Total extra-peritoneal repair of groin hernia: prospective evaluation at a tertiary care center

BACKGROUND

The laparoscopic repair of groin hernia is increasingly being used. However, the relative merits and demerits of laparoscopic repair are debatable. The present study was undertaken to evaluate the total extra-peritoneal (TEP) repair of groin hernia.

METHODS

This prospective study was undertaken at a single surgical unit between January 2004 and June 2006. Consecutive patients with elective groin hernias were offered laparoscopic TEP repair. Indigenous balloon or telescopic dissection was used to create extra-peritoneal space. Polypropylene mesh was used in all of the patients and mesh fixation was performed with tackers.

RESULTS

A total of 185 patients with age range 18-92 years were included; 180 were males. TEP repair was attempted in 298 groin hernias in 185 patients with a success rate of 89.5%. Indigenous balloon or telescopic dissection was used to create extra-peritoneal space. Thirty-one (31, 10.5%) TEP repairs were converted to transabdominal pre-peritoneal or open repair. Two patients developed recurrence during follow-up.

CONCLUSION

TEP is an excellent technique for laparoscopic groin hernia repair, with acceptable rates of complication.

The first successful simultaneous pancreas-kidney transplant in India

Insulin-dependent diabetes mellitus is associated with renal failure, diabetic retinopathy, neuropathy and vasculopathy. We report the first successful simultaneous pancreas-kidney transplant in India in a young diabetic with renal failure. The dual transplant has cured his diabetes and renal failure and has had a beneficial effect on his neuropathy, retinopathy and quality of life. Obstacles to dual transplant in India include a lack of suitable recipients and a cadaver donor programme that is still in its infancy.

Hemodialysis prognostic nutrition index as a predictor for morbidity and mortality in hemodialysis patients and its correlation to adequacy of dialysis. Council on Renal Nutrition National Research Question Collaborative Study Group

OBJECTIVE

Prospectively examine the use of a hemodialysis prognostic nutrition index (HD-PNI) as a predictor for morbidity and mortality in hemodialysis patients and its correlation to adequacy of dialysis.

DESIGN

Prospective randomized collaborative study group.

SETTING

There were 211 chronic hemodialysis centers; 202 from 43 United States, 9 from Canada.

PATIENTS

There were 1527 hemodialysis patients undergoing treatment a minimum of 3 months and at least 18 years of age. Sample mirrored United States Renal Data System data for age, sex, race, and etiology of renal failure.

INTERVENTIONS

None; routinely collected demographic, biochemical, and clinical data for 8-month baseline and 3-month predictive phases.

METHODS

HD-PNI calculated from baseline data as linear mathematical equation using level of serum albumin, level of serum creatinine, and number of days and times hospitalized; HD-PNI risk defined as >/=0.8. Adequacy of dialysis calculated as urea reduction ratio (URR) from baseline data; adequacy risk defined as URR of </=65%.

MAIN OUTCOME MEASURES

Number of times and days hospitalized, mortality.

RESULTS

For this research, 1167 patients completed the study (76%) with 360 (24%) dropped due to death, incomplete data, transfer, or change in modality. Patients completing study with HD-PNI risk (n = 208, 18%) compared with patients who had no HD-PNI risk (n = 959, 82%) were hospitalized more often (57.2% v 28.5%, P <. 01), hospitalized with infection more often (14.6% v 4.6%, P <.01), and had greater mortality (7.7% v 2.5%, P <.01). Stratification of HD-PNI risk by URR of >/=65% did not significantly improve prediction.

CONCLUSIONS

Use of HD-PNI is an effective screening tool to identify hemodialysis patients at risk for morbidity and mortality. No correlation was found between URR and HD-PNI.

The effect of blood draw methodology on selected nutritional parameters in chronic renal failure

The reliability and validity of any clinical laboratory test is directly affected by the integrity of the blood specimen obtained for analysis. Renal failure patients undergo a high number of laboratory tests, primarily to monitor the quality of care. Subsequent tests to confirm laboratory abnormalities are costly and place the patient at unnecessary risk for additional blood loss. Three of the four Health Care Financing Administration core clinical outcome indicators have nutritional implications and use laboratory values as part of review criteria: adequacy of dialysis, albumin, and anemia. National Kidney Foundation-Dialysis Outcomes Quality Initiative (DOQI) Clinical Practice Guidelines have recommended standardized predialysis and postdialysis blood draw procedures to increase accuracy for adequacy of dialysis. The National Committee on Clinical Laboratory Standards publishes peer-reviewed guidelines for venipuncture. Together, the adoption of these standards would minimize preanalytical variation and improve the data used to monitor the quality of care in renal patients.

Variation in blood sample collection for determination of hemodialysis adequacy. Council on Renal Nutrition National Research Question Collaborative Study Group

Inadequate dialysis has been associated with high morbidity and mortality in end-stage renal disease (ESRD) patients receiving maintenance hemodialysis. The accurate estimation of dialysis adequacy, measured either as a calculated urea kinetics (Kt/V) or a simple urea reduction ratio (URR) is dependent on the proper collection of blood samples for predialysis and postdialysis blood urea nitrogen (BUN) determination. Because no established protocol exists for blood sampling, we surveyed the study cohort of dialysis centers participating in the National Kidney Foundation Council on Renal Nutrition National Research Question Collaborative Study to determine the comparability of BUN data that were collected to calculate URR to determine adequacy of dialysis. Surveys were completed by 100% of the 202 units participating: 195 in the United States (from 43 states) and seven from Canada, treating approximately 15,000 hemodialysis patients in total. The distribution of the sample by the type of facility mirrored that of 1996 United States Renal Data System (USRDS) Annual Report facilities data. Results showed a 5.0% error in predialysis blood draw and an 8.4% to 41.6% error in the postdialysis counterpart. There was a large variability in the observed postdialysis methods in general. Dilution of predialysis sample with either heparin or saline will falsely underestimate Kt/V and URR. The presence of access-derived, recirculated blood in the postdialysis sample will falsely overestimate Kt/V and URR. Excessive delay in drawing postdialysis sample will reduce Kt/V and URR because of urea rebound. Adoption by all dialysis providers of a uniform blood sample draw procedure will result in a consistency necessary to allow reliable and valid comparison of adequacy of dialysis parameters within and between ESRD patients, units, and clinical trials.

Using the hemodialysis prognostic nutrition index and urea reduction ratio to predict morbidity and mortality: a pilot study of the 1995 council on renal nutrition national research question

OBJECTIVE

To validate the use of the hemodialysis prognostic nutrition index (HPNI) in an alternate hemodialysis population and to determine if use of urea reduction ratio would improve use in outcome prediction for morbidity and mortality.

DESIGN

Prospective random cohort.

SETTING

Hospital based non-for-profit outpatient dialysis unit.

PATIENTS

Forty chronic hemodialysis patients, 50% men, 50% black, 16% diabetic, 67.2 mean months on hemodialysis, mean age 54.5 years.

INTERVENTIONS

None; observational; tracking of routinely collected demographic, biochemical, and clinical data.

MAIN OUTCOME MEASURES

Number of times and days hospitalized, mortality

RESULTS

Plotting of HPNI against urea reduction ratio produced risk quadrants for hospitalization that were more predictive than HPNI alone.

CONCLUSION

Application continues as a multicenter collaborative Council on Renal Nutrition National Research Question.

Treatment of lupus nephritis: a meta-analysis of clinical trials

The best therapeutic choice in lupus nephritis remains shrouded in a body of controversial literature. The purpose of this review was to assess and compare by meta-analysis the efficacy of therapeutic agents used in the treatment of lupus nephritis using outcomes of end-stage renal disease (ESRD) and total mortality. An exhaustive search was performed using MEDLINE (1970 to 1995) and manual search of bibliographic notations and nonindexed sources. Twenty prospective controlled trials with treatment allocation by random assignment or consecutive enrollment were identified using diagnostic evidence of systemic lupus erythematosus based on American Rheumatism Association (ARA) criteria and clinical/biopsy evidence of lupus nephritis. One trial was excluded, resulting in 19 trials (n = 440) using treatment groups of oral prednisone alone, azathioprine with and without concomitant prednisone, oral cyclophosphamide with prednisone, azathioprine and oral cyclophosphamide with prednisone, and intravenous cyclophosphamide with prednisone. Crude risk data was pooled. An adjusted pooled risk was calculated using the random effects model of DerSimonian and Laird. Two measures of clinical effectiveness were used to compare treatments: absolute risk differences and number needed to treat. Analysis was completed between treatment groups as follows: oral prednisone compared with all immunosuppressive agents with prednisone and all treatment groups compared with one another. When compared with oral prednisone alone, immunosuppressive agents used in conjunction with oral prednisone were found to be statistically more effective for both total mortality and ESRD (absolute risk differences, 13.2% and 12.9%, respectively). When treatment groups were compared, intravenous cyclophosphamide in conjunction with oral prednisone was found to be statistically more effective than oral prednisone alone for both total mortality and ESRD (absolute risk differences, 19.9% and 16.2%, respectively). The simultaneous use of azathioprine and oral cyclophosphamide concomitant with oral prednisone was found to be 16.9% more effective than oral prednisone alone in reducing incidence of ESRD. No difference was seen in total mortality and data represented only two studies (n = 30). No immunosuppressive agent was found to be statistically more effective than another for either total mortality or ESRD. Future prospective studies are needed to control for numerous variables and renal function changes to provide more definitive answers.

Use of pharmacy computer prescription database to access hypertensive patients for mailed survey research

OBJECTIVE

To evaluate the use of a pharmacy computer prescription database (PCPD) to identify and sample hypertensive patients outside of their treatment setting for mailed, self-administered survey research comparing the presence and lack of participation incentives and mailed follow-up reminders.

SETTING

Two independent, privately owned, free-standing community pharmacies.

PARTICIPANTS

A total of 735 individuals identified from a PCPD search who had been prescribed at least 1 of 130 PCPD medications potentially used in hypertensive therapy.

METHODS

PCPD was searched by the pharmacist/owner per protocol; participants were sent an individually addressed cover letter on pharmacy letterhead signed by the pharmacist that requested voluntary anonymous completion of an enclosed self-administered, quality-of-life opinion survey; the first search used no incentive or follow-up; the second search used an incentive and mailed a follow-up reminder. Research protocol followed published ethics guidelines.

RESULTS

There was a mean 84% return with incentive and follow-up strategies compared with a mean 25% return without strategies (p < 0.01) for all drug groups between searches; no statistical difference in response was shown between the same drug groups (alpha 1-blockers, calcium-channel blockers, and centrally acting alpha 2-agonists) within searches.

CONCLUSIONS

Acceptable response rates (74-93% return) can be obtained with traditional follow-up mailed incentives, prescription issuance within 6 months, incentives to both hypertensive and nonhypertensive responders, and sampling strategies within potential drug groups. Methodology can be adapted to other populations by alternative drug sampling strategies.

Correlations of Na+-Li+ exchange activity with Na+ and Li+ binding and phospholipid composition in erythrocyte membranes of white hypertensive and normotensive individuals: a nuclear magnetic resonance investigation

Enhanced Na+-Li+ exchange activity has been reported in red blood cells (RBCs) of white patients with essential hypertension compared with RBCs of normotensive individuals. To understand the factors responsible for this finding, we applied novel and conventional spectroscopic and kinetic methods to blood samples from 10 hypertensive and 10 normotensive individuals. We measured the kinetic parameters (V std, V max, and K m) for RBC Na+-Li+ exchange by atomic absorption spectrophotometry and used 23Na and 7Li nuclear magnetic resonance relaxation methods to measure Na+ and Li+ binding to RBC membranes as well as 31P nuclear magnetic resonance spectroscopy to measure membrane phospholipid compositions. We found significant differences between the two groups for the affinity of Na+ for the RBC membrane (0.202 +/- 0.054 mmol/L-1 for hypertensive patients versus 0.296 +/- 0.071 mmol/L-1 for normotensive subjects, P<.005). The kinetic parameters of RBC Na+-Li+ exchange (V std, V max, and K m) were 0.32 +/- 0.09 and 0.66 +/- 0.17 mmol Li+/L cell.h and 160 +/- 62 mmol/L, respectively, for hypertensive patients versus 0.21 +/- 0.06 and 0.32 +/- 0.14 mmol Li+/L cell.h and 86 +/- 69 mmol/L for normotensive subjects (P<.05). The fractions of phosphatidylserine and phosphatidylethanolamine were 0.153 +/- 0.009 and 0.294 +/- 0.016 for hypertensive patients versus 0.138 +/- 0.013 and 0.325 +/- 0.018 for normotensive subjects (P<.05). The Na+ binding constants were negatively correlated with the Km values for both the hypertensive (r=-.61, P=.01) and normotensive (r=-.43, P=.04) groups. Changes in lipid-protein interactions in the RBC membranes of hypertensive patients appear to be responsible for weaker Na+ binding to the membrane and for the faster rates of RBC Na+-Li+ exchange.

Pharmacy computer prescription databases: methodologic issues of access and confidentiality

OBJECTIVE

To examine methodologic issues of access and confidentiality regarding the use of pharmacy computer prescription databases (PCPDs) for participant selection to receive mailed, self-administered, hypertensive quality-of-life survey outside a primary-care setting.

DESIGN

Two separate PCPD searches by pharmacist owners for patients prescribed at least one of 130 potential antihypertensive medications. The first PCPD used a nonrandom sample of all patients (n = 635); the second PCPD used a random sample (n = 100) of three specific antihypertensive drug groups. Research protocol was approved by the investigators' institutional review board.

SETTING

Two independent, privately owned PCPDs.

PATIENTS OR OTHER PARTICIPANTS

Individuals prescribed at least 1 of 130 PCPD medications potentially used in antihypertensive treatment.

INTERVENTIONS

Individually addressed cover letter on pharmacy letterhead signed by a pharmacist requesting voluntary completion of the enclosed, self-administered, opinion survey on quality of life.

MAIN OUTCOME MEASURE

Anonymous survey return to off-site post office box in envelope provided.

RESULTS

Favorable or no opposition to PCPD methodology from pharmacist or participants. Ethical opposition was encountered when incorporating PCPD sampling technique into grant proposal.

CONCLUSIONS

The American Pharmaceutical Association Code of Ethics is used as a basis to provide recommendations to examine and justify PCPD investigative use. Increasing availability of PCPD technology encourages more efficient and easier methods of research strategy. PCPD use, however, demands identical stringent guidelines used in traditional research and raises potential issues regarding pharmacist-patient confidentiality as well as the right of PCPD use by others.

Quality of life in treatment of hypertension. A metaanalysis of clinical trials

A metaanalysis was performed to determine the effects on quality of life (QL) in hypertension as reported in published clinical trials of antihypertensive drug therapy. All studies included compared active treatment to baseline (placebo or no treatment) with the patients as their own control and used blinded, randomized trials. Change was measured by self and/or interviewer-assisted evaluation, standardized psychomotor/cognitive tests, or sleep laboratory observations. After an exhaustive literature search (1970 to 1990), nine published trials of 27 population groups (n = 1620) using 14 drugs from six pharmacological groups met selection criteria and were analyzed for five QL constructs: sexual function, sleep, psychomotor, general well-being, and mood. Small positive effect size (d) improvement with treatment was seen for sleep (d = 0.106), psychomotor (d = 0.283), general well-being (d = 0.139), and mood (d = 0.167) while no effect could be determined for sexual function (d = -0.030) based on 95% confidence intervals. Either a comparably small improvement with treatment or no effect was seen among various pharmacological drug groups; no negative effect with treatment was identified. A larger positive effect could be postulated if the drug choice was individualized to the patient rather than randomized as in clinical trial methodology. Although none of the drug groups had a clearly superior effect, a more frequent positive effect with angiotensin converting enzyme inhibitors and beta-blockers was seen for all constructs. Narrower demographics and smaller sample sizes may have biased similar positive effects in calcium-channel blockers and diuretics.

A phase I trial of high-dose diaziquone and autologous bone marrow transplantation: an Illinois Cancer Council study

Diaziquone (AZQ), a synthetic quinone with demonstrated activity against acute nonlymphocytic leukemia (ANLL), primary CNS tumors, and non-Hodgkin's lymphoma (NHL), is virtually devoid of nonhematopoietic toxicity at conventional doses. As a prelude to its inclusion into bone marrow transplant (BMT) preparative regimens, a phase I study of high-dose AZQ with autologous BMT (ABMT) was performed. Patients with refractory solid tumors and lymphomas were treated with a single 24-hour infusion of AZQ at 50 to 355 mg/m2 in dose escalations of 20%. Fifty-six patients received 69 courses. Those receiving greater than 60 mg/m2 had nadir granulocyte and platelet counts less than 500/microL and 20,000/microL, respectively. Nausea, vomiting, stomatitis, and diarrhea were mild, transient, and not dose-related. Transient minimal elevations of liver function tests were seen in five patients and were also not dose-related. The maximally tolerated dose (MTD) of high-dose AZQ was found to be 245 mg/m2, with nephrotoxicity being dose-limiting. Significant azotemia was seen in four of 12 patients treated at 295 and 355 mg/m2, including fatal anuric renal failure in three of these patients. Reversible proteinuria also occurred in 24 of 26 courses above 150 mg/m2, including nephrotic range proteinuria in eight courses, all at doses of 205 to 355 mg/m2. The proteinuria was also associated with multiple proximal tubular defects including generalized aminoaciduria and proximal renal tubular acidosis. There were six early deaths including two of early renal failure (295 and 355 mg/m2), two of sepsis (205 and 245 mg/m2), one of a pulmonary embolus (85 mg/m2), and one of progressive disease (60 mg/m2). Of 50 patients who were assessable for response, there were seven responses including two of 10 with primary CNS tumors, one of 12 with malignant melanoma, one of five with non-small-cell lung carcinoma, two of two with breast carcinoma, and one of one with ovarian carcinoma. Because of its activity in ANLL and NHL and its unique toxicity spectrum, high-dose AZQ may improve the efficacy of current BMT preparative regimens without significantly increasing their nonhematopoietic toxicity.

Asymptomatic, nonketotic, severe hyperglycemia with hyponatremia

We describe five patients with asymptomatic, nonketotic, severe hyperglycemia (serum glucose concentrations between 45.8 and 92 mmol/L) in the face of renal insufficiency are described. As opposed to most of the previously described patients with hyperglycemic, nonketotic, hyperosmolar coma, our patients were hyponatremic. The lack of symptoms in our patients may be related to the absence of cerebral cellular dehydration. Aggressive treatment of hyperglycemia in such patients is unnecessary. Attention to the serum sodium level as well as to the serum glucose concentration will allow recognition of this clinical entity.

Nuclear magnetic resonance studies of lithium transport in erythrocyte suspensions of hypertensives

We have applied a nuclear magnetic resonance (NMR) method, based on the 7Li nucleus, to discriminate between intracellular and extracellular lithium ions (Li+) in red blood cell (RBC) suspensions. The NMR method was compared with atomic absorption, a technique that requires physical separation of intra- and extracellular Li+ prior to chemical analysis. The rates and rate constants of RBC Na(+)-Li+ countertransport measured by the 7Li NMR method correlated significantly with the measurements made by atomic absorption for both the hypertensive (r = 0.964) and control (r = 0.961) groups. The rates of RBC Na(+)-Li+ countertransport measured by NMR were significantly higher for hypertensive patients than for normotensive controls. The fact that the NMR method does not require cell membrane lysis, and its potential to reveal structural and mechanistic information on Li+ binding and transport in cellular systems, makes it promising for understanding the basis of Li+ transport variations in RBCs, and possibly other tissues, from hypertensive patients.

Pneumocystis carinii pneumonia: a lethal complication of "pulse" methylprednisolone therapy

A previously healthy, HIV-negative, 67-year-old man developed rapidly progressive glomerulonephritis. Following "pulse" methylprednisolone therapy he developed Pneumocystis carinii pneumonia. This complication should be recognized as a potential hazard of "pulse" steroid therapy.

Occurrence of renal tubular dysfunction in lupus nephritis

We prospectively evaluated 30 patients who presented with active systemic lupus erythematosus (SLE) for the presence of tubular abnormalities. All patients fulfilled the American Rheumatology Association criteria for SLE. When appropriate, a renal biopsy was performed. Of the 30 patients studied, 12 had no abnormal tubular study results, whereas 18 patients had some form of defect in the handling of potassium, sodium, or hydrogen ions. Eight patients had distal renal tubular acidosis (dRTA) due to an isolated proton secretory defect. Five had dRTA of the gradient or acid back-leak type. Two had an unresponsive voltage-dependent form of dRTA; one had a responsive voltage-dependent form of dRTA. One individual had hyporeninemic hypoaldosteronism and one had dRTA plus hypoaldosteronism. Clinically, patients with the abnormal tubular study results more often presented with nephritis or nephrotic sediment, peripheral edema, or anemia. Renal biopsies failed to demonstrate any difference in glomerular histologic findings and calculated activity, chronicity, or interstitial indexes. We conclude that SLE may be associated with a variety of tubular defects.

Myocardial infarction with normal results of coronary angiography following diltiazem withdrawal

Abrupt withdrawal of calcium channel blocking agents has been associated with symptoms of ischemic heart disease, but acute myocardial infarction has not been noted. Herein is described a severely uremic patient who had an acute myocardial infarction shortly after discontinuance of diltiazem, although results of subsequent coronary arteriography were normal. It is postulated that myocardial damage occurred because of increased intracellular calcium flux, augmented myocardial contractility, and/or drug withdrawal-related coronary spasm.

Hypertension, mineralocorticoid-resistant hyperkalemia, and hyperchloremic acidosis in an infant with obstructive uropathy

An 8-week-old infant with hypertension, hyperkalemia, and hyperchloremic acidosis, presumably due to chloride shunt type of distal renal tubular acidosis, is described. The patient's renin-aldosterone axis was intact. The infant was also found to have an obstructed solitary kidney. Despite correction of the obstruction and improvement in the glomerular filtration rate accompanied by normal development, hyperkalemia and renal tubular acidosis persisted. The defect was still demonstrable 9 months following relief of the obstruction. We conclude that neonatal obstructive uropathy can result in renal tubular acidosis of the chloride shunt type. The reversibility of this defect is, as yet, unknown.

Systemic lupus erythematosus presenting with hyporeninemic hypoaldosteronism in a 10-year-old girl

Hyperkalemia has been noted to occur spontaneously in patients with long-standing systemic lupus erythematosus who did not have advanced renal insufficiency. The patients previously described all had relatively normal renin-aldosterone systems, and the hyperkalemia was thus presumed to be secondary to a primary defect in renal tubular potassium secretion. We describe at 10-year-old girl with lupus nephritis, without significant renal insufficiency, who had hyperkalemia from hyporeninemic hypoaldosteronism postulated to be due to vasculitis involving the afferent/efferent arterioles and juxtaglomerular apparatus.

Red cell fragmentation syndrome with the use of subclavian hemodialysis catheters

The red cell fragmentation syndrome can occur due to abnormalities of the heart or the blood vessels or vascular malformations. We describe three patients who developed symptomatic hemolytic anemia due to red cell fragmentation with the use of single-lumen subclavian hemodialysis catheters. Retrospective analysis of 75 other patients who had undergone dialysis through this catheter disclosed five additional cases. Red cell fragmentation appears to be associated with partial catheter occlusion by thrombus or development of a clot at the catheter tip or both. The fragmentation resolved in all cases on withdrawal of the catheter. All patients with this catheter should be closely monitored for the red cell fragmentation syndrome, and the catheter should be withdrawn if it develops. White cell fragmentation was also seen in one patient.