Longer treatment time and slower ultrafiltration in hemodialysis: associations with reduced mortality in the DOPPS

Longer treatment time (TT) and slower ultrafiltration rate (UFR) are considered advantageous for hemodialysis (HD) patients. The study included 22,000 HD patients from seven countries in the Dialysis Outcomes and Practice Patterns Study (DOPPS). Logistic regression was used to study predictors of TT > 240 min and UFR > 10 ml/h/kg bodyweight. Cox regression was used for survival analyses. Statistical adjustments were made for patient demographics, comorbidities, dose of dialysis (Kt/V), and body size. Europe and Japan had significantly longer (P < 0.0001) average TT than the US (232 and 244 min vs 211 in DOPPS I; 235 and 240 min vs 221 in DOPPS II). Kt/V increased concomitantly with TT in all three regions with the largest absolute difference observed in Japan. TT > 240 min was independently associated with significantly lower relative risk (RR) of mortality (RR = 0.81; P = 0.0005). Every 30 min longer on HD was associated with a 7% lower RR of mortality (RR = 0.93; P < 0.0001). The RR reduction with longer TT was greatest in Japan. A synergistic interaction occurred between Kt/V and TT (P = 0.007) toward mortality reduction. UFR > 10 ml/h/kg was associated with higher odds of intradialytic hypotension (odds ratio = 1.30; P = 0.045) and a higher risk of mortality (RR = 1.09; P = 0.02). Longer TT and higher Kt/V were independently as well as synergistically associated with lower mortality. Rapid UFR during HD was also associated with higher mortality risk. These results warrant a randomized clinical trial of longer dialysis sessions in thrice-weekly HD.     

Intubation routes for enteroclysis

The transnasal and peroral intubation routes for enteroclysis examination are described. A survey of 22 patients who underwent enteroclysis by both approaches revealed an overwhelming preference for the transnasal route. Transnasal intubation for enteroclysis is rapidly performed with adequate catheter control and in most patients is associated with less discomfort compared with the peroral route.     

Absolute ethanol injection of the adrenal artery: hypertensive reaction

Transcatheter injection of 0.4 ml of absolute ethanol into the adrenal artery was performed in three Rhesus monkeys. The injection produced a mean increase of 60 mmHg in systolic blood pressure and 50 mmHg in diastolic blood pressure within two minutes. Hypertension was accompanied by cardiac arrhythmias (two monkeys) and sinus tachycardia (one monkey). These changes were probably related to an acute catecholamine release. Embolization of the inferior phrenic artery with Gelfoam powder produced only a mild blood pressure elevation in three monkeys (6 mmHg systolic pressure and 10 mmHg diastolic pressure).     

Regulation of hematopoiesis: helper and suppressor influences of the thymus

Thymocytes from normal mice strains as well as from genetically determined stem cell defective W/Wv anemic mice were cocultured with syngeneic (or congeneic) bone marrow cells. We assayed these cocultures for the proliferation of erythroid progenitor cell types (BFU-E and CFU- E) using the plasma clot technique. Results indicate that when concentrations of thymocytes were lower than bone marrow cells, significant suppression of erythroid growth was observed. However, when the concentration of thymocytes exceeded that of the bone marrow cells in culture (greater than 1:1), significant enhancement of erythroid growth was demonstrated. The W/Wv anemic bone marrow appears to respond to this interaction by enhancement at all concentrations of added normal thymocytes. The regulatory functions observed can be diminished by treatment of the thymocytes in vitro with anti-theta serum plus complement. Thus, we establish regulatory functions for anti-theta- sensitive regulatory cells (TSRC) with both positive (enhancement) and negative (suppression) components.     

Percutaneous aspiration, drainage, and biopsies in children

Percutaneous aspiration, drainage, and biopsy techniques can be performed safely and effectively in infants and children. Over the past 4 years we performed 11 aspiration, nine drainage, and 14 biopsy procedures in patients aged 1 day to 17 years. Success was achieved in 88% and 93% of drainages and biopsies, respectively. Our experience suggests that aspiration and drainage procedures are effective in the diagnosis and management of fluid collections and are often the only procedure required and that percutaneous biopsy techniques are applicable to the pediatric population.     

Total body irradiation and high-dose etoposide: a new preparatory regimen for bone marrow transplantation in patients with advanced hematologic malignancies [published erratum appears in Blood 1987 Jun;69(6):1789]

In a phase I/II study, 47 patients (median age, 24 years) with hematologic malignancies (33 patients with acute leukemia not in first remission and 14 patients with other advanced malignant hematologic disorders) were treated with total body irradiation and high doses of etoposide (VP16-213) followed by bone marrow transplantation. At the time of analysis, 21 patients were alive, and 19 of them were in continued complete remission for 101 days to greater than 40 months (median, 12 months). The actuarial disease-free survival rate of the 33 acute leukemia patients is 43% (2 SEM, 18%) and the actuarial relapse rate is 32% (2 SEM, 20%). Five of the 14 patients with the other hematologic malignancies are alive, and four of them continue to be free of disease for 8 to 27 months. Pharmacokinetic studies established a strong correlation between the administered drug doses and their plasma levels and also demonstrated complete drug clearance prior to marrow grafting. An etoposide dose of 60 mg/kg body weight was found to be the maximum tolerated dose. This new preparatory regimen was well tolerated and was not associated with specific acute or long-term regimen-related toxicities. Our data suggest that total body irradiation with high-dose etoposide presents a viable alternative to other preparatory regimens. The role of this novel combination remains to be defined by future prospective randomized trials.     

Craniosynostosis: image quality, confidence, and correctness in diagnosis

The authors used the diagnosis of craniosynostosis to compare subjective evaluation of image quality with objective diagnostic utility. They studied in detail the responses of one observer, who read plain radiographs, computed tomographic (CT) scans, and three-dimensional reconstructions of CT scans (obtained with three different methods) for 82 patients with this diagnosis. The observer rated image quality and certainty in diagnosis made from each image. Subjective and objective performances were found to be strongly linked. High-quality images served as the basis for more accurate diagnoses than low-quality images. The increase in diagnostic performance results primarily from increased specificity, a fact that suggests that specificity and the concomitant diagnosis of normalcy are the focus of attention when image quality is evaluated.