‘Flexible’ or ‘lifestyle’ dialysis: Is this the way forward?

BACKGROUND: Despite the advent of two new dialysis options, nocturnal home haemodialysis and short daily haemodialysis, many units are yet to build them into the modalities on offer to end-stage renal failure patients. The reasons behind this inertia are complex but primarily include anxieties about workload, budgetary implications and outcome data. METHOD: The Geelong dialysis programme, where both nocturnal home haemodialysis and short daily haemodialysis are offered, is compared with Australian and New Zealand national profiles. RESULTS: Significant profile differences emerge when comparing sessions/week and h/week between the three groups. Most Australian (92.93%) and New Zealand (95.07%) haemodialysis patients dialyse for three sessions/week. This contrasts to Geelong where only 73.6% dialyse for three sessions/week. 18.8% of Geelong haemodialysis patients versus 1.8% (Australia) and 0.9% (New Zealand) dialyse for five or more sessions/week. Australia and New Zealand follow similar h/session patterns although more Australians (44.2%) dialyse for 4 h and fewer (24.2%) for 5 h than their New Zealand counterparts (39.6% and 29.8%, respectively), and few dialyse outside the 3.5-5 h window. In contrast, 6.7% of Geelong patients dialyse for 2-2.5 h/session versus Australia (0.9%) and New Zealand (0.2%). This represents the Geelong short daily dialysis programme. More Geelong patients (>15%) dialyse >/=8 h/week and represent the Geelong nocturnal home haemodialysis programme. CONCLUSION: The flexible Geelong programme has been supported without exceeding the budget applied to a conventional dialysis programme with the same patient numbers.     

Tetanus in patients with chronic wounds – are we aware?

The incidence of tetanus in patients with wounds is unknown; however, recently concern has been raised over the proportion of tetanus cases in which a chronic wound is the portal of entry for Clostridium tetani. Varicose ulcers, dermatosis and necrosed tumours are estimated to be the point of entry for C. tetani spores in 11-14% of three cases. Of diabetic patients in the USA who contracted tetanus, a diabetic foot ulcer was responsible in 25% of cases despite this chronic wounds have yet to be considered as a risk factor for tetanus. An audit was undertaken and a survey devised to form the basis of the data collection to assess if patients with chronic wounds are up-to-date in accordance with the tetanus immunisation programme. Over a 5-day period, the data were prospectively collected and the tetanus status of a 100 patients retrospectively analysed. The status was then compared with general practitioner (GP) records via telephone follow-up. One hundred patients (n = 100) were available in the audit period, with the majority being male (n = 51). The age range was 22-91 years old (median 70 years). Nearly half of the samples (n = 48) were diabetic, with the majority of patients (n = 35) having venous leg ulcers. Only 15% had a biopsy of their wound. The duration of wounds varied from 1 to 480 months. Patients were asked to confirm their tetanus status. Almost half of the patients were unsure of their tetanus status 48% (n = 48), almost a third 30% (n = 30) thought they were not covered and 22% (n = 22) thought they were up-to-date. After confirming with the GP records, the results were as follows: almost half of the patients, 43% (n = 43) were not covered, 33% (n = 33) were up-to-date, 13% had no immunisation records available at the GPs, 10% had no GP contact details and 1% no contact was possible. Currently, tetanus prophylaxis is given based on the vaccination history of the patient but as identified that this can prove to be unreliable. With the burden of chronic wound and ageing population set to increase, levels of protection amplify the risk of tetanus faced by those suffering from chronic wounds. Strict caution should be taken in those patients who were born before the national childhood vaccination programme, implemented in 1961. Moreover, every effort should be made to ensure that such individuals complete their primary course. By ensuring each patient is actively immunised, protection against tetanus, a potential killer, is provided.     

‘Protective premedication’: an option with gabapentin and related drugs?

Substantial progress has been made during the last decades in our understanding of acute pain mechanisms, and this knowledge has encouraged the search for novel treatments. Of particular interest has been the observation that tissue injury initiates a number of modulations of both the peripheral and the central pain pathways, which convert the system from a 'physiological' to a 'pathological' mode of processing afferent information. Gabapentin, which binds to the alpha(2)delta subunit of the voltage-dependent calcium channel, is active in animal models of 'pathological' but not in models of 'physiological' pain. Consequently, attention has so far been focused on neuropathic pain as a target for the clinical use of gabapentin and analogues. Recently, several reports have indicated that gabapentin may have a place in the treatment of post-operative pain. This article presents a brief summary of the potential mechanisms of post-operative pain, and a systematic review of the available data of gabapentin and pregabalin for post-operative analgesia. It is concluded that the results with gabapentin and pregabalin in post-operative pain treatment published so far are promising. It is suggested that future studies should explore the effects of 'protective premedication' with combinations of various antihyperanalgesic and analgesic drugs for post-operative analgesia.     

‘Insignificant’ prostate cancer on prostatectomy and cystoprostatectomy: variation on a theme ‘low‐volume/ low‐grade’ prostate cancer?

Although ‘insignificant’ prostate cancer has been examined separately in radical prostatectomy (RP) and radical cystoprostatectomy (RCP) studies, it is not entirely clear whether cancers designated as ‘insignificant’ on RP and RCP represent the same, similar or different forms of prostate cancer. Insignificant prostate cancer has been traditionally defined based on the pathological findings in the whole prostate gland. In addition to the pathological determinants of ‘insignificant’ prostate cancer, it is also important to account for the biological and the clinical context of the disease, as well as patient age and health status to designate a prostate cancer ‘insignificant’. This review examines and compares prostate cancers described as ‘insignificant’ on RP and RCP. We conclude that in most cases these low‐volume/low‐grade prostate cancers represent an early stage and clinically ‘silent’ disease, which are only detected in different clinical settings.