Showing papers by "Marcia A. Ciol published in 2005"

Relative nephroprotection during Escherichia coli O157:H7 infections: association with intravenous volume expansion.

Abstract: Objective. The hemolytic uremic syndrome (HUS) consists of hemolytic anemia, thrombocytopenia, and renal failure. HUS is often precipitated by gastrointestinal infection with Shiga toxin–producing Escherichia coli and is characterized by a variety of prothrombotic host abnormalities. In much of the world, E coli O157:H7 is the major cause of HUS. HUS can be categorized as either oligoanuric (which probably signifies acute tubular necrosis) or nonoligoanuric. Children with oligoanuric renal failure during HUS generally require dialysis, have more complicated courses, and are probably at increased risk for chronic sequelae than are children who experience nonoligoanuric HUS. Oligoanuric HUS should be avoided, if possible. The presentation to medical care of a child with definite or possible E coli O157:H7 infections but before HUS ensues affords a potential opportunity to ameliorate the course of the subsequent renal failure. However, it is not known whether events that occur early in E coli O157:H7 infections, particularly measures to expand circulating volume, affect the likelihood of experiencing oligoanuric HUS if renal failure develops. We attempted to assess whether pre-HUS interventions and events, especially the volume and sodium content of intravenous fluids administered early in illness, affect the risk for developing oligoanuric HUS after E coli O157:H7 infections. Methods. We performed a prospective cohort study of 29 children with HUS that was confirmed microbiologically to be caused by E coli O157:H7. Infected children were enrolled when they presented with acute bloody diarrhea or as contacts of patients who were known to be infected with E coli O157:H7, or if they had culture-confirmed infection, or if they presented with HUS. HUS was defined as hemolytic anemia (hematocrit 3 ), and renal insufficiency (serum creatinine concentration that exceeded the upper limit of normal for age). A wide range of pre-HUS variables, including demographic factors, clinical history, medications given, initial laboratory values, and volume and content of parenteral fluid administered, were recorded and entered into analysis. Estimates of odds ratios were adjusted for possible confounding effects using logistic regression analysis. Twenty-nine children who were E coli O157:H7, and were hospitalized at the Children9s Hospital and Regional Medical Center, Seattle, were studied. The main outcome measured was development of oligoanuric renal failure. Oligoanuria was defined as a urine output Results. As a group, the children with oligoanuric renal failure presented to medical attention and were evaluated with laboratory testing later than the children with nonoligoanuric renal failure. On initial assessments, the children with oligoanuric outcomes had higher white blood cell counts, lower platelet counts and hematocrits, and higher creatinine concentrations than the children with nonoligoanuric outcomes, but these determinations probably reflect later points of these initial determinations, often when HUS was already developing. Stool cultures were obtained (medians of 3 vs 2 days, respectively) and positive (medians of 7 vs 4 days, respectively) at later points in illness in the children in the oligoanuric than in the nonoligoanuric group. Intravenous volume expansion began later in illness in the children who subsequently developed oligoanuric renal failure than in those whose renal failure was nonoligoanuric (medians: 4.5 vs 3.0 days, respectively). Moreover, the 13 patients with nonoligoanuric renal failure received more intravenous fluid and sodium before HUS developed (1.7- and 2.5-fold differences, respectively, between medians) than the 16 patients with oligoanuric renal failure. These differences were even greater when the first 4 days of illness were examined, with 17.1- and 21.8-fold differences, respectively, between medians. In a multivariate analysis adjusted for age, gender, antibiotic use, and free water volume administered intravenously to these children during the first 4 days of illness, the amount of sodium infused remained associated with protection against developing oligoanuric HUS. Dialysis was used in each of the children with oligoanuric renal failure and in none of the children with nonoligoanuric renal failure. The median length of stay in hospital after the diagnosis of HUS was 12 days in the oligoanuric group and 6 days in the nonoligoanuric group. Conclusions. Early recognition of and parenteral volume expansion during E coli O157:H7 infections, well before HUS develops, is associated with attenuated renal injury failure. Parenteral hydration in children who are possibly infected with E coli O157:H7, at the time of presentation with bloody diarrhea and in advance of culture results, is a practice that can accelerate the start of volume expansion during the important pre-HUS interval. Rapid assessment of stools for E coli O157:H7 by microbiologists and reporting of presumptive positives immediately can alert practitioners that patients are at risk for developing HUS and can prompt volume expansion in children who are not already being so treated. Our data also suggest that isotonic intravenous solutions might be superior to hypotonic fluids for use as maintenance fluids. Children who are infected with E coli O157:H7 and are given intravenous volume expansion need careful monitoring. This monitoring should be even more assiduous as HUS evolves.

Mobility Limitations in the Medicare Population: Prevalence and Sociodemographic and Clinical Correlates

Abstract: Objectives: To examine the prevalence of and clinical markers associated with mobility limitations in Medicare Current Beneficiary Community Survey (MCBS) respondents. Design: Cross-sectional analysis of a community survey. Setting: Community. Participants: Twelve thousand seven hundred sixty-nine respondents from the 2001 MCBS, aged 65 and older. Measurements: Four questions from the MCBS were used to create four levels of mobility limitation: none, mild, moderate, and severe. Sampling weights were used to calculate estimates of means and proportions of the entire Medicare population for each mobility limitation category. A polytomous logistic regression analysis was used to model the association between four levels of mobility limitation and sociodemographic and clinical variables. Results: Prevalence of mobility limitations ranged from 9.5 million (mild) to 1.2 million (severe). Increasing severity of mobility limitation was associated with older age, being female, reporting fair or poor health, being overweight, smoking, having a greater number of comorbidities, having an annual income below $25,000, having less than a high school education, being unmarried, and living with others. Conclusion: National prevalence estimates suggest that functional mobility limitation is a significant problem for many older adults and is associated with some potentially modifiable characteristics.

Effect of balance training on muscle activity used in recovery of stability in children with cerebral palsy: a pilot study.

Abstract: This study explored possible neural mechanisms that contribute to improvements in balance control produced by reactive balance training in children with cerebral palsy (CP). Six children with CP (four males, two females; mean age 9y 4mo), two with spastic hemiplegia (Gross Motor Function Classification System [GMFCS] level I) and four with spastic diplegia (GMFCS level II,) were given 5 days of intensive training in reactive balance control (100 perturbations per day on a moveable force platform). Surface electromyography was used to characterize changes in neuromuscular responses pretraining, immediately posttraining, and 1 month posttraining. Training in reactive balance control resulted in improvements in directional specificity of responses (a basic level of response organization) and other spatial/temporal characteristics including: (1) faster activation of muscle contraction after training, allowing children to recover stability faster; (2) emergence of a distal-proximal muscle sequence; and (3) improved ability to modulate the amplitude of muscle activity (increased amplitude of agonist and decreased amplitude of antagonist, reducing coactivation). Each child with spastic hemiplegia or diplegia showed a different combination of factors that contributed to improved performance; the level of change in neural factors depended on the severity of involvement of the child: hemiplegia vs diplegia, and level of involvement within each diagnostic category.

Effect of Communication Disability on Satisfaction With Health Care: A Survey of Medicare Beneficiaries

Abstract: Purpose: To examine the prevalence and characteristics of community-dwelling Medicare beneficiaries reporting a communication disability and the relationship between that disability and dissatisfac...

Incidence of and Risk Factors for Falls Following Hip Fracture in Community-dwelling Older Adults

Abstract: Background and Purpose. Hip fracture is a major medical problem among older adults, leading to impaired balance and gait and loss of functional independence. The purpose of this study was to determine the incidence of and risk factors for falls 6 months following hospital discharge for a fall-related hip fracture in older adults. Subjects. Ninety of 100 community-dwelling older adults (≥65 years of age) hospitalized for a fall-related hip fracture provided data for this study. Methods. An observational cohort study used interviews and medical records to obtain information on demographics, prefracture health, falls, and functional status. Self-report of falls and performance-based measures of balance and mobility were completed 6 months after discharge. Results. A total of 53.3% of patients (48/90) reported 1 or more falls in the 6 months after hospitalization. Older adults who fell following discharge had greater declines in independence in activities of daily living and lower performance on balance and mobility measures. Prefracture fall history and use of a gait device predicted postdischarge falls. Discussion and Conclusion. Falls following hip fracture can be predicted by premorbid functional status.

Stress is associated with subsequent pain and disability among men with nonbacterial prostatitis/pelvic pain.

Abstract: Background: Nonbacterial prostatitis is a syndrome characterized by persistent pelvic area pain in men with or without voiding symptoms. Its causes are poorly understood, and evidence-based treatments are lacking. Although psychological stress has been proposed as an etiological factor, the literature lacks prospective studies using standardized measures to examine associations between stress and male pelvic pain problems over time.Purpose: This study examined whether perceived stress was associated longitudinally with pain intensity and pain-related disability in a sample of men with nonbacterial prostatitis/pelvic pain.Methods: Men (N = 224) completed measures of perceived stress, pain intensity, and pain-related disability 1 month after a health care visit with a new nonbacterial prostatitis/pelvic pain diagnosis and 3, 6, and 12 months later.Results: Greater perceived stress during the 6 months after the health care visit was associated with greater pain intensity (p = .03) and disability (p = .003) at 12 months, even after controlling for age, symptom duration, and pain and disability during the first 6 months.Conclusions: These findings support further research into the associations between stress and male pelvic pain syndromes, as well as the assessment of stress in the evaluation of patients with pelvic pain.

Health Concerns of Patients With Nonbacterial Prostatitis/Pelvic Pain

Abstract: Background Heightened awareness of patients’ reasons for physician visits for male pelvic pain (nonbacterial prostatitis) and symptom concerns may increase patient satisfaction with care and help guide better management of this syndrome, for which evidence-based treatment is lacking. Methods We interviewed men with recent health maintenance organization visits for new episodes of nonbacterial prostatitis (N = 286; mean age, 46.7 years) and again 3, 6, and 12 months later. We inquired about their reasons for the visit and, at each interview, symptom concerns. We used Poisson regression to examine the association between baseline symptom worry and health care utilization during the 14 months after the index visit. Results Most patients reported concern at the index visit that they might have an infection (73%) or cancer (68%). One year later, 43% reported prostatitis symptoms in the past month. Among these, many were still concerned that their symptoms would worsen if untreated (71%), that they had cancer (46%) or an infection (45%), and that they might need surgery (44%). Controlling for patient age and baseline symptom severity, we found that baseline symptom worry predicted prostatitis-related health care visits over the 14 months after the index visit ( P = .005). Conclusions Despite symptom improvement following a health care visit for a new episode of pelvic pain/nonbacterial prostatitis, continued patient concerns about cancer, infection, and symptom worsening without treatment were common, even 1 year later. Patient worry may be associated with increased health care utilization.

Toe spreading ability in men with chronic pelvic pain syndrome

Abstract: We examined toe-spreading ability in subjects with chronic pelvic pain syndrome (CPPS) to test the hypothesis that subjects with CPPS could have deficiencies in lower extremity functions innervated by sacral spinal roots. Seventy two subjects with CPPS and 98 volunteer controls were examined as part of a larger study on CPPS. All the subjects underwent a detailed urologic and neurological examination including a toe-spreading examination with a quantitative scoring system. We compared the groups in terms of ability of toe-spreading as either "complete" (all toes spreading) or "incomplete" (at least one interdigital space not spreading) and also by comparing the number of interdigital spaces. For CPPS subjects only, we also analyzed the variation of the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) scales by toe-spreading categories. CPPS subjects were less often able to spread all toes than subjects without CPPS (p = 0.005). None of the NIH-CPSI sub-scales (pain, urinary symptoms, and quality of life), nor the total score showed an association with toe spreading ability. We found toe spreading to be diminished in subjects with CPPS. We hypothesize that incomplete toe spreading in subjects with CPPS may be related to subtle deficits involving the most caudal part of the spinal segments.