol

Scandinavian-style boiled coffee, which raises serum cholesterol, was found to contain more lipid material than drip filter coffee, which does not. Ten volunteers consumed a lipid-enriched fraction from boiled coffee for six weeks: the supplement provided 77 g of water, 1.3 g of lipid, and 1.6 g of other solids per day. Serum cholesterol rose in every subject; the mean rise was 0.74 mmol/l after three weeks (range -0.09 to 1.48 mmol/l) and 1.06 SD 0.37 mmol/l or 23% after six weeks (range 0.48 to 1.52 mmol/l). The increase was mainly due to low-density-lipoprotein cholesterol, which rose by 29%, but very-low-density lipoprotein cholesterol was also raised, as evidenced by a 55% rise in triglycerides. High-density-lipoprotein cholesterol was unchanged. After supplementation had ended, lipid levels returned to baseline. Boiled coffee thus contains a lipid that powerfully raises serum cholesterol.