Is it time to reconsider subcutaneous administration of epoetin?

Anemia treatment in nondialysis chronic kidney disease (ND-CKD) and dialysis CKD patients (D-CKD) has been recently scrutinized in the literature and by the lay press. New evidence suggests that patients receiving epoetin and achieving higher hemoglobin have a higher risk of death and cardiovascular complications. Data from the Centers for Medicare & Medicaid Services demonstrate upward spiraling costs of injectables, especially epoetin, in the care of CKD patients. There is considerable literature favoring the use of subcutaneous administration of epoetin compared to intravenous route in hemodialysis patients. Evidence clearly shows that the subcutaneous route achieves the target hemoglobin level at a lower administered dose. Thus, the same clinical effect can be achieved at a lower cost. Despite the economic and evidentiary justifications for subcutaneous administration of epoetin, adoption of this strategy has been limited, especially in the United States. Reasons include: inflexibility by dialysis providers because of reduced profitability, claims that patients oppose the subcutaneous route because of pain at the site of injection, concerns regarding pure red cell aplasia associated with subcutaneous administration, and greater hemoglobin cycling with the subcutaneous route. In this article, the advantages and disadvantages of the subcutaneous route are reviewed.     

Can dietary changes reduce blood pressure in the long term?

PURPOSE OF REVIEW: Recent dietary guidelines for the prevention and treatment of hypertension emphasized a healthy eating pattern called the Dietary Approaches to Stop Hypertension (DASH) diet, in addition to avoidance of obesity, high salt intake, and excessive alcohol intake. Our new challenge is to examine the long-term efficacy and effectiveness of dietary change, including the DASH diet, on blood pressure in the general population, or in a high-risk population. We reviewed recent short-term and long-term studies, both observational and interventional, which investigated whether dietary change can reduce blood pressure. RECENT FINDINGS: The efficacy of several nutrients has been investigated in short-term trials (e.g. polyunsaturated fatty acids, including omega-3 fatty acids, and trans fatty acids), but no substantial effect of these nutrients on blood pressure has been proved, except for dietary fiber. The PREMIER trial showed the effectiveness of implementing the DASH diet for 6 months in addition to the established recommendations on lifestyle modification, but other long-term trials of dietary modification did not show sufficient blood pressure reduction. However, long-term observational studies have shown that a higher intake of fruit and vegetables and a lower intake of red meat (except fish) can prevent higher blood pressure increase with age. SUMMARY: More effective programs of dietary modification are needed to achieve greater reduction of blood pressure. Long-term studies of population-wide dietary interventions to decrease the blood pressure level of a whole population are also needed.     

Zygoma fixture in the management of advanced atrophy of the maxilla: technique and long‐term results

Despite refinements in surgical technique, including bone grafting and sophisticated prosthetic reconstructions, there are limitations to what can be achieved with bone‐anchored fixed prostheses in patients with advanced atrophy of the maxillae. A new approach was suggested by a long‐term study on onlay bone grafting and simultaneous placement of a fixture based on a new design: the zygoma fixture, and the aim of this study was to assess its potential. Twenty‐eight consecutive patients with severely resorbed edentulous maxillae were included, 13 of whom had previously had multiple fixture surgery in the jawbone that had failed. A total of 52 zygoma fixtures and 106 conventional fixtures were installed. Bone grafting was deemed necessary in 17 patients. All patients have been followed for at least five years, and nine for up to 10 years. All patients were followed up with clinical and radiographic examinations, and in some cases rhinoscopy and sinoscopy as well. Three zygoma fixtures failed; two at the time of connection of the abutment and the third after six years. Of the conventional fixtures placed at the time of the zygoma fixture, 29 (27%) were lost. The overall prosthetic rehabilitation rate was 96% after at least five years of function. There were no signs of inflammatory reaction in the surrounding antral mucosa. Four patients with recurrent sinusitis recovered after inferior meatal antrostomy. To conclude, the zygoma fixture seems to be a valuable addition to our repertoire in the management of the compromised maxilla.     

Atypical HUS: time to take stock of current guidelines and outcome measures?

European guidelines for the assessment and management of atypical HUS were written in 2009. Since then our understanding of this group of diseases has advanced. Evidence is emerging that eculizumab, a monoclonal antibody inhibiting C5 activation, is effective, and potentially superior to current treatment with plasmapheresis. The evidence base for the benefits of plasmapheresis consists of case series and small reports. Before we embark on a change of management policy it is vital that we set up a system for genetic diagnosis, standardised protocols and a means to collect predetermined outcome measures, so that we do not make the same mistakes with assessment of the effectiveness of eculizumab as we did for plasmapheresis.     

Does concomitant vaginal prolapse repair affect the outcomes of the transobturator tape procedure in the long term?

Introduction and hypothesis

Little information is available on the effects of concomitant vaginal prolapse repair on the outcomes of the transobturator tape (TOT) procedure. The purpose of this study is to assess the results and complications of TOT when combined with vaginal prolapse repair with a long-term follow-up.

Methods

We conducted a retrospective cohort study of 232 female patients who underwent the TOT procedure at two institutions. There were two groups: group 1 consisted of patients who had undergone TOT alone and group 2 consisted of patients who had undergone concomitant vaginal prolapse repair. The outcomes were analyzed considering four postoperative parameters: objective cure, subjective cure, resolution of urgency urinary incontinence (UUI), and patient satisfaction. The mean follow-up was 66.3 months (range 60–85).

Results

A total of 117 patients in group 1 and 104 patients in group 2 were documented in this study. The subjective and objective cure rates were 87.17 %, 64.95 % in group 1 and 89.42 %, 68.26 % in group 2. Patient satisfaction rates (visual analog scale [VAS] score ≥80) were 71.79 and 83.65 % in groups 1 and 2 respectively (p?=?0.035). Complications were reported according to the Clavien–Dindo classification with grade I 7.7 %, grade II 69.2 %, grade IIIa 7.7 %, and grade IIIb 15.4 %, and grade I 9.5 %, grade II 47.6 %, grade IIIa 42.8 %, and grade IIIb 0 % in groups 1 and 2 respectively.

Conclusions

Concomitant vaginal prolapse repair with TOT does not have any negative effects on continence outcomes; on the contrary, it increases patient satisfaction.     

Significance of serum troponin T and C-reactive protein in the long?term prognosis of hemodialysis patients

Objective To investigate the long-term prognostic factors and the significance of serum cardiac troponin T (cTnT) and C-reactive protein (CRP) in maintenance hemodialysis (MHD) patients. Methods Clinical data of 76 MHD patients in our hospital from January 2002 to January 2003 were retrospectively analyzed. Time and cause of death in the next 10 years were recorded. Survival rate was calculated by Kaplan?Meier and impact factors of long-term prognosis were explored. Significance of cTnT and CRP was elucidated by COX regression analysis. Results CRP was positive in 28 cases (36.8%) and cTnT was positive in 22 cases (28.9%) among 76 patients. The median survival time was 37.9 months, 2-year survival rate was 65.9% and 10-year survival rate was 24.2%. Univariate analysis found positive CRP, positive cTnT, old age, diabetes, cardiocerebrovascular disease, anemia, low serum albumin, Kt/V decline were associated with long-term prognosis. Multivariate analysis showed that increased age (P＝0.010), cardiocerebrovascular disease (P＝0.048), positive cTnT (P＝0.036), positive CRP (P＝0.009) were independent risk factors of the 10-year survival of MHD patients. Ten-year mortality of cardiocerebrovascular diseases in positive cTnT group was not significantly different as compared with negative cTnT group (50.0% vs 35.4%, P＝0.248). But the positive cTnT group had higher 2-year mortality than negative cTnT group (40.9% vs 14.6%, P＝0.015). Mortality of cardiocerebrovascular disease was higher in positive CRP group as compared to negative CRP group at both 2-year and 10-year time (48.1% vs 7.0%, P＝0.000; 66.7% vs 23.3%, P＝0.000). Compared with both negative cTnT and CRP group, both positive cTnT and CRP group had much higher all-cause mortality (92.9% vs 55.6%, P＝0.030), higher mortality of cardiocerebrovascular disease at 10-year (64.3% vs 25.0%, P＝0.009), and higher mortality of cardiocerebrovascular disease at 2-year (57.1% vs 5.6%, P＝0.000). Conclusions Aging, cardiocerebrovascular disease, positive cTnT and positive CRP are independent risk factors of long-term prognosis for MHD patients. Positive cTnT can predict cardiocerebrovascular mortality of MHD patients in 2 years, while positive CRP can predict short- and long-term cardiocerebrovascular mortality. Positive cTnT combined with positive CRP may be more valuable in predicting the poor prognosis of MHD patients.     

Do AshSplit haemodialysis catheters provide better flow rates in the long term?

BACKGROUND: Recently, interventional radiologists have adopted an increasingly prominent role in the placement and management of hemodialysis catheters, as well as in the research and development of new and better catheters. The purpose of this study was to evaluate the viability and hemodialysis efficiency of the AshSplit catheter and the Permcath catheter. METHODS: 204 consecutive patients requiring radiological insertion of hemodialysis catheters were followed, retrospectively, over a 42-month period. Both hemodialysis catheters were placed using a combination of ultrasonic and fluoroscopic guidance and tunneled appropriately. Information collected included catheter insertion sites, insertion complications, catheter duration, and final outcome. RESULTS: Over the study period of two years, 269 catheters were placed into 204 patients with end stage renal failure. Patients received either an AshSplit (101 patients, 127 catheters) or a Permcath (103 patients, 142 catheters). Vascular access route of choice was the right internal jugular vein (67% AshSplit, 71% Permcath). Insertion complications occurred in 18 patients overall (6.6%), with only 1 requiring further intervention (hemopneumothorax). Flow rates averaged 259 mls/min for AshSplits and 248 mls/min for Permcaths (p < 0.001). Follow-up of catheter viability for 42 months yielded a mean AshSplit catheter duration of 246 days (range 6-932) and 239 days (range 1-1,278) for Permcath (p = 0.46). Reasons for catheter failure and elective catheter removal were similar in both groups; however, Permcaths required significantly more thrombolysis than AshSplits, p < 0.001. CONCLUSION: The AshSplit provides significantly better flow rates and less thrombolysis compared to the Permcath, with similar catheter dwell times.     

Palmar and dorsal fixed-angle plates in AO C-type fractures of the distal radius: is there an advantage of palmar plates in the long term?

Background

The aim of the present study was to compare the in vivo articulation of the healthy knee to the contralateral knee of subjects with acute and chronic PCL injuries.

Methods

Magnetic resonance was used to generate sagittal images of 10 healthy knees and 10 knees with isolated PCL injuries (5 acute and 5 chronic). The subjects performed a supine leg press against a 150 N load. Images were generated at 15 degree intervals as the knee flexed from 0 to 90 degrees. The tibiofemoral contact (TFC), and the centre of the femoral condyle (as defined by the flexion facet centre (FFC)), were measured from the posterior tibial cortex.

Results

There was no significant difference in the TFC and FFC between the healthy knee and contralateral knee of subjects with acute and chronic PCL injuries in the medial and lateral compartments of the knee.

Conclusions

The findings of this study suggest there is no predisposing articulation abnormality to PCL injury, in the setting of chronic injury the contralateral knee does not modify its articulation profile and the contralateral knee can be used as a valid control when evaluating the articulation of the PCL deficient knee.