Surgical revascularization versus amputation for peripheral vascular disease in dialysis patients: a cohort study

BACKGROUND: Surgical treatment of peripheral vascular disease (PVD) in dialysis patients is controversial. METHODS: We examined the post-operative morbidity and mortality of surgical revascularization or amputation for PVD in a retrospective analysis of United States Renal Data System. Propensity scores for undergoing amputation were derived from a multivariable logistic regression model of amputation. RESULTS: Of the Medicare patients initiated on dialysis from Jan 1, 1995 to Dec 31, 1999, patients underwent surgical revascularization (n = 1,896) or amputation (n = 2,046) in the first 6 months following initiation of dialysis were studied. In the logistic regression model, compared to claudication, presence of gangrene had a strong association with amputation [odds ratio (OR) 19.0, 95% CI (confidence interval) 13.86–25.95]. The odds of dying within 30 days and within1 year were higher (30 day OR: 1.85, 95% CI: 1.45–2.36; 1 yr OR: 1.46, 95% CI: 1.25–1.71) in the amputation group in logistic regression model adjusted for propensity scores and other baseline factors. Amputation was associated with increased odds of death in patients with low likelihood of amputation (< 33(rd )percentile of propensity score) and moderate likelihood of amputation (33(rd )to 66(th )percentile) but not in high likelihood group (>66(th )percentile). The number of hospital days in the amputation and revascularization groups was not different. CONCLUSION: Amputation might be associated with higher mortality in dialysis patients. Where feasible, revascularization might be preferable over amputation in dialysis patients

Maximal care considerations when treating patients with end-stage heart failure: ethical and procedural quandaries in management of the very sick

Deciding who should receive maximal technological treatment options and who should not represents an ethical, moral, psychological and medico-legal challenge for health care providers. Especially in patients with chronic heart failure, the ethical and medico-legal issues associated with providing maximal possible care or withholding the same are coming to the forefront. Procedures, such as cardiac transplantation, have strict criteria for adequate candidacy. These criteria for subsequent listing are based on clinical outcome data but also reflect the reality of organ shortage. Lack of compliance and non-adherence to lifestyle changes represent relative contraindications to heart transplant candidacy. Mechanical circulatory support therapy using ventricular assist devices is becoming a more prominent therapeutic option for patients with end-stage heart failure who are not candidates for transplantation, which also requires strict criteria to enable beneficial outcome for the patient. Physicians need to critically reflect that in many cases, the patient’s best interest might not always mean pursuing maximal technological options available. This article reflects on the multitude of critical issues that health care providers have to face while caring for patients with end-stage heart failure

Brain energy rescue:an emerging therapeutic concept for neurodegenerative disorders of ageing

The brain requires a continuous supply of energy in the form of ATP, most of which is produced from glucose by oxidative phosphorylation in mitochondria, complemented by aerobic glycolysis in the cytoplasm. When glucose levels are limited, ketone bodies generated in the liver and lactate derived from exercising skeletal muscle can also become important energy substrates for the brain. In neurodegenerative disorders of ageing, brain glucose metabolism deteriorates in a progressive, region-specific and disease-specific manner — a problem that is best characterized in Alzheimer disease, where it begins presymptomatically. This Review discusses the status and prospects of therapeutic strategies for countering neurodegenerative disorders of ageing by improving, preserving or rescuing brain energetics. The approaches described include restoring oxidative phosphorylation and glycolysis, increasing insulin sensitivity, correcting mitochondrial dysfunction, ketone-based interventions, acting via hormones that modulate cerebral energetics, RNA therapeutics and complementary multimodal lifestyle changes

A922 Sequential measurement of 1 hour creatinine clearance (1-CRCL) in critically ill patients at risk of acute kidney injury (AKI)

Meeting abstrac

Deal Initiation in Mergers and Acquisitions

We investigate the effects of target initiation in M&As. We find target-initiated deals are common and that important motives for these deals are target economic weakness, financial constraints, and negative economy-wide shocks. We determine that average takeover premia, target abnormal returns around merger announcements, and deal value to EBITDA multiples are significantly lower in target-initiated deals. This gap is not explained by weak target financial conditions. Adjusting for self-selection, we conclude that target managers' private information is a major driver of lower premia in target-initiated deals. This gap widens as information asymmetry between merger partners rises

Disclosure of unnoticed rib fractures with the use of ultrasonography in minor blunt chest trauma

WOS: 000185807800026PubMed: 14500082Objective: Rib fractures are the most common injuries resulting from blunt chest trauma. The sensitivity of chest X-rays in showing the rib fractures is limited particularly in those involving the cartilage part of the rib. We investigated the possible rib fractures, those overlooked on chest X-rays, with the use of ultrasonography in minor blunt chest trauma. Methods: A total of 37 patients, with minor blunt chest trauma showing no evidence of a rib fracture on chest X-rays, were examined with ultrasonography performed with a 7.5-MHz linear transducer. Logistic regression analysis was done to outline the clinical predictors of these insidious rib fractures. Results: A total of 15 (40.5%) patients showed rib lesions, whereas 22 (59.5%) patients had no evidence of rib lesions. Fracture of the rib associated with a subperiosteal hematoma was the most common finding in ten (66.7%) patients followed by the fracture of the rib alone in four (26.7%) patients, and subperiosteal hematoma alone in one (6.7%) patient. A total of eight (53.3%) patients had bony rib fractures, whereas seven (46.7%) patients had chondral rib fractures. Age (P = 0.617), gender (P = 0.552), type of etiology (P = 0.954), duration of pain (P = 0.234) and site of trauma (P = 0.740) did not appear as significant predictors for these rib fractures. However, the involved part of the rib showed a significant correlation with either age (P = 0.042) or duration of pain (P = 0.033). Bony rib fractures significantly occurred in elderly patients, and the duration of pain in patients with bony rib fractures was significantly longer than that of patients with chondral rib fractures. Conclusions: Ultrasonography is a useful imaging method in showing the rib fractures those overlooked on chest X-rays in minor blunt chest trauma, and no significant clinical feature exists as a predictor for these insidious fractures. However, bony rib fractures significantly Occur in elderly patients and result in a longer duration of pain. (C) 2003 Elsevier B.V. All rights reserved

Doppler sonography of the normal lacrimal gland

WOS: 000227685200006PubMed: 15756661Purpose. We used Doppler sonography to determine the resistance index (RI) and pulsatility index (PI) of the normal lacrimal artery (LA) in both females and males. We also compared the values obtained at various periods of reproductive life. Methods. The study was performed in 25 prepubertal girls, 28 females of reproductive age, and 27 postmenopausal women, 23 pregnant women, and 104 healthy males. Doppler sonography was used to determine the RI and PI of the LA. Results. The mean PI for the entire patient population was 1.48 +/- 0.60 and the RI was 0.72 +/- 0.09. The RI and PI values of the LA did not differ between males and females. Similarly, the mean RI and PI values of the LA did not change significantly between the various reproductive phases. Conclusion. The PI and Rl of the lacrimal gland are similar in both sexes. Moreover, they are not altered by changes in levels of sex steroids. (c) 2005 Wiley Periodicals, Inc. J Clin Ultrasound 33:123-126, 2005; Published online in Wiley InterScience (www.interscience.wiley.com)