BACKGROUND: Cardiovascular mortality in end-stage renal failure patients is high and early risk stratification in these patients may aid clinical management improving outcomes. Cardiac troponin T (cTnT) is a component of the cardiac myocyte which is released into the circulation following myocardial necrosis. It has been shown to be of prognostic significance in patients with unstable angina. The role of cTnT in patients with renal disease remains unclear. The aim of this investigation, therefore, was to assess the prognostic significance of cTnT in chronic renal impairment patients, pre-dialysis. METHODS: Ninety-six patients with chronic renal impairment were followed prospectively after cTnT determination by a quantitative laboratory method. The clinical outcomes after 2 years were determined. The measured cTnT values were correlated with biochemical parameters and clinical end-points. RESULTS: A cut-off of 0.1 ng/ml was used in assessing the prognostic significance of cTnT. Twenty-five patients had a cTnT >0.1 ng/ml, whilst 71 had a cTnT 0.1 ng/ml was 42% compared with 14% in those with levels below the cut-off. Thirty-three patients died or had a vascular event. The rate of death or a vascular event in the elevated group was 64% compared with 24% in those with levels below the cut-off. At the end of the study, 23 patients were treated by continuous ambulatory peritoneal dialysis, 29 by haemodialysis, 22 had functioning renal transplants and one patient was not on renal replacement therapy. Factors that were found to significantly affect cTnT were diabetes, age and urea. cTnT was found to be a significant predictor of survival in these patients. Patients with high cTnT values were more likely to end up on haemodialysis. No relation of renal function to cTnT level was found. CONCLUSIONS: These results show that in patients with renal impairment, the measurement of cTnT prior to commencing renal replacement is a significant independent predictor of survival. cTnT did show potential as a prognostic test to stratify patients with a high cardiovascular risk and may enable intensive risk factor modification in this patient group. This may be of further use in selection of patients' suitability for renal transplantation.

Cardiovascular Diseases↗

PubMed2003

Electrocardiographic left ventricular hypertrophy in renal transplant recipients: prognostic value and impact of blood pressure and anemia.

Left ventricular hypertrophy (LVH) is an independent risk factor for death and cardiovascular disease in the general population and dialysis patients. However, the causes and consequences of LVH have not been well described in renal transplant recipients (RTR). A retrolective cohort study was conducted in 473 RTR who were alive and free of cardiac disease at 1 yr. LVH was defined using the Cornell electrocardiographic (EKG) criteria. A total of 416 patients had an interpretable first-year EKG (88%), and 284 had an interpretable fifth-year EKG (78% of 5-yr survivors). Baseline characteristics were similar in patients with and without EKG. Of 416 patients, 57 had LVH in the first year, whereas 38 of 284 patients had LVH in the fifth year, of which 18 cases were de novo. Baseline LVH was a risk factor for death (RR 1.9 [1.22, 3.22]) and congestive heart failure (CHF) (RR 2.27 [1.08, 4.81]) and was independent of other major prognostic variables. Persistent or de novo LVH in the fifth year predicted subsequent death (RR 2.15 [1.14,4.01]) and CHF (2.71 [1.17, 6.30]). Anemia and diastolic BP were independent risk factors for increasing Cornell voltage (a marker of LV mass) between first and fifth years. Systolic BP was the only predictor of de novo LVH at 5 yr. It seems that EKG LVH is a significant risk factor for death and CHF in RTR and that anemia and hypertension are risk factors for LV growth. Whether aggressive treatment of hypertension and anemia can improve outcomes merits further study.

Adult↗

PubMed2002

Congestive heart failure in renal transplant recipients: risk factors, outcomes, and relationship with ischemic heart disease.

Cardiovascular disease (CVD) is the major cause of death in renal transplant recipients (RTR). Several cohort studies have examined CVD in RTR, but none have addressed the development of congestive heart failure (CHF). CHF would hypothetically be a frequent and prognostically important event in RTR. A retrolective cohort study was, therefore, conducted in two Canadian centers to describe the incidence, risk factors for, and interrelationships between de novo CHF, de novo ischemic heart disease (IHD), and mortality in 638 consecutive adult RTR who were free of cardiac disease at 1 yr posttransplant. Detailed clinic and hospital records were available for 99% of patients. Median follow-up was 7 yr (range, 1 to 28 yr). De novo CHF occurred as frequently as de novo IHD (1.26 versus 1.22 events/100 patient-years, respectively) and appeared to carry a similar prognosis (relative risk for death, 1.78 [confidence interval, 1.21 to 2.61] for CHF versus 1.50 [1.05 to 2.13] for IHD). The incidence of CHF was considerably higher than that in the Framingham cohort, whereas the incidence of IHD was not, suggesting that renal transplantation might correspond more to a state of "accelerated heart failure" than to "accelerated atherosclerosis." Age, diabetes, gender, BP, and anemia were identified as independent risk factors for de novo CHF, whereas age, diabetes, gender, BP, and rejection were independent risk factors for de novo IHD. Optimal strategies for treatment of BP and anemia in RTR will need to be determined in randomized controlled trials.

Adult↗

PubMedDate not supplied

Community readiness: the journey to community healing.

Community readiness is a research-based theory that provides a basic understanding of the intervention process in communities. This theory allows us to accurately describe the developmental level of a community relative to a specific issue or problem. In order to move the community toward implementing and maintaining efforts that are effective and sustainable, community mobilization must be based on involvement of multiple systems and utilization of within-community resources and strengths. Successful local prevention and intervention efforts must be conceived from models that are community-specific, culturally relevant, and consistent with the level of readiness of the community to implement an intervention. The community readiness model is an innovative method for assessing the level of readiness of a community to develop and implement prevention programming. It can be used as both a research tool to assess distribution of levels of readiness across a group of communities or as a tool to guide prevention efforts at the individual level. This tool has proven useful in addressing a gamut of problems ranging from health and nutritional issues to environmental and social issues. The model identifies specific characteristics related to different levels of problem awareness and readiness for change.

Alcoholism↗

PubMedDate not supplied

Laparoscopic transhiatal surgery of the esophagus.

OBJECTIVE: Esophagectomy is an operation with high morbidity and mortality. Its adoption as a minimally invasive operation worldwide has been slow, but the potential benefits of reducing the trauma of surgery need to be considered. Our 30-month experience with transhiatal esophagectomy in a district general hospital is presented herein. METHODS: Patients were considered for surgery after radiological staging had excluded inoperable disease. Laparoscopic staging was initially performed. Patients with tumors of the esophagus and high-grade dysplasia in a Barrett's esophagus were included. RESULTS: Twenty-nine patients were referred for consideration for resectional surgery. Nine underwent outpatient laparoscopy only. Twenty patients (age range, 34 to 78, 15 males:5 females) underwent resectional surgery. Seventeen transhiatal resections were completed, 2 were converted to open procedures, and 1 transhiatal resection of a benign tumor was performed. Median time of surgery was 415 minutes (range, 320 to 480) and blood loss was 300 mL (range, 200 to 350). The median length of post-operative ventilation and critical care stay were 1 (range, 1 to 4) and 4 (range, 2 to 8) days. Median duration of hospitalization was 17 days (range, 10 to 28). Thirty-day mortality was 0; 1 patient who was converted to an open procedure died after a cerebrovascular event on day 34. CONCLUSION: A zero mortality rate for laparoscopic resection and a low-morbidity rate compare well with morbidity and mortality in reported series using this method and open surgery. Laparoscopic transhiatal esophagectomy is an advanced, complex procedure that can be performed safely in a district general hospital setting.

Adenocarcinoma↗