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Biomedical subjects

P Homel

Publications and source records attributed to P Homel.

15 recordsLinked to original sources
PubMed1998

Standardized hemodialysis prescriptions promote inadequate treatment in patients with large body mass.

BACKGROUND: Although a relation between the adequacy of hemodialysis and mortality has been established, hemodialysis prescription is rarely individualized precisely in adults with end-stage renal disease in the United States. OBJECTIVE: To test whether persons who receive standardized hemodialysis prescriptions have an increased risk for inadequate hemodialysis with increasing body mass. DESIGN: Cross-sectional study. SETTING: Four ambulatory hemodialysis facilities in Brooklyn, New York. PATIENTS: 214 patients receiving hemodialysis. Patients were sorted by body weight into quartiles (groups 1 through 4, in ascending order). MEASUREMENTS: Urea reduction ratio (percentage reduction in blood urea nitrogen concentration after a hemodialysis session), prescribed length of hemodialysis, and body weight quartile at the start of the study. Urea reduction ratio was measured at the start of the study and at weeks 4, 8, and 12, and a mean value was calculated for each patient. Inadequate hemodialysis was defined by a urea reduction ratio of 65% or less. RESULTS: Women had a higher mean urea reduction ratio (72% +/- 6%) than men (67.6% +/- 7%) (P < 0.001). The urea reduction ratio was inversely related to body weight (r = -0.47; P = 0.001). It was greater in group 1 (74% +/- 5.2%) than in group 2 (70% +/- 5.7%), group 3 (68% +/- 5.8%), or group 4 (66% +/- 8.4%) (P < 0.05). Logistic regression done with a urea reduction ratio of 65% or less as the outcome variable showed that the odds of receiving inadequate hemodialysis were increased 3.5-fold in men (95% CI, 1.53-fold to 8-fold; P = 0.003), 10-fold in group 3 (CI, 2.1-fold to 50.3-fold; P = 0.003), and 13-fold in group 4 (CI, 2.6-fold to 61.6-fold; P = 0.001). CONCLUSIONS: Standardized hemodialysis prescriptions result in inadequate hemodialysis in many patients who weigh more than 68.2 kg.

Adult↗
PubMed1998

Diabetes mellitus after renal transplantation: as deleterious as non-transplant-associated diabetes?

BACKGROUND: Despite use of lower doses of corticosteroid hormones after renal allotransplantation in the era of cyclosporine and tacrolimus, posttransplant diabetes mellitus remains a common clinical problem. METHODS: We prospectively investigated the effect of posttransplant diabetes on long-term (mean follow-up, 9.3+/-1.5 years) graft and patient survival in the 11.8% of our renal transplant population (n = 40) who developed diabetes after kidney transplantation, and we compared outcome in 38 randomly chosen nondiabetic control patients who had received transplants concurrently. RESULTS: Twelve-year graft survival in diabetic patients was 48%, compared with 70% in control patients (P = 0.04), and Cox's regression analysis revealed diabetes to be a significant predictor of graft loss (P = 0.04, relative risk = 3.72) independent of age, sex, and race. Renal function at 5 years as assessed by serum creatinine level was inferior in diabetic patients compared to control patients (2.9+/-2.6 vs. 2.0+/-0.07 mg/dl, P = 0.05). Two diabetic patient who experienced graft loss had a clinical course and histological features consistent with diabetic nephropathy; other diabetes-related morbidity in patients with posttransplant diabetes included ketoacidosis, hyperosmolar coma or precoma, and sensorimotor peripheral neuropathy. Patient survival at 12 years was similar in diabetic and control patients (71% vs. 74%). CONCLUSIONS: Posttransplant diabetes mellitus is associated with impaired long-term renal allograft survival and function, complications similar to those in non-transplant-associated diabetes may occur in posttransplant diabetes, and, hence, as in non-transplant-associated diabetes, tight glycemic control may also be warranted in patients with posttransplant diabetes.

Acute Disease↗
PubMed1998

The paucity of minimal change disease in adolescents with primary nephrotic syndrome.

Data are sparse regarding the histological lesions associated with the primary nephrotic syndrome in adolescents. To our knowledge there are only two published articles that have specifically addressed the histopathological lesions that typify idiopathic nephrotic syndrome in the adolescent population. We reviewed our experience from the last 14 years of children between the ages of 12 and 18 years who were referred to our center for the evaluation of the nephrotic syndrome. A total of 29 adolescents met the inclusion criteria for this review. All patients were biopsied prior to the initiation of treatment. The sex ratio consisted of 52% males and 48% females and the racial breakdown was largely African-American, with 83% black adolescents, 7% Hispanic, and 10% Caucasian patients. Minimal change nephrotic syndrome (MCNS), the predominant lesion of children at an early age, was noted in only 20% of patients. The majority of patients (55.2%) had focal segmental glomerulosclerosis (FSGS); 7% had IgM nephropathy and 3.5% had diffuse mesangial hypercellularity. Only 7% of biopsied adolescents had membranoproliferative glomerulonephritis. Our results indicate that the most common lesion in this predominantly African-American patient population is FSGS, with only a small number showing MCNS. Thus, in our experience derived from a racially mixed population, adolescents with the nephrotic syndrome are less likely to have MCNS than younger children.

Adolescent↗
PubMed1998

Predictive value of functional status for mortality in patients on maintenance hemodialysis.

In patients receiving maintenance hemodialysis, laboratory indices (such as serum albumin concentration) are predominantly utilized to assess well-being, while measures of functional status are rarely applied. However, the serum albumin concentration declines with advancing age, and the mean age of patients starting maintenance hemodialysis is now over 63 years. Using a 14-level modified Karnofsky activity scale, we measured baseline functional status in 522 randomly selected hemodialysis patients and prospectively monitored them for 3 years to determine the predictive value of our modified Karnofsky score for mortality. At onset of study, serum albumin and creatinine concentrations as well as hematocrit were measured and the comorbid conditions documented. At baseline, the 522 subjects (270 women and 252 men) included 327 blacks (63%), 154 whites (29%), 31 Hispanics (6%), and 10 Asians (2%) of mean age 59 +/- (SD) 15 years. The mean duration of end-stage renal disease was 4 +/- 3.6 years, and the mean serum albumin concentration was 3.7 +/- 0.4 g/dl. 166 (32%) of the patients died during the observation period. Cox regression analysis revealed inverse relations between mortality and both our modified Karnofsky score (p = 0.0001) and serum albumin concentration (p = 0.001). The predictive value of a low modified Karnofsky score for mortality persisted after analysis of subjects stratified according to serum albumin concentration (< 4 g/dl, n = 382, p = 0.0001 vs. > or = 4 g/dl, n = 140, p = 0.008). With a modified Karnofsky score (< 70 vs. > or = 70), the relative risk of death during the 3-year follow-up period was 1.44 (95% confidence interval 1.236, 1.675; p < 0.0001). Forward stepwise Cox regression analysis showed that advanced age (p = 0.0005), white race (p = 0.0009), diabetes mellitus (p = 0.01), and a low serum albumin concentration (p = 0.003) were independently associated with an increased risk of mortality during follow-up after adjustment for other factors. A modified Karnofsky score (p = 0.14) did not predict survival in the Cox model when other independent variables were included. We conclude that in patients with end-stage renal disease sustained on maintenance hemodialysis, a poor functional status (measured on a modified Karnofsky activity scale) is associated with early mortality. Periodic measurement of modified Karnofsky score is a simple, low-cost, and reliable means of identifying patients on dialysis at risk for early death.

Adult↗
PubMed1997

RNA transport in dendrites: a cis-acting targeting element is contained within neuronal BC1 RNA.

In nerve cells, a select group of RNAs has been localized to dendritic domains. Here we have examined dendritic RNA transport in sympathetic neurons in primary culture, using a microinjection protocol with neuronal BC1 RNA and with BC1-derived sequence segments. After cytoplasmic microinjection, full-length BC1 RNA was selectively transported to dendrites; in contrast, control RNAs such as nuclear RNAs and random-sequence irrelevant RNAs remained restricted to cytoplasmic areas proximal to the injection sites. Chimeric RNAs were constructed that contained the full-length BC1 sequence inserted upstream or downstream of the coding regions of nondendritic mRNAs. After microinjection, such chimeric RNAs were specifically targeted to dendrites; microinjected corresponding nonchimeric mRNAs were not. Dendritic transport of BC1 RNA was rapid: the average dendritic delivery rate within the first hour after microinjection was 242 +/- 25 microm/hr. Whereas a 5'-BC1 segment of 62 nucleotides was transported to dendrites to extents and at levels similar to full-length BC1 RNA, a 3'-BC1 segment of 60 nucleotides did not exit injected somata to any significant degree. A cis-acting dendritic targeting element is thus contained in the 5' part of neuronal BC1 RNA. These results demonstrate that mechanisms exist in neurons for fast and specific transport of selected RNAs to dendrites.

Animals↗
PubMed1997

What happens after discharge? Return hospital visits after ambulatory surgery.

The purpose of this study was to examine the frequency of return hospital visits after ambulatory surgery discharge and to identify any predictor variables for its occurrence. A retrospective review of hospital records for all patients returning to the same hospital within 30 days after ambulatory surgery was conducted. Data on return hospital visits that resulted in rehospitalization (as an inpatient or to the ambulatory surgery unit [ASU]) or treatment as an outpatient in the emergency room were recorded. A total of 6243 patients underwent ambulatory surgery over 12 consecutive months and 187 returned to the same hospital of which 1.3% were for complications. Of all the returns, 54% returned to the emergency room (ER) and 46% were rehospitalized as inpatients or to ASU. To identify factors associated with an increased likelihood of return, two case controls for each return visit were obtained from medical records of ambulatory surgical patients operated on during the same time period. Results of the multivariate analysis on the matched case controls identified urology as the only significant surgical service that predicted returns. (Odds ratio 27.87; confidence interval [CI] 3.78-74.86; P = 0.0002). A separate analysis of the most common ASU procedures performed identified two surgical procedures that predicted hospital return as compared with overall ambulatory surgery population: patients undergoing varicocelectomy and hydrocelectomy procedures were 8.3 times more likely to return (CI 2.090-23.75; P = 0.0042); patients undergoing dilation and curettage were three times as likely to return (CI 1.78-5.55; P = 0.0002). Bleeding was the most common reason for all hospital returns (41.5%), with 76.5% of these patients treated and discharged through the ER. The increased likelihood of return visits after urology procedures warrants further evaluation. As patients with bleeding were most likely to return to the ER and discharged, more effective pre- and postprocedure patient education may further reduce this occurrence. Better informing patients regarding the prognosis of bleeding, and advising them of medical alternatives, could reduce inappropriate patient returns to the ER.

Adult↗
PubMed1997

Determinants of type of initial hemodialysis vascular access.

Vascular access thrombosis is more common with polytetrafluoroethylene (PTFE) grafts than with native arteriovenous fistulae (AVF). Recent studies report an unexplained excess vascular access morbidity in women on hemodialysis. We studied 92 consecutive end-stage renal disease (ESRD) patients receiving their first permanent hemodialysis vascular access at initiation of hemodialysis to identify variables that determine assignment of either a PTFE graft or a native AVF. Independent variables included: age, gender, race, etiology of ESRD, and whether or not access surgery was electively planned before need for dialytic therapy. The 51 women and 41 men included 65 blacks, 13 Hispanics, 11 whites, and 3 Orientals aged 50 +/- (SD) 16 years. Of the 92 subjects, 54 (59%) received an AVF, while 38 (41%) received a PTFE graft. 36 (94%) of 38 PTFE grafts were placed in the upper arm as compared with 9 (17%) of 54 AVF (p = 0.0001). Also, 45 (83%) of 54 AVF were placed in the forearm as compared with only 2 (6%) of 38 PTFE grafts (p = 0.0001). Women were more likely to receive a PTFE graft - 28 (55%) of 51 - than men - 10 (24%) of 41 (p = 0.003). By contrast, men were more likely to get an AVF - 31 (76%) of 41 - than women - 23 (45 %) of 51 (p = 0.003). The log linear analysis confirmed that this finding was significant (p = 0.0018) for the coefficient of interaction between gender and type of vascular access. No other independent variable had a significant relationship with type of vascular access. We conclude that women with ESRD are more likely to receive a PTFE graft for hemodialysis, while men are more likely to get an AVF. These findings may explain, in part, the reported excess vascular access morbidity in women on hemodialysis.

Adult↗
PubMed1996

Excess morbidity in patients starting uremia therapy without prior care by a nephrologist.

Many inner-city residents with progressive renal disease do not receive specialist care from a nephrologist, and often arrive in the emergency room manifesting life-threatening uremic symptoms requiring emergency rescue dialysis. We examined the relationship between the quality of medical care received during progression to end-stage renal disease, and the clinical condition and morbidity at initiation of renal replacement therapy. During a 5-year period (January 1990 to December 1994), we prospectively studied 139 consecutive inner-city residents with a confirmed diagnosis of chronic renal failure who were starting uremia therapy. At onset of study, subjects were sorted into one of three groups depending on the extent of medical care received during the 3 years immediately preceding initiation of hemodialysis: nephrologist, nonnephrologist (physician), or no medical care. Information obtained from each subject included length of hospital stay during the admission for initiation of dialysis therapy and the type of hemodialysis vascular access used for first dialysis treatment (permanent v temporary). Predialysis blood urea nitrogen concentration, serum creatinine concentration, serum albumin concentration, and serum bicarbonate concentration were measured once immediately before the first dialysis. The 139 study subjects (62 men and 77 women) comprised 116 blacks (83%), 15 Hispanics (11%), and eight whites (6%), and had a mean age of 56 +/- 15 years (+/-SD). Only 59 (43%) subjects received prior specialist nephrologist care, and their mean length of hospital stay (12 +/- 23 days) was shorter than that of subjects who received nonnephrologist care (n = 63 [45%]; 25 +/- 21 days) or those who received no prior medical care (n = 17 [12%]; 29 +/- 23 days) (P = 0.002). Temporary hemodialysis vascular access was used for the first dialysis in all 17 (100%) of the subjects with no prior medical care, in 56 (89%) of the 63 subjects who received prior care from a nonnephrologist, and in 21 (36%) of the 59 subjects who received prior care from a nephrologist (P = 0.0001). Subjects who received prior care from a nephrologist had a lower mean serum creatinine concentration at initiation of dialysis (11 +/- 4.4 mg/dL) than did either the subjects who received nonnephrologist care (13 +/- 5.4 mg/dL) or no medical care (16 +/- 5.7 mg/dL) (P = 0.003). In addition, subjects who received prior care from a nephrologist had less severe metabolic acidosis than the subjects in the other two groups (P = 0.04). We infer that initiation of uremia therapy is delayed in inner-city residents with progressive renal failure who do not receive specialist nephrologic care, and that as a consequence these patients suffer excess short-term morbidity.

Anemia↗
PubMed1996

Age and race as prognostic factors in endometrial carcinoma.

This research was undertaken to evaluate the effects of age and race on prognosis of patients with endometrial carcinoma. A total of 279 patients with endometrial carcinoma treated at State University of New York-Health Science Center and Kings County Hospital Brooklyn, New York from 1975 to 1990 were retrospectively analyzed. Patients were arbitrarily divided into young and old groups (< or = 60 years or > 60 years old, respectively). The distribution of grade, clinical stage, and extent of myometrial invasion by age was determined for the entire group and for black and white patients, respectively. Young and old patients were stratified by clinical stage, grade, and extent of myometrial invasion. The corrected median survival of young and old patients by race was evaluated by Kaplan Meier's method of analysis. Older patients in general had higher clinical stage, higher grade, and greater depth of myometrial invasion than younger patients. Also, black patients had higher clinical stage, higher grade, and greater depth of myometrial invasion than white patients. Older black patients had the least favorable distribution of prognostic factors. Overall younger patients had a median survival of 200 months compared to 90 months for older patients (p = 0.0085). The overall corrected median survival for whites was 232 months compared to 108 months for blacks (p = 0.0001). The median survival of older black patients was worst at 40 months, compared to 155 months for older white patients (p = 0.0005). Age is a very important prognostic factor in endometrial carcinoma for both blacks and whites, and it appears to be more pronounced in older black patients.

Adult↗
PubMed1992

The public perception of the risks and benefits of alcohol consumption.

A survey of the community was undertaken in August 1989 to assess the public's perception of the risks and benefits of alcohol use, and their understanding of recommended levels of safe alcohol consumption. A household sample of 500 men and women (18 to 65 years) in metropolitan and rural New South Wales were asked their opinions about the risks and benefits of alcohol use, the health and social consequences of 'drinking too much', and the number of standard drinks that would produce a low, medium and high risk to the health of an adult man and woman. The major perceived benefits of alcohol use were relaxation and medication; the major health and social problems attributed to alcohol abuse were brain and liver damage, and domestic violence and family problems. The quantities of alcohol which respondents thought could be consumed with a 'low' risk to health were close to National Health and Medical Research Council recommended levels of safe consumption.

Adult↗
PubMed1991

Public attitudes towards alcohol control policies.

In August 1989 we surveyed a household sample of 500 adults from 84 randomly selected census collector districts in metropolitan and rural New South Wales about their support for 'alcohol control policies' that aim to reduce the prevalence of alcohol-related problems by lowering population alcohol consumption. There was very little support for policies which increased the price or reduced the availability of alcohol. There was moderate support for controls on alcohol advertising, and substantial opposition to policies that would reduce the price of alcohol or increase its availability. Approval for alcohol control policies was more likely to be expressed by women and by persons whose self-reported alcohol consumption was low. If these findings from New South Wales are representative of Australian attitudes then proponents of alcohol control policies face a major task in persuading the public to support them.

Adult↗
PubMed1990

The drug market position of cocaine among young adults in Sydney.

A study was undertaken to explore the 'market position' of cocaine among young adults in Sydney, Australia. The intention was to estimate how likely Australia is to experience an epidemic of cocaine use if the availability of the drug was to increase. A sample of 499 young adults in which illicit drug users were overrepresented were surveyed. The results suggested that there was not a large untapped market for cocaine. In terms of risk and attraction, cocaine was perceived to be more like the traditional 'hard drugs' of heroin, stimulants and hallucinogens than the traditional 'soft drugs' of alcohol and marijuana. Only 5% of the sample were prepared to try cocaine if offered it by a close friend.

Adolescent↗