Biomedical subjects

David Cruess

Publications and source records attributed to David Cruess.

17 recordsLinked to original sources

PubMed2007

Laparoscopic appendectomy in children: use of the endoloop vs the endostapler.

HYPOTHESIS: Two techniques are used for laparoscopic appendectomy (LA): division of the mesoappendix with the harmonic scalpel and ligation of the appendix with an endoloop (EL), or division of the mesoappendix and appendix with an endostapler (ES). Using an ES is a cost-effective technique that provides an outcome benefit in children who require appendectomy. DESIGN: Case series. SETTING: Academic, tertiary care children's hospital. PATIENTS: Seventy-five children who underwent LA from January 1, 2002, to March 31, 2004. INTERVENTION: Laparoscopic appendectomy. MAIN OUTCOME MEASURES: Age, diagnosis, length of stay, surgical time, total operating room time, complications, and instrumentation costs were compared between the EL and ES groups. RESULTS: There was no significant difference in age, length of stay, perforated, gangrenous, or acute appendicitis diagnoses, or complications between the groups. The surgical time and total operating room time for LA in children in the ES group were significantly shorter than in children in the EL group by 15% and 17%, respectively (P<.05). The disposable equipment costs for LA were $201 per case in the ES group vs $400 per case in the EL group. The mean 14.9-minute increase in total operating room time in children in the EL group resulted in $373 of additional operating room and anesthesia costs. The decreased disposable equipment costs and shorter surgical time of LA in the ES group led to cost savings of $572 per case as compared with children who underwent LA with an EL. CONCLUSIONS: There is no significant difference in outcome between children who undergo LA with an EL or with an ES. However, this study supports the use of the ES for LA as a more cost-effective technique that is associated with reduced surgical time.

Adolescent↗

PubMed2006

Expression of the proto-oncoprotein breast cancer nuclear receptor auxiliary factor (Brx) is altered in eutopic endometrium of women with endometriosis.

OBJECTIVE: To evaluate the expression of estrogen receptor alpha (ERalpha), estrogen receptor beta (ERbeta), and breast cancer nuclear receptor auxiliary factor (Brx) in eutopic endometrium of normal women and women with endometriosis. DESIGN: Prospective observational study. SETTING: Tertiary care and research center. PATIENT(S): Twenty-nine women with endometriosis and 35 healthy ovulatory volunteers of similar ages. INTERVENTION(S): Endometrial biopsy. MAIN OUTCOME MEASURE(S): Expression of immunohistochemical staining intensity and localization of ERalpha, ERbeta, and Brx proteins in eutopic endometrium during the menstrual cycle. RESULT(S): Expression of ERalpha and ERbeta was highest in the proliferative phase and was similar in both groups. Brx expression differed between healthy volunteers and those with endometriosis. During the proliferative phase, immunostaining intensity of Brx was greater in both the glandular and the stromal compartments of biopsies from patients with endometriosis compared to healthy volunteers; nuclear stromal Brx staining was more common in patients with endometriosis. CONCLUSION(S): The spatiotemporal expression of Brx was altered in eutopic endometrium of women with endometriosis. These findings suggest a fundamental alteration in the endometrium of women who have endometriosis. The role of Brx in ectopic implantation of endometrium deserves further study.

A Kinase Anchor Proteins↗

PubMed2005

Personal satisfaction and mentorship are critical factors for today's resident surgeons to seek surgical training.

The specific aim of this study was to summarize the viewpoints of the Resident and Associate Society of the American College of Surgeons (RAS-ACS) membership regarding current training and quality of life-related issues prior to implementation of the new duty-hour guidelines. The goal was to gain insight of the members that may be useful to recruit and guide the future training of surgical residents. An Internet-based survey was developed to evaluate the viewpoints of RAS-ACS. The survey was administered by Esurveymaker.com via the ACS Web page from 2000 to 2003. RAS-ACS member participation was voluntary and anonymous. Analyses were performed to determine the frequency of response for each survey item. Two hundred thirty-five members completed the survey representing 5 per cent of RAS-ACS. Eighty-four per cent were general surgery residents. Personal satisfaction (64%) and mentorship (49%) were top factors for respondents to pursue surgical training; discussion with colleagues and future income was less important. Forty-five per cent reported that job performance was their most important concern during residency. A rewarding surgical career and family life were ranked as the most important expectations. Eighty-six per cent reported that they were satisfied with their residency, and 66 per cent reported that work hours should be limited. Personal satisfaction and mentorship were critical factors for members of the RAS-ACS to seek surgical training. Although most of the members report that work hours should be limited, an overwhelming majority reports satisfaction with surgical training prior to institution of the new duty-hour guidelines. Further emphasis on mentorship and work-hour reform may be beneficial in recruiting medical students into surgical residencies.

Female↗

PubMed2003

Survival by time of day of hemodialysis: analysis of United States Renal Data System Dialysis Morbidity and Mortality Waves III/IV.

BACKGROUND: Whether morning shift hemodialysis is associated with improved survival in comparison to patients receiving afternoon shift hemodialysis has not been shown for a representative sample of US chronic hemodialysis patients. METHODS: We conducted a historical cohort study of a national database (US Renal Data System Dialysis Morbidity and Mortality Waves III/IV) of 6,939 patients who started hemodialysis therapy from January 1, 1990, through December 31, 1993. Patients were followed up through April 9, 2000, and censored at the time of change to a different modality, including transplantation. We estimated the adjusted hazard ratio for all-cause mortality based on the time of day of hemodialysis (0500 to 1200 for morning shift, 1200 to 1800 for afternoon shift, 1800 to midnight for evening shift). Cox regression analysis was used to adjust for other factors associated with survival. RESULTS: For patients aged 60 years and older, the unadjusted 4-year survival rate for patients on morning shift hemodialysis was 28.8% versus 24.1% for patients on afternoon shift hemodialysis and 38.7% for patients on evening shift hemodialysis (P < 0.01 by log-rank test for both versus afternoon shift hemodialysis). Both morning shift (adjusted hazard ratio, 0.90; 95% confidence interval [CI], 0.83 to 0.98; P = 0.02) and evening shift hemodialysis (adjusted hazard ratio, 0.62; 95% CI, 0.48 to 0.80; P < or = 0.001) were independently associated with a lower risk for mortality compared with afternoon shift hemodialysis. No such differences were seen for patients younger than 60 years. Both morning shift and evening shift hemodialysis were independently associated with improved survival compared with afternoon shift hemodialysis in elderly chronic hemodialysis patients. No such association was found for younger patients.

Age Factors↗

PubMed2003

Impact of renal transplantation on survival in end-stage renal disease patients with elevated body mass index.

BACKGROUND: Cadaveric renal transplantation is associated with a survival advantage compared with dialysis patients remaining on the renal transplantation waiting list, but this advantage has not been confirmed in obese end-stage renal disease (ESRD) patients. METHODS: Using data from the USRDS, we studied 7521 patients who presented with ESRD from 1 April 1995 to 29 June 1999 and later enrolled on the renal transplantation waiting list with body mass indices (BMI) >or=30 kg/m(2) at the time of presentation to ESRD, and followed until 6 November 2000. Recipients of preemptive renal transplantation or organs other than kidneys were excluded. Cox non-proportional hazards regression models were used to calculate adjusted, time-dependent hazard ratios (HR) for time to death in a given patient during the study period, controlling for renal transplantation, demographics and comorbidities (Form 2728). RESULTS: The incidence of mortality was 3.3 episodes per 100 patient-years (PY) in cadaveric renal transplantation and 1.9/100 PY in living donor renal transplantation compared with 6.6 episodes/100 PY in all patients on the transplant waiting list. In comparison to maintenance dialysis, both recipients of solitary cadaveric kidneys (HR 0.39, 95% CI 0.33 to 0.47), and recipients of living donor kidneys (HR 0.23, 95% CI 0.16 to 0.34) had statistically significant improved survival. A benefit of cadaveric renal transplantation did not apply to patients with BMI >or=41 kg/m(2) (HR 0.47, 95% CI, 0.17 to 1.25, P = 0.13). CONCLUSIONS: Obese patients on the renal transplant waiting list had a significantly lower risk of mortality after renal transplantation compared with those remaining on dialysis.

Adult↗

PubMed2003

Predictive value of diminutive colonic adenoma trial: the PREDICT trial.

BACKGROUND & AIMS: Diminutive adenomas (1-9 mm in diameter) are frequently found during colon cancer screening with flexible sigmoidoscopy (FS). This trial assessed the predictive value of these diminutive adenomas for advanced adenomas in the proximal colon. METHODS: In a multicenter, prospective cohort trial, we matched 200 patients with normal FS and 200 patients with diminutive adenomas on FS for age and gender. All patients underwent colonoscopy. The presence of advanced adenomas (adenoma >or= 10 mm in diameter, villous adenoma, adenoma with high grade dysplasia, and colon cancer) and adenomas (any size) was recorded. Before colonoscopy, patients completed questionnaires about risk factors for adenomas. RESULTS: The prevalence of advanced adenomas in the proximal colon was similar in patients with diminutive adenomas and patients with normal FS (6% vs. 5.5%, respectively) (relative risk, 1.1; 95% confidence interval [CI], 0.5-2.6). Diminutive adenomas on FS did not accurately predict advanced adenomas in the proximal colon: sensitivity, 52% (95% CI, 32%-72%); specificity, 50% (95% CI, 49%-51%); positive predictive value, 6% (95% CI, 4%-8%); and negative predictive value, 95% (95% CI, 92%-97%). Male gender (odds ratio, 1.63; 95% CI, 1.01-2.61) was associated with an increased risk of proximal colon adenomas. CONCLUSIONS: Diminutive adenomas on sigmoidoscopy may not accurately predict advanced adenomas in the proximal colon.

Adenoma↗

PubMed2003

Teledermatology: an intraobserver diagnostic correlation study, part I.

Many studies have been published recently on the effectiveness of teledermatology as a diagnostic tool; however, much of the data comes from live 2-way video teleconferencing consultations and very little comes from more readily available "store and forward" consultations. Moreover, most published studies compare the diagnoses of 2 different dermatologists (interobserver comparison). Given the lack of data on baseline interdermatologist diagnostic variability, the interpretation of currently available diagnostic correlation data is somewhat difficult. The objective of this study is to measure the degree of diagnostic concordance between a dermatologist seeing a patient via a teledermatology consult system and the same dermatologist seeing the same patient face-to-face in a dermatology clinic at a tertiary medical center. A random sample of 404 patients was selected from patients who had routine appointments at our dermatology clinic.

Adolescent↗

PubMed2003

Teledermatology: an intraobserver diagnostic correlation study, Part II.

This is part II of an intraobserver diagnostic correlation study comparing teledermatology with traditional face-to-face evaluation. Part I discussed the methodology and diagnostic correlation results between teledermatology and in-person consultation (Cutis. 2003;71:399-403). This second part reports the diagnostic certainty level between the 2 groups, which are shown to be significantly different (teledermatology, 7/10; in-person, 9/10). This difference held true in every category of skin condition evaluated (P < or = .0065). Unlike other studies, we found that teledermatologists recommended biopsies 10% more frequently than clinic-based evaluators. We discuss the reasons for the lower diagnostic certainty level of teledermatologists, as well as the limitations of this study. Despite the limitations, we conclude that teledermatology appears to be an effective method of delivering dermatologic care in the appropriate setting.

Biopsy↗

PubMed2002

Hospitalized congestive heart failure after renal transplantation in the United States.

PURPOSE: African Americans have increased risk for congestive heart failure (CHF) compared to Caucasians in the general population, but the risk of CHF in African American renal transplant recipients has not been studied in a national renal transplant population. METHODS: Therefore, 33,479 renal transplant recipients in the United States Renal Data System (USRDS) from 1 July, 1994 to 30 June, 1997 were analyzed in an historical cohort study of the incidence, associated factors, and mortality of hospitalizations with a primary discharge diagnosis of CHF [International Classification of Diseases-9 (ICD9) Code 428.x]. RESULTS: African American renal transplant recipients had increased age-adjusted risk of hospitalizations for congestive heart failure compared to African Americans in the general population [rate ratio 4.60, 95% confidence interval (CI) 4.59-4.62]. In logistic regression analysis, African American recipients had increased risk of congestive heart failure after renal transplantation, independent of other factors. Among other significant factors associated with congestive heart failure, the strongest were graft loss and allograft rejection. No maintenance immunosuppressive medications were associated with CHF. In Cox regression analysis patients hospitalized for CHF had increased all-cause mortality compared with all other recipients (hazard ratio 3.69, 95% CI, 2.23-6.10), but African American recipients with CHF were not at significantly increased risk of mortality compared to Caucasian recipients with CHF. CONCLUSIONS: African Americans recipients were at high risk for CHF after transplant independent of other factors. The reasons for this increased risk should be the subject of further study. All potential transplant recipients should receive particular attention for the diagnosis and prevention of CHF in the transplant evaluation process, which includes preservation of allograft function.

Adolescent↗

PubMed2002

Hospitalizations for cytomegalovirus disease after renal transplantation in the United States.

PURPOSE: Risk factors, sites, and mortality of hospitalized cytomegalovirus (CMV) disease in renal transplant recipients have not been studied in a national population. METHODS: Therefore, 33,479 renal transplant recipients in the United States Renal Data System from 1 July 1, 1994 to June 30, 1997 were analyzed in an historical cohort study of patients with a primary discharge diagnosis of CMV disease (ICD9 Code 078.5x). RESULTS: Renal transplant recipients had an incidence density of hospitalized CMV disease of 1.26/100 person years, and 79% of hospitalizations for CMV disease occurred in the first six months post transplant. The leading manifestation of hospitalized infection was pneumonia (17%). In logistic regression analysis controlling for transplant era, pre-transplant dialysis > or = 6 months, maintenance mycophenolate mofetil (MMF) therapy, and allograft rejection, but not induction antibody therapy, were significantly associated with hospitalized CMV disease. Compared with recipients with negative CMV serology (R-) who had donor kidneys with negative CMV serology (D-), D+/R- had the highest risk of hospitalization for CMV disease [adjusted odds ratio (AOR) 5.19, 95% confidence interval (CI) 3.89-6.93] followed by D+/R+ recipients, whereas D-/R+ were not at significantly increased risk. In Cox Regression analysis the relative risk of death associated with hospitalized CMV disease was 1.32 (95% CI 1.02-1.71). CONCLUSIONS: Even in modern era, renal transplant recipients were at high risk for hospitalizations for CMV disease, which were associated with decreased patient survival. Current prophylactic measures have apparently not reduced the high risk of D+/R- recipients. Prolonged pre-transplant dialysis and maintenance MMF should also be considered risk factors for hospitalized CMV infection, and prospective trials of prophylactic antiviral therapy should be performed in these subgroups.

Adolescent↗

PubMed2002

Effect of donor factors on early graft survival in adult cadaveric renal transplantation.

Previous studies of the effect of donor factors on renal transplant outcomes have not tested the role of recipient body mass index, donor/recipient weight ratios and age matching, and other factors. We analyzed 20,309 adult (age 16 or older) recipients having solitary cadaveric renal transplants from adult donors from 1 July 1994 to 30 June 1998 in an historical cohort study (the 2000 United States Renal Data System) of death censored graft loss by the Cox proportional hazards models, which corrected for characteristics thought to affect outcomes. The only independently significant findings in Cox Regression analysis were a high donor/ recipient age ratio (> or = 1.10, e.g. a 55-year-old donor given to a recipient age 50years or younger, adjusted hazard ratio (AHR) 3.22, 95% confidence interval (CI) 2.36-4.39) and African American donor kidneys (AHR 1.64, 95% CI, 1.24-2.17). African American recipients and older donors were not at independently increased risk of graft failure in this model. Among donor factors, older donor kidneys given to younger recipients and donor African American kidneys were independently associated with graft loss in recipients of cadaver kidneys. The task for the transplant community should be to find the best means for managing all donor organs without discouraging organ donation.

Adult↗

PubMed2002

Acute coronary syndromes after renal transplantation in patients with end-stage renal disease resulting from diabetes.

Coronary heart disease is the leading cause of death in both diabetes mellitus and end-stage renal disease. Although renal transplantation is known to reduce mortality in end-stage renal disease, its effect on the incidence of acute coronary syndromes is unknown. Using data from the United States Renal Data System, we studied 11,369 patients with end-stage renal disease due to diabetes enrolled on the renal and renal-pancreas transplant waiting list from 1 July 1994 to 30 June 1997. Cox nonproportional hazards regression models were used to calculate the adjusted, time-dependent relative risk for the most recent hospitalization for acute coronary syndromes (including acute myocardial infarction, unstable angina, or other acute coronary syndromes, ICD9 Code 410.x or 411.x) for a given patient in the study period. Demographics and comorbidities were controlled by using data from the medical evidence form (HCFA 2728). After renal transplantation, patients had an incidence of acute coronary syndromes of 0.79% per patient year, compared to 1.67% per patient year prior to transplantation. In comparison to maintenance dialysis, renal transplantation was independently associated with a lower risk for acute coronary syndromes (hazard ratio 0.38, 95% confidence interval, 0.30-0.49). Patients with end-stage renal disease due to diabetes on the renal transplant waiting list were much less likely to be hospitalized for acute coronary syndromes after renal transplantation. The reasons for this decreased risk should be the subject of further study.

Angina, Unstable↗

PubMed2002

Chronic dialysis patients have high risk for pulmonary embolism.

Pulmonary embolism has been considered uncommon in chronic dialysis patients, but has not been adequately studied in a large population. In the US Renal Data System (USRDS), 76,718 patients presenting with end-stage renal disease (ESRD) between January 1, 1996, and December 31, 1996, were analyzed in an historical cohort study. The outcome was hospitalizations with a primary discharge diagnosis of pulmonary embolism (International Classification of Diseases, Ninth Revision code 415.1x) occurring within 1 year of the first ESRD treatment and excluding those occurring after renal transplantation. For dialysis patients, hospitalization rates for pulmonary embolism were obtained from the hospitalization section of the 1999 USRDS. For the general population, hospitalization rates for pulmonary embolism were obtained from the National Hospital Discharge Survey for 1996. Comorbidities from the Medical Evidence Form (Centers for Medicare and Medicaid Services, previously known as the Health Care Financing Administration; form 2728) were used to generate approximated stratified models of adjusted incidence ratios for pulmonary embolism (comorbidities could not be stratified for the general population). In 1996, the overall incidence rate of pulmonary embolism was 149.90/100,000 dialysis patients compared with 24.62/100,000 persons in the US population, with an age-adjusted incidence ratio of 2.34 in dialysis patients. Younger dialysis patients had the greatest relative risk for pulmonary embolism. The age-adjusted incidence ratio of pulmonary embolism after excluding dialysis patients with known risk factors for pulmonary embolism was 2.11. Ninety-five percent confidence intervals for all age categories in both models were statistically significant. Chronic dialysis patients have high risk for pulmonary embolism, independent of comorbidity.

Adolescent↗

PubMed2002

Graft loss and acute coronary syndromes after renal transplantation in the United States.

The impact of graft loss on acute coronary syndromes (ACS) after renal transplantation has not been studied in a national population. It was hypothesized that ACS might be more frequent after graft loss, as many of the benefits of a functioning allograft on metabolism and volume regulation would be lost. Data from the 2000 United States Renal Data System (USRDS) was used to conduct an historical cohort study of ACS in 14,237 patients who received renal transplants between April 1, 1995, and June 30, 1998, (followed until April 28, 2000) with valid information from CMS Form 2728, excluding patients with hospitalized ACS before renal transplant. Cox nonproportional regression models were used to calculate the time-dependent adjusted hazard ratio (AHR) of graft loss (censored for death) for time-to-first hospitalization for ACS (International Classification of Diseases 9th Modification Diagnosis Codes [ICD9] code 410.x or 411.x) occurring after transplant. The incidence of ACS was 12.1 per 1000 patient-years (PY) in patients after graft loss versus 6.5 per 1000 PY after transplantation (excluding patients with graft loss). As a time-dependent variable, graft loss had an AHR of 2.54 (95% confidence interval, 1.09 to 5.96; P = 0.031 by Cox regression). Other risk factors associated with ACS included diabetes, older recipient, and male recipient. Allograft rejection was NS. Renal transplant recipients share some of the risk factors for ACS with the general population. In addition, graft loss was identified as a unique risk factor for ACS in this population.

Acute Disease↗

PubMedDate not supplied

Military deployment human exposure assessment: urine total and isotopic uranium sampling results.

Currently the Department of Defense (DoD) does not use exposure biomarkers to measure service members' exposure to environmental chemicals. Blood and urine exposure biomarkers for volatile organic compounds (VOC), selected heavy metals, depleted uranium (DU), and chemical warfare agents are currently available but have not been field tested or validated by the DoD in military deployments as a tool to document exposures. The Military Deployment Human Exposure Assessment Study, a prospective cohort of 46 soldiers deployed to Bosnia, was designed to field test blood and urine exposure biomarkers as a mechanism to document exposures to these chemicals during military deployments. Blood and urine were collected before, during, and after deployment. Standard questionnaire, environmental, and occupational monitoring data collection methods were conducted for comparison to the exposure biomarker results. This article compares and reports the pre-, during, and postdeployment urine total and isotopic uranium measurements and compares them to perceived exposures captured on questionnaire, to environmental data collected by the United Nations Environmental Program in Bosnia, and to standard U.S. urine uranium reference levels (CDC, 2003). Additionally, the questionnaire and environmental and occupational measurements are reported. The results of the study indicate that exposure biomarkers may be a valuable tool to the DoD in exposure and risk assessment with regard to environmental and occupational exposures to uranium.

Bosnia and Herzegovina↗

PubMedDate not supplied

Risk factors for pulmonary embolism in chronic dialysis patients.

BACKGROUND: Risk factors for pulmonary embolism (PE) in end stage renal disease (ESRD) patients have not been studied in a large population. METHODS: 375,152 patients in the United States Renal Data System initiated on dialysis between 1 January 1992 and 30 June 1997 were analyzed in an historical cohort study of hospitalized PE (ICD9 Code 415.1x) occurring prior to receipt of renal transplant. Cox regression models were used to analyze risk factors for PE in dialysis. Dialysis modality was analyzed in an intention to treat fashion, thus patients who changed modalities later were considered to have remained on the same modality. RESULTS: The incidence of pulmonary embolism did not increase over time. Independent risk factors for hospitalizations for PE were similar to those in the general population (older age, females, systemic lupus erythematosus, lower risk for Asians) with the addition of peritoneal dialysis (vs. hemodialysis, adjusted odds ratio 1.56, 95% CI 1.15-2.13), polycystic kidney disease, and congestive heart failure. Notably, in Cox regression analysis, no relation was seen with baseline laboratory results (hematocrit, serum albumin, serum creatinine) or comorbidity (except congestive heart failure) and PE risk. Dialysis patients with PE had increased mortality (hazard ratio 1.20, 95% confidence interval 1.08-1.33). CONCLUSIONS: The incidence of PE did not increase significantly in ESRD patients from 1992-1997. PE were associated with increased mortality. Peritoneal dialysis patients may have higher risk of PE than hemodialysis patients, and other high-risk groups were identified.

Adult↗

PubMedDate not supplied

Hospitalizations for bacterial pneumonia after renal transplantation in the United States.

PURPOSE: Bacterial pneumonia has been cited as the leading cause of infectious death in renal transplant recipients but has not been studied in a national transplant population. SUBJECT AND METHODS: Retrospective analysis of the incidence, risk factors and mortality of hospitalized bacterial pneumonia (ICD9 Code 481.x486.x) for 33,479 renal transplant recipients in the United States Renal Data System transplanted from 1 July 1994-30 June 1997. RESULTS: Among all transplant recipients, 4.7% were hospitalized for a primary discharge diagnosis of pneumonia in the study period (2.86 episodes per 100 person years). 9.9% had bronchoscopy and 4.8% had open lung biopsy. A specific etiology was not identified in 72.5% of patients. The hospitalization rate for pneumonia and hazard for mortality due to hospitalized pneumonia were both constant over time. In logistic regression analysis, pneumonia prior to transplant (odds ratio 1.73, 95% confidence interval, 1.32-2.26), older recipient age, diabetes, delayed graft function, rejection (occurring at any time after transplant during the time of the study), duration of pre-transplant dialysis, and positive recipient cytomegalovirus serology were associated with pneumonia. In Cox Regression, hospitalization for pneumonia was associated with greater risk of mortality (hazard ratio 1.64, 95% CI, 1.42-1.89). CONCLUSIONS: Renal transplant recipients with a previous history of pneumonia are at increased risk for subsequent pneumonia, which is associated with substantially decreased patient survival. Given the low rate of specific etiologies identified in this study, invasive diagnosis may be underutilized in this population.

Aged↗