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There has been a notable lack of research activity regarding major infections in patients with advanced chronic kidney disease. To an outsider, this might seem unexpected, because uremia has long been considered a state of immune hyporesponsiveness and rates of major bacterial infection, like septicemia and pneumonia, are known to be orders of magnitude more likely in dialysis populations than in the general population. This article reviews recent literature on the topic, focusing predominantly on the clinical epidemiology of major bacterial infections in dialysis patients, the links between bacterial infections and cardiovascular disease, and randomized trials of interventions designed to prevent these infections.
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PMID:Infections in patients with chronic kidney disease. 1782 17

Variability in the health of human populations is greater in economically vulnerable areas. We tested whether this variability reflects and can be explained by: (1) underlying vulnerabilities and capacities of populations and/or (2) differences in the distribution of individual socioeconomic status between populations. Health outcomes were rates of mortality from 12 causes (cardiovascular disease, malignant neoplasms, accidents, chronic lower respiratory disease, cerebrovascular disease, pneumonia and influenza, diseases of the nervous system, suicide, chronic liver disease and cirrhosis, diabetes, homicide, HIV/AIDS) for 59 New York City neighborhoods in 2000. Negative binomial regression models were fit with a measure of socioeconomic vulnerability, median income, predicting each mortality rate. Overdispersion of each model was used to assess whether variability in mortality rates increased with increasing neighborhood socioeconomic vulnerability. To assess the two hypotheses, we examined changes in the variability of mortality rates (as indicated by changes in overdispersion of the models) for outcomes with significant non-constant variability after accounting for (1) vulnerabilities and capacities (social control, quality of local schools, unemployment, low education), and (2) the distribution of individual socioeconomic status (low income, poverty, socioeconomic distribution, high income). Some variability in all mortality rates was explained by accounting for a range of potential vulnerabilities and capacities, supporting the first explanation. However, variability in some causes of mortality was also explained in part by accounting for the distribution of individual resources, supporting the second explanation. The results are consistent with a theory of underlying socioeconomic vulnerabilities of human populations. In areas with lower levels of income, other characteristics of those neighborhoods exacerbate or temper the economic vulnerability, leading to more or less healthy conditions. Understanding the vulnerabilities and capacities that characterize populations may help us better understand the production of population health, and may inform efforts aimed at improving population health.
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PMID:Population vulnerabilities and capacities related to health: a test of a model. 1802 2

Twenty percent of deaths in the United States occur in nursing homes, yet less than 1% come to autopsy. The current study analyzed causes and manners of death in all nursing homes between 1993 and 2003, investigated by the coroner of Allegheny County, PA, which has the second highest elderly population in the United States. Two hundred eight decedents were identified, aged 19 to 91 years, 58% women and 42% men, 88% Caucasian and 22% African-American. Fifty-eight percent were accidental and 38.5% were natural manners of death, with 2 homicides, 2 suicides, and 3 undetermined cases. The manner of death was significantly different between Caucasians and African-Americans, with 92.6% of accidental deaths occurring in Caucasians and 6.6% in African-Americans (P < 0.1). Most common natural deaths were arteriosclerotic cardiovascular disease, nonarteriosclerotic cardiovascular disease, pneumonia, pulmonary thromboembolism, chronic obstructive pulmonary disease (COPD), seizure disorder, and atraumatic intracranial hemorrhage. Blunt force trauma was the single most commonly identified traumatic accidental death. Accidental deaths were more common in Caucasians than African-Americans. Homicides and suicides were rare events (<2%). Blunt force trauma is a major autopsy finding in accidental nursing home deaths, and a root-cause analysis may be helpful in developing policies and procedures to decrease the incidence of blunt force trauma.
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PMID:Nursing home deaths which fall under the jurisdiction of the coroner: an 11-year retrospective study. 1804 14

Oral health is receiving increased recognition as an important factor for the health of women and children. This article describes pathological oral conditions and the physiological mechanisms involved in the maintenance of oral health during illness and hospitalization, including the importance of the production and secretion of adequate saliva. Alterations in physiology of saliva induced by hormonal changes that occur during pregnancy are described along with possible roles in pathophysiological conditions associated with pregnancy. The roles of xerostomia and periodontal disease as sources of pathological bacteria involved in aspiration pneumonia, ventilator-associated pneumonia, and chronic inflammation are described. The bidirectional interaction between oral health and general overall health is described, with special emphasis on cardiovascular disease. Specific evidence-based nursing measures to reduce the complications associated with poor oral health in at-risk patients are provided.
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PMID:Nursing care & management of pathological oral conditions among women and children. 1815 26

Respiratory care centers (RCCs) provide effective care for patients who have been in intensive care and have undergone prolonged mechanical ventilation. Between February 2002 and December 2005, 891 patients who met the admission criteria of RCCs were referred to our RCC at Kaohsiung Medical University Hospital in southern Taiwan for attempted weaning. We recorded demographic and clinical data, including variables identified previously as predictive of weaning success among highly selected populations. The common causes of respiratory failure at RCC admission were neuromuscular disease (29.2%), pneumonia (27.5%), cancer (18.0%), cardiovascular disease (10.1%), sepsis (5.7%) and post-surgery (1.6%). The percentage of patients successfully weaned was 40.2%, while 59.8% remained dependent on ventilators. In a stepwise multivariate logistic regression analysis, significant predictors of weaning success included neuromuscular disease (odds ratio [OR], 2.64), APACHE II score (OR, 0.93) and blood urea nitrogen level at RCC admission (OR, 0.99). The results could be helpful in the accreditation of medical care quality and may provide guidelines for future research and education programs.
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PMID:Successful weaning predictors in a respiratory care center in Taiwan. 1828 Dec 25

To identify specific risk factors and clinical outcomes of community-acquired pneumonia (CAP) caused by gram-negative bacilli (GNB), we compared the clinical features and outcomes of patients with CAP due to GNB with those of patients with non-GNB pneumonia. We performed a prospective observational study of 912 cases of adult CAP in Asian countries from January 2002 to December 2004. Systemic laboratory evaluation for determining the etiology and clinical evaluation were performed. Of 912 cases with CAP, 93 (10.1%) cases were caused by GNB: 59 with K. pneumoniae, 25 P. aeruginosa, 7 Enterobacter species, 1 Acinetobacter baumannii, and 1 Serratia marcescens. CAP caused by GNB was more frequently associated with septic shock, malignancy, cardiovascular diseases, smoking, hyponatremia, and dyspnea, according to multivariate analysis (P < 0.05). Overall 30-day mortality rate was 7.3% (65/885). Mortality was significantly higher in the GNB group than in the non-GNB group [18.3% (17/93) vs. 6.1% (48/792); P < 0.001]. GNB as a causative microorganism was found to be one of the independent risk factors for mortality (adjusted OR = 2.63, 95% CI 1.02-6.78, P = 0.046) with nursing home residence, mechanical ventilation, cardiovascular disease, respiratory rate > 30/min, and hyponatremia (all P < 0.05). GNB was not only a frequent etiology of severe CAP but also an independent risk factor for mortality. Data suggest that an initial empirical antimicrobial coverage of GNB including P. aeruginosa should be seriously considered in cases of severe pneumonia, especially in patients with underlying malignancy, underlying cardiovascular diseases, smoking, septic shock, and hyponatremia.
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PMID:Clinical outcomes and risk factors of community-acquired pneumonia caused by gram-negative bacilli. 1831 21

Several studies have reported positive associations between oral infections and systemic diseases. The purpose of the present study was to evaluate the effects of oral symptoms on mortality from cardiovascular disease (CVD) and pneumonia. Using data from a cohort study in Japan, we analyzed 4,139 individuals aged 40-79 years. The baseline questionnaire included the following items related to oral symptoms: 'sensitive teeth', 'difficulty in chewing tough food substances', 'bleeding gums', and 'mouth feels sticky'. We used the Cox proportional hazard model to estimate hazard ratios (HRs) and 95% confidence intervals (95%CIs) for mortality, after adjustments for lifestyle, socio-economic factors, and history of diseases. Persons complaining that their 'mouth feels sticky' had a two-fold higher risk of pneumonia (HR = 2.1; 95%CI, 1.2-3.6), while those complaining of 'sensitive teeth' had a lower risk of CVD (HR = 0.4; 95%CI, 0.2-0.9). Some oral symptoms may be predictors of mortality from pneumonia and CVD.
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PMID:Oral symptoms predict mortality: a prospective study in Japan. 1843 82

Obesity is a worldwide epidemic and is known to increase the risk of cardiovascular disease, type 2 diabetes, and certain forms of cancer. In addition, obesity is now recognized as an important risk factor in the development of several respiratory diseases. Of these respiratory diseases, it has already been well established that obesity can lead to obstructive sleep apnea (OSA) and obesity-hypoventilation syndrome (OHS). More recent data suggest that the prevalence of wheezing and bronchial hyper-responsiveness, two symptoms often associated with asthma, are increased in overweight and obese individual. Indeed, epidemiological studies have reported that obesity is a risk factor for the development of asthma. Furthermore, a number of studies indicate that obesity is also associated with a higher risk of developing deep vein thrombi, pulmonary emboli, pulmonary hypertension, and pneumonia. Finally, weight reduction has been shown to be effective in improving the symptoms and severity of several respiratory diseases, including OSA and asthma. Thus, overweight and obese patients should be encouraged to lose weight to reduce their risk of developing respiratory diseases or improve the course of pre-existing conditions.
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PMID:Obesity and respiratory diseases. 1902 35

This study was aimed at describing disease patterns in a rural zone of Oromiya region, Ethiopia through a retrospective analysis of discharge records for 22,377 inpatients of St. Luke Hospital, Wolisso, Ethiopia in the period 2005-2007. The leading cause of admission was childbirth, followed by injuries, malaria and pneumonia. Injuries were the leading cause of in-hospital deaths, followed by pneumonia, malaria, cardiovascular disease and AIDS. Vulnerable groups (infants, children and women) accounted for 73.3% of admissions. Most of the disease burden resulted from infectious diseases, the occurrence of which could be dramatically reduced by cost-effective preventive and curative interventions. Furthermore, a double burden of disease is already emerging at the early stage of the epidemiological transition, with a mix of persistent, emerging and re-emerging infectious diseases and increasing prevalence of chronic conditions and injuries. This will lead to fundamental changes in the volume and composition of demand for healthcare, with a more complex case mix and more costly service utilization patterns. The challenge is to address the double burden of disease, while focusing on poverty-related conditions and targeting vulnerable groups. Monitoring disease and service utilization patterns through routine hospital information systems can provide sustainable, low-cost support for evidence-based health practice.
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PMID:Poverty, inequality and health: the challenge of the double burden of disease in a non-profit hospital in rural Ethiopia. 1915 75

The US Renal Data System Coordinating Center identifies patients with chronic kidney disease (CKD) in administrative data sets and determines the overall size of the population with a diagnosis of CKD, with such major comorbid conditions as diabetes and congestive heart failure, and associated expenditures. A 2-year observation period is used to define individuals with at least 1 International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code from inpatient claims or at least 2 from outpatient claims or physician and supplier service claims for kidney disease and comorbid conditions. This method is applied to the 5% general Medicare data and extrapolated to the general Medicare population. In the Medicare and dually enrolled Medicare/Medicaid populations, 8% to 10% have CKD or end-stage renal disease, and these groups account for 27% to 35% of expenditures. Hospitalization rates for all patients with cardiovascular disease, congestive heart failure, infection, and pneumonia are greatest for dialysis patients and patients with CKD compared with patients without CKD. Regarding detection in groups at high risk of CKD, approximately 1 in 5 patients with diabetes, only 1 in 50 patients with hypertension, and 1 in 4 patients with diabetes and hypertension had at least 1 microalbuminuria test in a year. CKD is a major pubic health issue with large financial implications. Continued surveillance and detection programs are needed to address the burden of disease, level of comorbidity, and access to care. Long-term trend analyses are needed to determine whether morbidity and mortality rates change based on greater detection and treatment efforts.
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PMID:CKD surveillance using administrative data: impact on the health care system. 1923 58


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