Comparing outcomes in renal replacement therapy: how should we correct for case mix?

The need to evaluate the effectiveness of clinical practice to justify expensive therapy in the face of financial constraints in all areas of health care delivery makes it necessary to identify groups of patients who are likely to benefit most from treatment. Various risk stratification methods have been used for analyzing survival probabilities for patients receiving renal replacement therapy. Complicated risk stratification methods produce large numbers of risk groups of small sizes, which makes comparison between individual centers difficult. We compared three simple methods of risk stratification, that divided patients into low-, medium-, and high-risk groups, in a cohort of 1,407 patients who commenced renal replacement therapy in five European countries during a 7-year period. Method 1 considered age (>55 years) and diabetes alone; method 2 used a higher age limit (>70 years) and comorbid illnesses, including those other than diabetes; and method 3 used only the number of comorbidities (none, 1, or > or =2) for stratification. Kaplan-Meier survival curves were constructed for comparison between risk groups and Cox's regression model used to assess strength of relationship with mortality. Although patient survival was significantly different between the low-, medium-, and high-risk groups using all three methods, Cox's regression analysis showed that method 2 provided the greatest discrimination between risk groups. In predicting mortality, method 2 (based on comorbidities and age) showed the highest sensitivity and specificity (84% and 80%, respectively) compared with method 1 (80% and 74%) and method 3 (64% and 82%). Validation of this approach in other populations in a prospective study is required before this method, which takes into account the influences of both age and comorbidity for risk stratification, can be used for comparing survival data and for presenting results of renal replacement therapy.     

The combination of intravitreal triamcinolone and phacoemulsification surgery in patients with diabeticfoveal oedema and cataract

Background  

The management of diabetic patients with refractory macular oedema or patients with no adequate pre-operative view to administer laser treatment provide a challenge to the ophthalmologist. We wished to assess the use, safety and effect of intravitreal triamcinolone injection at the time of cataract surgery in patients with diabetic foveal oedema and sight limiting lens opacities.     

急性重度有机磷农药中毒32例的救治

0引言在急性重度有机磷农药中毒(AOPP)救治过程中,早期的内科常规处理,结合抗胆碱药及复能剂的应用,并积极进行肠道水疗,血液灌流,后期营养支持等综合救治,能提高AOPP在基层医院的抢救成功率、存活率.我院2000-3/2005-03收治32例重度AOPP患者,获得满意治疗效果.     

Delivery of normal twins following the intracytoplasmic injection of spermatozoa from a patient with 47,XXY Klinefelter's syndrome

Klinefelter's syndrome is a disorder of gonadal development and typically reveals a 47,XXY karyotype although mosaic forms also occur. Azoospermia is a common feature, but severe oligozoospermia and fertility have been reported. In this study, we have used intracytoplasmic sperm injection (ICSI) to achieve a live twin birth using spermatozoa from a 47,XXY man who has occasional spermatozoa present in the ejaculate. Spermatozoa were obtained from multiple ejaculates and frozen prior to commencing IVF treatment. Nine good quality embryos developed from the injection of 13 oocytes. All nine embryos were frozen. The initial transfer of two frozen-thawed embryos was unsuccessful. In the following cycle, the transfer of two additional frozen-thawed embryos resulted in the delivery of normal, healthy male and female twins. Five embryos remain frozen. It has generally been thought that the germ cells of 47,XXY men are unable to proceed through meiosis. Any spermatozoa produced have been assumed to come from a normal germ cell and therefore likely to have a normal karyotype. However, recent evidence suggests that meiosis of 47,XXY germ cells may be possible. Whether spermatozoa in these men arise from meiosis of 47,XXY germ cells, or from germ cells which have attained a normal karyotype by loss of an X chromosome, is unclear. Any risks in using spermatozoa from these patients have not yet been established. Patients need to be advised accordingly, and preimplantation or prenatal diagnosis should be considered. A cautious approach to the treatment of these patients is therefore warranted.      

Pressure ulcers in trauma patients with suspected spine injury: a prospective cohort study with emphasis on device‐related pressure ulcers

Of all patients in a hospital environment, trauma patients may be particularly at risk for developing (device‐related) pressure ulcers (PUs), because of their traumatic injuries, immobility, and exposure to immobilizing and medical devices. Studies on device‐related PUs are scarce. With this study, the incidence and characteristics of PUs and the proportion of PUs that are related to devices in adult trauma patients with suspected spinal injury were described. From January–December 2013, 254 trauma patients were visited every 2 days for skin assessment. The overall incidence of PUs was 28·3% (n = 72/254 patients). The incidence of device‐related PUs was 20·1% (n = 51), and 13% (n = 33) developed solely device‐related PUs. We observed 145 PUs in total of which 60·7% were related to devices (88/145). Device‐related PUs were detected 16 different locations on the front and back of the body. These results show that the incidence of PUs and the proportion of device‐related PUs is very high in trauma patients.     

Minimizing atelectasis formation during general anaesthesia—oxygen washout is a non-essential supplement to PEEP

Background: Following preoxygenation and induction of anaesthesia, most patients develop atelectasis. We hypothesized that an immediate restoration to a low oxygen level in the alveoli would prevent atelectasis formation and improve oxygenation during the ensuing anaesthesia.

Methods: We randomly assigned 24 patients to either a control group (n?=?12) or an intervention group (n?=?12) receiving an oxygen washout procedure directly after intubation. Both groups were, depending on body mass index, ventilated with a positive end-expiratory pressure (PEEP) of 6–8 cmH₂O during surgery. The atelectasis area was studied by computed tomography before emergence. Oxygenation levels were evaluated by measuring blood gases and calculating estimated venous admixture (EVA).

Results: The atelectasis areas expressed as percentages of the total lung area were 2.0 (1.5–2.7) (median [interquartile range]) and 1.8 (1.4–3.3) in the intervention and control groups, respectively. The difference was non-significant, and also oxygenation was similar between the two groups. Compared to oxygenation before the start of anaesthesia, oxygenation at the end of surgery was improved in the intervention group, mean (SD) EVA from 7.6% (6.6%) to 3.9% (2.9%) (P?=?.019) and preserved in the control group, mean (SD) EVA from 5.0% (5.3%) to 5.6% (7.1%) (P?=?.59).

Conclusion: Although the oxygen washout restored a low pulmonary oxygen level within minutes, it did not further reduce atelectasis size. Both study groups had small atelectasis and good oxygenation. These results suggest that a moderate PEEP alone is sufficient to minimize atelectasis and maintain oxygenation in healthy patients.     

Oral and intestinal Candida colonization in patients undergoing hematopoietic stem-cell transplantation

We investigated (1) the prevalence and quantity of, as well as risk factors for, orointestinal Candida colonization in patients undergoing hematopoietic stem-cell transplantation (HSCT) and (2) the genetic relatedness of colonizing C. albicans strains. Mouth-wash and stool samples were collected from 77 patients before they underwent HSCT and on days 1, 8, and 15 and were quantitatively cultured. C. albicans isolates were genotyped by microsatellite-marker analysis. The prevalence and quantity of orointestinal Candida colonization varied over time. In 48% (13/27) of multicolonized patients, the same Candida genotype was present in oral and intestinal samples. Oral colonization and decontamination of the gut by vancomycin and paromomycin were risk factors for intestinal Candida colonization.