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.