Quality of life on chronic dialysis: comparison between haemodialysis and peritoneal dialysis.

BACKGROUND: Quality of life (QOL) assessment in patients on chronic haemodialysis (HD) or peritoneal dialysis (PD) has only rarely been carried out with the generic Euroqol-5D questionnaire. METHODS: All chronic HD and PD patients in the 19 centres of western Switzerland were requested to fill in the validated Euroqol-5D generic QOL questionnaire, assessing health status in five dimensions and on a visual analogue scale, allowing computation of a predicted QOL value, to be compared with the value measured on the visual analogue scale. RESULTS: Of the 558 questionnaires distributed to chronic HD patients, 455 were returned (response rate 82%). Fifty of 64 PD patients (78%) returned the questionnaire. The two groups were similar in age, gender and duration of dialysis treatment. Mean QOL was rated at 60+/-18% for HD and 61+/-19% for PD, for a mean predicted QOL value of 62+/-30 and 58+/-32% respectively. Results of the five dimensions were similar in both groups, except for a greater restriction in usual activities for PD patients (P = 0.007). The highest scores were recorded for self-care, with 71% HD and 74% PD patients reporting no limitation, and the lowest scores for usual activities, with 14% HD and 23% PD patients reporting severe limitation. Experiencing pain/discomfort (for HD and PD) or anxiety/depression (for PD) had the highest impact on QOL. CONCLUSIONS: QOL was equally diminished in HD and PD patients. The questionnaire was well accepted and performed well. Improvement could be achievable in both groups if pain/discomfort and anxiety/depression could be more effectively treated.     

An economic analysis of hormone replacement therapy for the prevention of fracture in young postmenopausal women

Osteoporosis is a major public health problem that will become increasingly important as our population ages. It leads to fractures that deeply affect the patients' quality of life. Osteoporosis is recognised as a leading factor in healthcare cost worldwide. For years, experts have recommended hormone replacement therapy (HRT), consisting of oestrogen with or without progestin, as the first-line therapy to prevent bone loss in postmenopausal women. Recently published randomised, controlled trials and well-designed meta-analyses confirm that HRT has both advantages and disadvantages. The advantages include prevention of osteoporotic fractures and colorectal cancer. The disadvantages are the resulting adverse effects such as coronary artery disease, stroke, thromboembolic events, breast cancer and cholecystitis. In the light of these findings, medical associations recommend against the routine use of oestrogen and progestin for the prevention of chronic conditions in postmenopausal women. HRT, administered for the prevention of fractures in all young postmenopausal women, would have an additional cost/year of life gained that is too expensive. However, this strategy seems to be cost-effective when young postmenopausal women at high risk for fractures are selected. Even if this strategy seems attractive, the adverse effects of HRT are not acceptable. This situation implies that other treatments must be found to prevent or treat osteoporosis. Among them, calcium and vitamin D were shown to be cost-saving in osteoporosis and even costs-effective in osteopoenia in young postmenopausal women.     

ACE inhibitors or angiotensin II receptor blockers in dialysed patients and erythropoietin resistance

BACKGROUND: To examine whether angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) are associated with a state of recombinant human erythropoietin (rHuEPO) resistance in hemodialyzed patients. METHODS: Cross-sectional study involving all dialysis facilities in French-speaking Switzerland. All patients treated with rHuEPO in March 2001 were included. Demographic, clinical and laboratory data were collected in 515 patients treated with chronic hemodialysis (HD) and rHuEPO. Patients were classified into five groups according to their antihypertensive treatment. The main outcomes of the study were the mean rHuEPO dosage and the prevalence of erythropoietin EPO resistance among the groups. Erythropoietin resistance was defined as a weekly rHuEPO dosage >300 units/kg/wk. RESULTS: The mean rHuEPO dosage and the prevalence of EPO resistance were similar in patients treated with ACEIs (n = 138, mean EPO dosage 109 units/kg/wk, EPO resistance 12%), ARBs (n = 59, mean EPO dosage 120 units/kg/wk, EPO resistance 7%), both (n = 10, mean EPO dosage 109 units/kg/wk, EPO resistance 10%), other drugs (n = 137, mean EPO dosage 110 units/kg/wk, EPO resistance 10%) and no antihypertensive treatment (n = 171, mean EPO dosage 90 units/kg/wk, EPO resistance 9%). Differences were not statistically significant. Patients with rHuEPO resistance were characterized by a higher frequency of hospitalization and a more pronounced inflammatory state. There was no difference in the use of ACEIs and ARBs between patients with and without EPO resistance (37 vs. 41%, ns). CONCLUSIONS: Neither the use of ACEIs nor ARBs is associated with a state of rHuEPO resistance among hemodialyzed patients.     

Three years of haemovigilance in a general university hospital

The aim of this study is to describe a newly implemented haemovigilance system in a general university hospital. We present a series of short cases, highlighting particular aspects of the reports, and an overview of all reported incidents between 1999 and 2001. Incidents related to transfusion of blood products were reported by the clinicians using a standard preformatted form, giving a synopsis of the incident. After analysis, we distinguished, on the one hand, transfusion reactions, that are transfusions which engendered signs or symptoms, and, on the other hand, the incidents where management errors and/or dysfunctions took place. Over 3 years, 233 incidents were reported, corresponding to 4.2 events for 1000 blood products delivered. Of the 233, 198 (85%) were acute transfusion reactions and 35 (15%) were management errors and/or dysfunctions. Platelet units gave rise to statistically (P < 0.001) more transfusion reactions (10.7 per thousand ) than red blood cells (3.5 per thousand ) and fresh frozen plasma (0.8 per thousand ), particularly febrile nonhaemolytic transfusion reactions and allergic reactions. A detailed analysis of some of the transfusion incident reports revealed complex deviations and/or failures of the procedures in place in the hospital, allowing the implementation of corrective and preventive measures. Thus, the haemovigilance system in place in the 'Centre Hospitalier Universitaire Vaudois, CHUV' appears to constitute an excellent instrument for monitoring the security of blood transfusion.     

Is early endoscopy in the emergency room beneficial in patients with bleeding peptic ulcer? A "fortuitously controlled" study

BACKGROUND AND STUDY AIMS: In previous randomized trials, early endoscopy improved the outcome in patients with bleeding peptic ulcer, though most of these studies defined "early" as endoscopy performed within 24 hours after admission. Using the length of hospital stay as the primary criterion for the clinical outcome, we compared the results of endoscopy done immediately after admission (early endoscopy in the emergency room, EEE) with endoscopy postponed to a time within the first 24 hours after hospitalization, but still during normal working hours ("delayed" endoscopy in the endoscopy unit, DEU). PATIENTS AND METHODS: We conducted a retrospective analysis of data from 81 consecutive patients with bleeding peptic ulcer admitted in 1997 and 1998 (age range 16 - 90 years). Of these 81 patients, 38 underwent DEU (the standard therapy at the hospital) and 43 underwent EEE. Patients in the two groups were comparable with regard to admission criteria, were equally distributed with respect to their risk of adverse outcome (assessed using the Baylor bleeding score and the Rockall score), and differed only in the treatment they received. Endoscopic hemostasis was performed whenever possible in all patients with Forrest types I, IIa, and IIb ulcer bleeding. RESULTS: We found similar rates in the two groups for recurrent bleeding (16 % in DEU patients vs. 14 % in EEE patients), persistent bleeding (8 % in DEU patients vs. none in EEE patients), medical complications (21 % in DEU patients vs. 26 % in EEE patients), the need for surgery (8 % in DEU patients vs. 9 % in EEE patients), and the length of hospital stay (5.1 days for DEU patients vs. 5.9 days for EEE patients). None of the differences between the two groups in these parameters were statistically significant. None of the patients died. CONCLUSIONS: Early endoscopy in an emergency room did not improve the clinical outcome in our 81 consecutive patients with bleeding peptic ulcer.