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Vascular pedicle width on chest radiograph as a measure of volume overload: meta-analysis

James d'Etienne, MD - Sat, 01/07/2012 - 05:00

West J Emerg Med. 2011 Nov;12(4):426-32. doi: 10.5811/westjem.2011.3.2023.

ABSTRACT

INTRODUCTION: Vascular pedicle width (VPW), a measurement obtained from a chest radiograph (CR), is thought to be an indicator of circulating blood volume. To date there are only a handful of studies that demonstrate a correlation between high VPW and volume overload, each utilizing different VPW values and CR techniques. Our objective was to determine a mean VPW measurement from erect and supine CRs and to determine whether VPW correlates with volume overload.

METHODS: MEDLINE database, Web of Science, and the Cochrane Central Register of Controlled Trials were searched electronically for relevant articles. References from the original and review publications selected electronically were manually searched for additional relevant articles. Two investigators independently reviewed relevant articles for inclusion criteria and data extraction. Mean VPW measurements from both supine and erect CRs and their correlation with volume overload were calculated.

RESULTS: Data from 8 studies with a total of 363 subjects were included, resulting in mean VPW measurements of 71 mm (95% confidence interval [CI] 64.9-77.3) and 62 mm (95% CI 49.3-75.1) for supine and erect CRs, respectively. The correlation coefficients for volume overload and VPW were 0.81 (95% CI 0.74-0.86) for both CR techniques and 0.81 (95% CI 0.72-0.87) for supine CR and 0.80 (95% CI 0.69-0.87) for erect CR, respectively.

CONCLUSION: There is a clinical and statistical correlation between VPW and volume overload. VPW may be used to evaluate the volume status of a patient regardless of the CR technique used.

PMID:22224132 | PMC:PMC3236159 | DOI:10.5811/westjem.2011.3.2023

Vascular pedicle width on chest radiograph as a measure of volume overload: meta-analysis

Hao Wang, MD - Sat, 01/07/2012 - 05:00

West J Emerg Med. 2011 Nov;12(4):426-32. doi: 10.5811/westjem.2011.3.2023.

ABSTRACT

INTRODUCTION: Vascular pedicle width (VPW), a measurement obtained from a chest radiograph (CR), is thought to be an indicator of circulating blood volume. To date there are only a handful of studies that demonstrate a correlation between high VPW and volume overload, each utilizing different VPW values and CR techniques. Our objective was to determine a mean VPW measurement from erect and supine CRs and to determine whether VPW correlates with volume overload.

METHODS: MEDLINE database, Web of Science, and the Cochrane Central Register of Controlled Trials were searched electronically for relevant articles. References from the original and review publications selected electronically were manually searched for additional relevant articles. Two investigators independently reviewed relevant articles for inclusion criteria and data extraction. Mean VPW measurements from both supine and erect CRs and their correlation with volume overload were calculated.

RESULTS: Data from 8 studies with a total of 363 subjects were included, resulting in mean VPW measurements of 71 mm (95% confidence interval [CI] 64.9-77.3) and 62 mm (95% CI 49.3-75.1) for supine and erect CRs, respectively. The correlation coefficients for volume overload and VPW were 0.81 (95% CI 0.74-0.86) for both CR techniques and 0.81 (95% CI 0.72-0.87) for supine CR and 0.80 (95% CI 0.69-0.87) for erect CR, respectively.

CONCLUSION: There is a clinical and statistical correlation between VPW and volume overload. VPW may be used to evaluate the volume status of a patient regardless of the CR technique used.

PMID:22224132 | PMC:PMC3236159 | DOI:10.5811/westjem.2011.3.2023

The influence of research compensation options on Practice-based Research Network (PBRN) physician participation: a North Texas (NorTex) PBRN study

Richard Young, MD - Fri, 09/09/2011 - 05:00

J Am Board Fam Med. 2011 Sep-Oct;24(5):562-8. doi: 10.3122/jabfm.2011.05.100291.

ABSTRACT

OBJECTIVE: To study the effect of two compensation approaches, continuing medical education (CME) credits (5 hours) or monetary ($150), on the participation rate of a physician needs assessment study.

METHODS: Physicians representing family medicine, internal medicine, pediatric, and geriatrics specialties, and practicing in ambulatory primary care clinics affiliated with the North Texas Primary Care (NorTex) PBRN clinics, were recruited to complete a survey relevant to their subspecialty and to conduct a self-audit/abstraction of five medical records. Physicians were recruited from four health care systems, and the recruiting methods varied by system. Study outcome was the rate of study completion by type of incentive.

RESULTS: One hundred five of 211 (49.8%) physicians approached to participate gave consent and 84 (39.8%) completed the study. There was no difference in the number of physicians randomly assigned to monetary compared with CME compensation for giving consent to participate (adjusted odds ratio = 1.42, confidence interval = 0.69, 2.93). However, physicians in the monetary compensation group were more likely to complete the study after giving consent (adjusted odds ratio = 4.70, confidence interval = 1.25, 17.58). This monetary effect was also significant from the perspective of all physicians approached initially (adjusted odds ratio = 2.78, confidence interval = 1.16, 6.67).

DISCUSSION: This study suggests that future PBRN investigators should receive monetary compensation for the opportunity cost of adding research activities to their already busy practices. This compensation may be especially vital for PBRNs to complete more ambitious projects requiring a significant time commitment from the participating physicians.

PMID:21900439 | DOI:10.3122/jabfm.2011.05.100291

Factors influencing work interference in patients with chronic low back pain: a Residency Research Network of Texas (RRNeT) study

Richard Young, MD - Fri, 09/09/2011 - 05:00

J Am Board Fam Med. 2011 Sep-Oct;24(5):503-10. doi: 10.3122/jabfm.2011.05.100298.

ABSTRACT

INTRODUCTION: Chronic low back pain (CLBP) is a disabling and expensive condition commonly seen in family physicians' offices. A complete understanding of factors contributing to patients' return to work remains elusive.

OBJECTIVE: To describe patients with CLBP seen in family physicians' offices and to explore factors interfering with return to work.

SUBJECTS: Three hundred sixty outpatients with CLBP for more than 3 months.

SETTING: Ten participating family physicians' offices of the Residency Research Network of Texas.

PRIMARY OUTCOME: The effect of pain on work effect as measured by a Likert scale.

RESULTS: Patients were typically female (72%), overweight or obese (mean body mass index, 33.4), had pain for many years (mean, 13.6 years), and screened positive for recent depressive symptoms (83%). The majority of patients took at least some opioid medication for their pain (59%). Multivariate linear regression analysis found that the largest single contributor to effect on work was the subjects' score on the SF-36 physical function scale (β = -0.382). Other contributors included average daily pain (β = 0.189), the frequency of flare-ups of pain (β = 0.108), the effect of the painful flare-ups (β = 0.170), and current depressive symptoms (β = 0.131) (adjusted R(2) for model = 0.535). Age, sex, race/ethnicity, total time the patient has had CLBP, other comorbidities (including a diagnosis of depression), disability status, use of opioids, history of intimate partner violence, social support, and procedures attempted were not predictive.

DISCUSSION: Future studies attempting to demonstrate the effectiveness of interventions in CLBP should measure depressive symptoms and the magnitude and effect of painful flare-ups, not just the overall pain score. The majority of CLBP patients seen in these practices take opioids for their pain. Screening and treating for depression may be reasonable for some patients, though evidence of its effectiveness is lacking.

PMID:21900433 | DOI:10.3122/jabfm.2011.05.100298

Echocardiographic indices do not reliably track changes in left-sided filling pressure in healthy subjects or patients with heart failure with preserved ejection fraction

Paul Bhella - Wed, 07/27/2011 - 05:00

Circ Cardiovasc Imaging. 2011 Sep;4(5):482-9. doi: 10.1161/CIRCIMAGING.110.960575. Epub 2011 Jul 25.

ABSTRACT

BACKGROUND: In select patient populations, Doppler echocardiographic indices may be used to estimate left-sided filling pressures. It is not known, however, whether changes in these indices track changes in left-sided filling pressures within individual healthy subjects or patients with heart failure with preserved ejection fraction (HFpEF). This knowledge is important because it would support, or refute, the serial use of these indices to estimate changes in filling pressures associated with the titration of medical therapy in patients with heart failure.

METHODS AND RESULTS: Forty-seven volunteers were enrolled: 11 highly screened elderly outpatients with a clear diagnosis of HFpEF, 24 healthy elderly subjects, and 12 healthy young subjects. Each patient underwent right heart catheterization with simultaneous transthoracic echo. Pulmonary capillary wedge pressure (PCWP) and key echo indices (E/e' and E/Vp) were measured at two baselines and during 4 preload altering maneuvers: lower body negative pressure -15 mm Hg; lower body negative pressure -30 mm Hg; rapid saline infusion of 10 to 15 mL/kg; and rapid saline infusion of 20 to 30 mL/kg. A random coefficient mixed model regression of PCWP versus E/e' and PCWP versus E/Vp was performed for (1) a composite of all data points and (2) a composite of all data points within each of the 3 groups. Linear regression analysis was performed for individual subjects. With this protocol, PCWP was manipulated from 0.8 to 28.8 mm Hg. For E/e', the composite random effects mixed model regression was PCWP=0.58×E/e'+7.02 (P<0.001), confirming the weak but significant relationship between these 2 variables. Individual subject linear regression slopes (range, -6.76 to 11.03) and r(2) (0.00 to 0.94) were highly variable and often very different than those derived for the composite and group regressions. For E/Vp, the composite random coefficient mixed model regression was PCWP=1.95×E/Vp+7.48 (P=0.005); once again, individual subject linear regression slopes (range, -16.42 to 25.39) and r(2) (range, 0.02 to 0.94) were highly variable and often very different than those derived for the composite and group regressions.

CONCLUSIONS: Within individual subjects the noninvasive indices E/e' and E/Vp do not reliably track changes in left-sided filling pressures as these pressures vary, precluding the use of these techniques in research studies with healthy volunteers or the titration of medical therapy in patients with HFpEF.

PMID:21788358 | PMC:PMC3205913 | DOI:10.1161/CIRCIMAGING.110.960575

Levels of acculturation and effect on glycemic control in Mexicans and Mexican Americans with type 2 diabetes

Richard Young, MD - Sat, 02/05/2011 - 05:00

Postgrad Med. 2011 Jan;123(1):66-72. doi: 10.3810/pgm.2011.01.2246.

ABSTRACT

BACKGROUND: Acculturation of Mexican Americans toward the predominant American culture has been shown to influence health outcomes. Little is known about the role of acculturation in diabetes control.

OBJECTIVE: To measure the association between acculturation and diabetes control in Mexicans and Mexican Americans with type 2 diabetes mellitus (T2DM).

DESIGN: Cross-sectional survey and chart review.

SETTING: Ambulatory family medicine clinics.

PATIENTS: Sixty-six Mexican and Mexican American adults with T2DM for ≥ 1 year. INSTRUMENT AND OUTCOMES: A survey tool was developed that included the General Acculturation Index developed by Balcazar et al to measure acculturation. Basic demographics, psychosocial factors, patient satisfaction, and patients' most recent hemoglobin A(1c) (HbA(1c)) levels were also obtained.

RESULTS: There was no significant correlation between acculturation score and HbA(1c) levels. On binary logistic regression, HbA(1c) levels were associated with patient satisfaction in having their questions answered (odds ratio [OR], 0.44; P < 0.05), interference of diabetes with daily life (OR, 1.4; P < 0.05), male gender (OR, 3.93; P < 0.01), and number of diabetes complications (OR, 1.81; P < 0.05). In the multivariate linear regression model, age (beta, -0.348; P < 0.05) and frequency of physician visits (beta, -0.403; P < 0.05) were the only variables significantly associated with glycemic control. Variables included in the model that were not associated with glycemic control include family history of diabetes and confidence in diabetes treatment efficacy.

CONCLUSIONS: Acculturation was not associated with glycemic control in this population. Family physicians should not assume that acculturation difficulties explain poor glycemic control in their Mexican American patients with T2DM.

PMID:21293085 | DOI:10.3810/pgm.2011.01.2246

Alcohol affects the late differentiation of progenitor B cells

Hao Wang, MD - Thu, 11/25/2010 - 05:00

Alcohol Alcohol. 2011 Jan-Feb;46(1):26-32. doi: 10.1093/alcalc/agq076. Epub 2010 Nov 22.

ABSTRACT

AIMS: Previous studies show that alcohol exposure can affect the differentiation of progenitor B cells. Before final commitment to a B lineage, progenitor B cells usually undergo several important stages. However, it is still unclear whether alcohol alters B cell differentiation at which stages. The aim of this study was to determine which stage(s) of progenitor cell differentiation are affected by alcohol and to elucidate the mechanism(s) responsible for the effect of alcohol on B cell differentiation.

METHODS: Oligoclonal-neonatal-progenitor (ONP) cells from bone marrow cells of 2-week-old mice were cultured under different conditions in vitro with or without the exposure of 100 mM alcohol. Phenotype analysis was performed at different time points and expression levels of transcription factors (TFs) and cytokine receptors were measured quantitatively and kinetically.

RESULTS: After 3 days in vitro culture, ONP cells differentiated into two populations: B220(-)CD11b(-) and B220(-)CD11b(+) cells. B220(-)CD11b(-) cells can further differentiate into B lineage cells only with the support of B220(-)CD11b(+) cells. Cells exposed to 100 mM of alcohol during the first 3 days of culture showed no statistically significant difference in B cell formation after 12 days compared with the control group. However, cells exposed to alcohol from Day 4 till the end of culture yield very few B cells. Expression levels of TFs and cytokine receptors were down-regulated kinetically among ONP cells co-cultured with the addition of 100 mM alcohol.

CONCLUSIONS: Alcohol affects the ONP cell differentiation into B lineage at a late stage. Alcohol also down-regulates the expression level of TFs and cytokine receptors resulting in the impairment of B cell differentiation.

PMID:21098503 | PMC:PMC3002845 | DOI:10.1093/alcalc/agq076

Referrals from a primary care-based sports medicine department to an orthopaedic department: a retrospective cohort study

Richard Young, MD - Fri, 10/22/2010 - 05:00

Br J Sports Med. 2011 Oct;45(13):1064-7. doi: 10.1136/bjsm.2010.072736. Epub 2010 Oct 19.

ABSTRACT

OBJECTIVE: To describe the impact of an expanded primary care-based sports medicine clinic on referrals to an orthopaedics clinic and to describe the patients seen and procedures performed.

DESIGN: Retrospective cohort study.

SETTING: Primary care-based sports medicine clinic and orthopaedics clinic at a tax-supported American safety net healthcare system.

PARTICIPANTS: All patients referred to the sports medicine clinic by other primary care physicians over a 1-year time period of July 2006-June 2007.

MAIN OUTCOME MEASURES: The referral rate from sports medicine clinic to orthopaedics clinic, the percentage of referred patients who were recommended surgery by the orthopaedists, the change in average waiting time to be seen in orthopaedics clinic and the most common conditions and procedures.

RESULTS: 4925 patients were seen by the sports medicine department; 118 (2.4%) of those patients were referred to the orthopaedic department. Of the referred patients, surgery was offered by orthopaedists to 80 (68%) patients. The average wait for initial consultation by the orthopaedic spine clinic decreased from 199 to 70 days; the wait for general orthopaedic clinic decreased from 97 to 19 days. No single patient complaint or musculoskeletal pathology predominated: knee degenerative joint disease (25.3%), mechanical low back pain (21.6%) and lumbar disc disease (19.9%). Knee injections and epidural steroid injections were the most common procedures performed.

CONCLUSIONS: Very few patients with musculoskeletal pathology were referred by a primary care-based sports medicine clinic to an orthopaedics clinic. Of the referred patients, sports medicine physicians and orthopaedists frequently agreed on the need for surgery. Expansion of a primary care-based sports medicine service could help relieve overburdened orthopaedics departments of patients with conditions not requiring surgery.

PMID:20961919 | DOI:10.1136/bjsm.2010.072736

Surgical treatment of hallux rigidus using a metatarsal head resurfacing implant: mid-term follow-up

Travis Motley, DPM - Fri, 07/09/2010 - 05:00

J Foot Ankle Surg. 2010 Jul-Aug;49(4):321-5. doi: 10.1053/j.jfas.2010.04.007.

ABSTRACT

The treatment of advanced hallux rigidus remains controversial, with many authors discussing arthrodesis versus arthroplasty. The purpose of this study is to report mid-term outcomes after implantation of a motion-preserving metatarsal head-resurfacing prosthetic and to present our technical considerations and modifications to the published technique to further enhance the clinical benefit of the procedure. Thirty-two implantations were performed in 30 patients. Twenty-three patients were women, 9 men. The average age was 62.8 years (range, 39-86 years). Patients were graded at baseline according to Hattrup and Johnson and completed the American Orthopaedic Foot & Ankle Surgery metatarsophalangeal clinical rating system preoperatively and postoperatively and a patient satisfaction question at final follow-up. Seventy-two percent of implantations were grade III hallux rigidus and 28% were grade II. The average follow-up was 27.3 months (range, 12-43 months). The mean change score for the overall American Orthopaedic Foot & Ankle Surgery scale was 236.8% (SD = 146.62, confidence interval [CI] = 186-287.6). A similar result was achieved between grade II (250.9%, SD = 240.3, CI = 93.9-407.9) and grade III (231.3%, SD = 95.83, CI = 195.14-270.46). No implants were revised or removed, and all patients stated that they were happy with their outcome and would repeat the procedure again if needed. In conclusion, metatarsal head resurfacing in combination with joint decompression, soft tissue mobilization, and debridement can achieve excellent results in grade II and III hallux rigidus. Salvage arthrodesis remains an option if future revisions are indicated.

PMID:20610200 | DOI:10.1053/j.jfas.2010.04.007

Long-term outcome of adults who undergo transplantation with single pediatric kidneys: how young is too young?

Saravanan Balamuthusamy, MD - Sat, 08/22/2009 - 05:00

Clin J Am Soc Nephrol. 2009 Sep;4(9):1500-6. doi: 10.2215/CJN.04610908. Epub 2009 Aug 20.

ABSTRACT

BACKGROUND AND OBJECTIVES: The optimal donor age for transplanting a single pediatric kidney in an adult recipient remains unknown. En block kidney transplantation is usually performed when the donor age is <5 yr.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We compared the outcomes of adult patients who underwent transplantation with single pediatric kidneys from donors who were younger than 5 yr (group 1, n = 40) and from donors who were aged 5 to 10 yr of age (group 2, n = 39) in our center.

RESULTS: The donor kidney sizes were significantly smaller in group 1 than in group 2 (P < 0.001), and group 1 required more ureteral stents than group 2 (73 versus 38%). The surgical complications, delayed graft function, and development of proteinuria were similar in both groups. Group 1 had slightly higher rejection episodes than group 2 (25 versus 18%; P = 0.67), and graft function was comparable in both groups. There were no statistical differences between the two groups in patient (P = 0.73) or death-censored graft (P = 0.68) survivals over 5 yr.

CONCLUSIONS: Single pediatric kidney transplants from donors who are younger than 5 yr can be used with acceptable complications and long-term outcomes as those from older donors.

PMID:19696216 | PMC:PMC2736693 | DOI:10.2215/CJN.04610908

Long-term outcome of single pediatric donor kidney transplants between African-American and non-African-American adults

Saravanan Balamuthusamy, MD - Fri, 07/31/2009 - 05:00

Clin Nephrol. 2009 Jul;72(1):55-61. doi: 10.5414/cnp72055.

ABSTRACT

BACKGROUND: African-American (AA) ethnicity has been considered a risk factor for graft loss after kidney transplant. The long-term graft survival of single pediatric donor kidney transplants in AA adults has not been reported.

METHODS: We retrospectively compared the outcome of 43 AA and 32 non-African-American (NAA) adults transplanted with single pediatric kidneys from donors aged 10 years or less in our center. A combination of tacrolimus, mycophenolic acid and steroid was utilized as the maintenance therapy.

RESULTS: Similar immunosuppressive dose and targeted level were achieved between the AA and the NAA groups. Median body weight (BW) of donors was 20 kg (8 - 36) in the AA group and 19 kg (8.5 - 35) in NAA group. There was no statistically significant difference in the incidence of rejection between the AA and NAA groups (26 vs. 16%, p = 0.45). The surgical complications, delayed graft function, and development of proteinuria and focal and segmental glomerulosclerosis (FSGS) were similar in both groups. The patient and graft survivals in the AA group were slightly higher compared to the NAA group. The death-censored analysis demonstrated no difference in graft survival between the AA and NAA groups (p = 0.90): 86 vs. 82% at 1 year, 70 vs. 71% at 3 years, and 62 vs. 64% at 5 years.

CONCLUSIONS: Single pediatric donor kidney transplant in AA adults can be achieved with acceptable complications and equivalent long-term outcomes as in NAA adults in the era of potent immunosuppressive regimen.

PMID:19640388 | DOI:10.5414/cnp72055

Calcific constrictive pericarditis with refractory hypokalemia in a patient with Gitelman's syndrome

Saravanan Balamuthusamy, MD - Fri, 03/06/2009 - 05:00

Am J Med Sci. 2009 Jan;337(1):74-6. doi: 10.1097/maj.0b013e31816dd313.

ABSTRACT

Calcific constrictive pericarditis can be idiopathic or associated with radiation therapy, surgery, infection, or autoimmune disorders. Gitelman's syndrome is a distal renal tubular defect involving the thiazide-sensitive luminal sodium chloride cotransporter and has been associated with nephrolithiasis and chondrocalcinosis. There has not been any case of calcific constrictive pericarditis reported so far in association with Gitelman's syndrome. We have reported a male patient with persistent hypokalemia and refractory ascites diagnosed with calcific constrictive pericarditis and Gitelman's syndrome.

PMID:19263512 | DOI:10.1097/maj.0b013e31816dd313

Myeloma kidney with isolated tubulointerstitial light chain deposition in a renal allograft

Saravanan Balamuthusamy, MD - Fri, 02/13/2009 - 05:00

Clin Transplant. 2009 Nov-Dec;23(6):848-52. doi: 10.1111/j.1399-0012.2009.00967.x. Epub 2009 Feb 5.

ABSTRACT

Myeloma kidney and myeloma-associated renal disorders including light chain deposition disease can occur as recurrent or de novo disease in renal allografts. These kidney disorders usually manifest with worsening allograft function and proteinuria. Identification of the precise cause of kidney disorder often requires kidney biopsy and demonstration of monoclonal light chains in the kidney. Here, we present an unusual case of light chain nephropathy in a living-related kidney transplant recipient involving light chain crystallization in the proximal tubule occurring within less than three months after transplant. The etiology of renal failure prior to transplant in our patient is not clear. To the best of our knowledge, the ultrastructural changes seen in our patient have not been described in literature previously. Our patient was treated with steroids, which resulted in short-term improvement in allograft dysfunction.

PMID:19210683 | DOI:10.1111/j.1399-0012.2009.00967.x

Comparative analysis of beta-blockers with other antihypertensive agents on cardiovascular outcomes in hypertensive patients with diabetes mellitus: a systematic review and meta-analysis

Saravanan Balamuthusamy, MD - Fri, 01/16/2009 - 05:00

Am J Ther. 2009 Mar-Apr;16(2):133-42. doi: 10.1097/MJT.0b013e31817fd87e.

ABSTRACT

OBJECTIVES: To analyze the effects of beta-blockers (BBs) on cardiovascular (CV) outcomes in diabetic patients with hypertension.

DATA SOURCE: Literature search was performed with relevant search words using PubMed and Ovid Gateway search engines for trials published in English from June 1996 to July 2007.

REVIEW METHODS: Systematic reviews of randomized control trials that used BBs as treatment or control therapy in diabetic patients with hypertension were included for the analysis. All the included studies use intention-to-treat analysis. Two individual authors procured the data. Myocardial infarction, stroke, CV mortality, and total mortality were the outcomes analyzed. Relative risk across the different groups was calculated using Mantel-Haenszel random- and fixed-effects model. Interstudy heterogeneity was computed by chi(2) test. Results were calculated with 95%confidence intervals (CIs) and were considered significant with double-sided alpha error less than 0.05. Funnel plot was used to assess for publication bias.

RESULTS: Eight trials (N = 130,270) met the inclusion criteria for the analysis. The relative risks for myocardial infarction, stroke, CV mortality, and total mortality were 1.08 (95% CI 0.82-1.42; P = 0.6), 1.13 (95% CI 0.95-1.36; P = 0.1), 1.15 (95% CI 0.83-1.6; P = 0.3), and 1.16 (95% CI 0.92-1.47; P = 0.2), respectively. BBs were associated with increased risk for CV mortality 1.39 (95% CI 1.07-1.804; P ,0.01) when compared with renin angiotensin blockade (RAS) therapy.

CONCLUSION: BBs have increased risk for CV mortality when compared with RAS blockade therapy in diabetic patients with hypertension. BBs do not have increased risk for myocardial infarction, stroke, CV mortality, and total mortality when compared with control antihypertensive therapy in diabetic patients with hypertension.

PMID:19145207 | DOI:10.1097/MJT.0b013e31817fd87e

Pioglitazone and the risk of myocardial infarction and other major adverse cardiac events: a meta-analysis of randomized, controlled trials

Saravanan Balamuthusamy, MD - Thu, 01/08/2009 - 05:00

Am J Ther. 2008 Nov-Dec;15(6):506-11. doi: 10.1097/MJT.0b013e318167180c.

ABSTRACT

A recent meta-analysis suggested that the use of rosiglitazone increases the risk of myocardial infarction (MI) in patients with type 2 diabetes mellitus. It is unclear whether this is a class effect of thiazolidinediones (TZD). We did a meta-analysis to evaluate cardiovascular outcomes with the use of pioglitazone. Randomized, controlled trials in which pioglitazone was compared with placebo or other hypoglycemic agents were considered for analysis. Studies were included if the data for MI were available. Studies were identified with use of relevant search words in Medline, Pubmed, EMBASE, CINAHL, and Cochrane databases. Data abstraction was done by 2 individual authors using a standardized protocol. The relative risk across all study groups was computed by the Mantel-Haenszel method, and interstudy heterogeneity was assessed by the chi method. All results were computed according to 95% confidence intervals. Five trials (N = 9965) met the inclusion criteria for analysis. The relative risk for MI was 0.86 (0.69-1.07; P = 0.17). The relative risks for stroke and revascularization were 0.79 (0.61-1.02; P = 0.07) and 0.40 (0.13-1.23; P = 0.11), respectively. Pioglitazone does not increase the risk for MI and may decrease the risk for stroke and revascularization.

PMID:19127132 | DOI:10.1097/MJT.0b013e318167180c

Family medicine residency educational characteristics and career satisfaction in recent graduates

Richard Young, MD - Wed, 10/22/2008 - 05:00

Fam Med. 2008 Jul-Aug;40(7):484-91.

ABSTRACT

BACKGROUND AND OBJECTIVES: Career satisfaction among family physicians has declined over the last 15 years. The purpose of this study was to determine what aspects of residency training are associated with family medicine career satisfaction in recent graduates.

METHODS: This was a cross-sectional national survey of 1000 family physicians who graduated within the last 10 years. Questions were primarily Likert type. Exploratory factor analysis was used to identify retained factors. Bivariate and multivariate linear regression analyses were performed to identify residency characteristics, demographics, and current work characteristics that were associated with career satisfaction.

RESULTS: The response rate was 55.8% (558/1000). Exploratory factor analysis found three factors that explained the majority of the variance in career satisfaction: overall work life, rigorous residency training, and demographic factors. Many features of residency training were associated with career satisfaction on bivariate analysis. Multivariate analysis found that training that was exceptionally broad and in-depth was independently associated with career satisfaction. The factors with the largest association with career satisfaction were medical career satisfaction and current work satisfaction.

DISCUSSION: Our findings suggest that residency education that was broad and in-depth was associated with early family medicine career satisfaction. This construct reflected rigorous training that included hands-on procedural experience, breadth of experiences with patients and illness, and care for complex hospitalized patients.

PMID:18928075

Femoral vs jugular venous catheterization for short-term dialysis access

Saravanan Balamuthusamy, MD - Thu, 10/16/2008 - 05:00

JAMA. 2008 Oct 15;300(15):1760-1; author reply 1761-2. doi: 10.1001/jama.300.15.1760-c.

NO ABSTRACT

PMID:18854533 | DOI:10.1001/jama.300.15.1760-c

The role of viscosupplementation in the ankle using hylan G-F 20

Travis Motley, DPM - Sat, 08/30/2008 - 05:00

J Foot Ankle Surg. 2008 Sep-Oct;47(5):377-84. doi: 10.1053/j.jfas.2008.06.013.

ABSTRACT

The use of intra-articular injections of high molecular weight elastoviscous solutions of hyaluronan or hylans (cross-linked derivatives of hyaluronan) to treat arthritis is termed viscosupplementation. The function of viscosupplementation is to restore the rheologic properties of synovial fluid. Although anecdotal data exist, no long-term studies regarding the use of viscosupplementation in the ankle have been published to date. The goal of this clinical trial was to compare pain reduction following ankle arthroscopy versus that following ankle arthroscopy combined with weekly intra-articular instillation of hylan G-F 20 during the first 3 postoperative weeks. In the series of patients described in this report, we found that both treatment groups experienced statistically significantly decreased pain following the intervention (P = .002 and P = .0009 for the arthroscopy alone and arthroscopy plus hylan groups, respectively), and that those who received 3 intra-articular injections of hylan G-F 20 following ankle arthroscopy improved statistically significantly (P = .0014) more than did those who underwent arthroscopy as a sole therapy. These preliminary results suggest that viscosupplementation combined with arthroscopy may be more beneficial than arthroscopy alone, and provide further insight into the role of viscosupplementation in the treatment of ankle osteoarthritis.

LEVEL OF CLINICAL EVIDENCE: 4.

PMID:18725116 | DOI:10.1053/j.jfas.2008.06.013

The effects of body mass index on graft survival in adult recipients transplanted with single pediatric kidneys

Saravanan Balamuthusamy, MD - Tue, 08/12/2008 - 05:00

Am J Nephrol. 2009;29(2):94-101. doi: 10.1159/000151293. Epub 2008 Aug 11.

ABSTRACT

BACKGROUND: There is insufficient data on the impact of recipient body mass index (BMI) on the long-term graft survival of adult patients transplanted with single pediatric kidneys.

METHODS: We performed a retrospective analysis of adult patients transplanted with single pediatric kidneys at our center. The recipients were classified into 2 groups: group 1 (BMI > or =30) and group 2 (BMI <30). Donor/recipient demographics, postoperative outcomes and survival rates were compared between the 2 groups.

RESULTS: There was no significant difference in donor/recipient demographics between the 2 groups. In group 1, the death-censored graft survival (DCGS) at 1, 3 and 5 years was 90% at all 3 time points, and in group 2 it was 86, 68 and 60%, respectively (p = 0.05). The mean glomerular filtration rate (with standard deviation in parentheses) at 1, 3 and 5 years was, respectively, 55 (15), 59 (19) and 55 (28) ml/min for group 1, compared to 65 (28), 69 (23) and 67 (20) ml/min in group 2 (p = NS). Multivariate analysis revealed a hazard ratio of 5.12 (95% confidence interval 1.06-24.7; p = 0.04) for graft loss in nonobese patients when compared to obese patients. Obese patients had an increased risk for acute rejections within the first month of transplant (p = 0.02).

CONCLUSION: Patients with a BMI > or =30 transplanted with single pediatric kidneys have better DCGS rates when compared to nonobese patients.

PMID:18689988 | DOI:10.1159/000151293

Silencing megalin and cubilin genes inhibits myeloma light chain endocytosis and ameliorates toxicity in human renal proximal tubule epithelial cells

Saravanan Balamuthusamy, MD - Fri, 05/02/2008 - 05:00

Am J Physiol Renal Physiol. 2008 Jul;295(1):F82-90. doi: 10.1152/ajprenal.00091.2008. Epub 2008 Apr 30.

ABSTRACT

Using target-specific short interfering (si) RNAs, we silenced the tandem endocytic receptors megalin and cubilin genes in cultured human renal proximal tubule epithelial cells. Transfection by siRNA resulted in up to 90% suppression of both megalin and cubilin protein and mRNA expression. In HK-2 cells exposed to kappa-light chain for up to 24 h, light chain endocytosis was reduced in either megalin- or cubilin-silenced cells markedly but incompletely. Simultaneous silencing of both the cubilin and megalin genes, however, resulted in near-complete inhibition of light chain endocytosis, as determined by measuring kappa-light chain protein concentration in cell cytoplasm and by flow cytometry using FITC-labeled kappa-light chain. In these cells, light chain-induced cytokine responses (interleukin-6 and monocyte chemoattractant protein-1) and epithelial-to-mesenchymal transition as well as the associated cellular and morphological alterations were also markedly suppressed. The results demonstrate that light chain endocytosis is predominantly mediated by the megalin-cubilin tandem endocytic receptor and identify endocytosis as a key step in light chain cytotoxicity. Blocking light chain endocytosis prevents its nephrotoxic effects on human kidney proximal tubule cells.

PMID:18448595 | DOI:10.1152/ajprenal.00091.2008

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