National survey of palliative care in end-stage renal disease in the UK.

BACKGROUND: Palliative care for patients with end-stage renal disease (ESRD) is a neglected aspect of nephrology. We carried out this survey to establish the current pattern of provision of palliative care for ESRD in the UK. METHODS: An anonymous but numbered questionnaire concerning local palliative care provision was sent to clinical directors of all 69 UK renal units. RESULTS: All the questionnaires were returned. Only 27 (39%) units employ nursing or Professions Allied to Medicine (PAM) staff with palliative care for ESRD patients as a specified part of their role. In 19 of these units, staff spend <4 h per week concerned with palliative care and only five units have staff working for >12 h a week in this role. Fifty-five (80%) units do not have a written protocol for palliative care. Anaemic ESRD patients with an expected survival of >3 months receive blood transfusion in 59 (86%) units, intravenous iron in 61 (88%) units and erythropoietin in 63 (91%) units. Only 37 (54%) units kept a record of patients seen by the unit staff but deemed not suitable for dialysis. CONCLUSION: There is a significant variation in provision of palliative care services across the UK. In some areas, access to palliative care is restricted to patients with malignant disease, and ESRD patients are excluded.     

Chilaiditi syndrome with eventration of the diaphragm: A rare coexistence

Simultaneous coexistence of Chilaiditi syndrome along with eventration of the diaphragm is a rare occurrence. We present a case of this rare occurrence in a 41 year old male patient who presented with respiratory distress.     

Peripheral venous access ports: Outcomes analysis in 109 patients

Purpose: To perform a retrospective outcomes analysis of central venous catheters with peripheral venous access ports, with comparison to published data. Methods: One hundred and twelve central venous catheters with peripherally placed access ports were placed under sonographic guidance in 109 patients over a 4-year period. Ports were placed for the administration of chemotherapy, hyperalimentation, long-term antibiotic therapy, gamma-globulin therapy, and frequent blood sampling. A vein in the upper arm was accessed in each case and the catheter was passed to the superior vena cava or right atrium. Povidone iodine skin preparation was used in the first 65 port insertions. A combination of Iodophor solution and povidone iodine solution was used in the last 47 port insertions. Forty patients received low-dose (1 mg) warfarin sodium beginning the day after port insertion. Three patients received higher doses of warfarin sodium for preexistent venous thrombosis. Catheter performance and complications were assessed and compared with published data. Results: Access into the basilic or brachial veins was obtained in all cases. Ports remained functional for a total of 28,936 patient days. The port functioned in 50% of patients until completion of therapy, or the patient's expiration. Ports were removed prior to completion of therapy in 18% of patients. Eleven patients (9.9% of ports placed) suffered an infectious complication (0.38 per thousand catheter-days)—in nine, at the port implantation site, in two along the catheter. In all 11 instances the port was removed. Port pocket infection in the early postoperative period occurred in three patients (4.7%) receiving a Betadine prep vs two patients (4.2%) receiving a standard O.R. prep. This difference was not statistically significant (p = 0.9). Venous thrombosis occurred in three patients (6.8%) receiving warfarin sodium and in two patients (3%) not receiving warfarin sodium. This difference was not statistically significant (p = 0.6). Aspiration occlusion occurred in 13 patients (11.7%). Intracatheter urokinase was infused in eight of these patients and successfully restored catheter function in all but two instances. These complication rates are comparable to or better than those reported with chest ports. Conclusion: Peripheral ports for long-term central venous access placed by interventional radiologists in the interventional radiology suite are as safe and as effective as chest ports.     

Groin pain after a tension-free vaginal tape or similar suburethral sling: management strategies

OBJECTIVE

To review different treatment strategies for women with groin pain after tension‐free vaginal tape (TVT) or similar suburethral sling procedures.

PATIENTS AND METHODS

The series comprised 450 women who had a TVT procedure, with a follow‐up of 3–50 months. Five women (1%) reported significant groin pain and were offered further treatment. In addition, one woman was referred from another centre and received treatment.

RESULTS

Women with pain were initially treated conservatively, and in most the pain resolved and required no further treatment. Persistent or severe discomfort was treated with a combined steroid (methyl prednisolone, 2 mL, 80 mg) and local anaesthetic (bupivacaine, 10 mL, 0.5%) injection in four women. There were no side‐effects from the treatment. One woman was relieved of her pain and required no further treatment. In one woman the local injections failed to improve her symptoms but the pain was not severe enough to warrant further treatment. Two women developed recurrent pain after an initially successful injection, and in these women the TVT was excised. One woman referred from another centre was primarily treated with TVT excision. In the three women treated with distal tape excision, the mean pain scores decreased from 8.7 before excision to 0.7 afterward. One woman is awaiting tape excision.

CONCLUSION

If conservative management fails to relieve the symptoms of groin pain it can be treated by injecting a mixture of steroid and local anaesthetic. However, local injection failed to provide long‐term relief in three of four women. More severe symptoms might require TVT mesh dissection and excision, which provided significant pain relief.

     

Carbon monoxide protects against ischemia-reperfusion injury in an experimental model of controlled nonheartbeating donor kidney

BACKGROUND: CO-releasing molecule-3 (CORM-3) is a transitional metal carbonyl that liberates carbon monoxide under appropriate conditions. Carbon monoxide exerts effects on intracellular apoptotic and inflammatory pathways, which suggest a role in reducing the effects of renal ischemia/reperfusion (I/R) injury. This study investigated the effects of CORM-3 administered at the time of reperfusion in a model of controlled nonheartbeating donor kidneys. METHODS: Porcine kidneys (n=4) were subjected to 10 min warm ischemia and 18 hr cold storage (CS) and then treated as follows: CORM-3 (50, 100, 200, and 400 microM doses), iCORM-3 (inactive carbon monoxide-releasing molecule, 50 microM), and control (no further intervention). Renal hemodynamics and function were then measured during 3-hr reperfusion with autologous blood using an isolated organ-perfusion system. RESULTS: CORM-3 at a concentration of 50 microM improved renal blood flow (RBF) compared with the iCORM and control groups (area under the curve 774+/-19 vs. 448+/-88 vs. 325+/-70, respectively, P=0.002). CO-releasing molecule-3 at a concentration of 50 microM also improved renal function during reperfusion with a greater area under the curve for creatinine clearance (CORM-3: 14+/-6 vs. iCORM: 3.3+/-0.1 vs. control: 2.2+/-2 mL/min, P=0.006) and higher urine output (CORM-3: 793+/-212 vs. iCORM: 368+/-72 vs. control: 302+/-211 mL, P=0.01). CO-releasing molecule-3 at a concentration of 100 microM exerted similar effects. Treatment with CORM-3 at higher doses (200 and 400 microM) led to poor renal hemodynamics and function after reperfusion. CONCLUSION: Low-dose CORM-3 significantly ameliorates the effects of ischemia/reperfusion in a porcine model of controlled nonheartbeating donor kidney transplantation.     

Peritonitis – the Eastern experience

Peritonitis is a common emergency encountered by surgeons the world over. This paper aims to provide an overview of the spectrum of peritonitis seen in the East. Studies dealing with the overall spectrum of secondary peritonitis in various countries of this region were identified using Pubmed and Google. These were analyzed for the site and cause of perforation and the mortality. It was observed that perforation of duodenal ulcers was the most the commonly encountered perforations. These are followed by small bowel and appendicular perforations. Colonic perforations were uncommon. The overall mortality ranges between 6–27%.     

Impact of Common Variants of PPARG, KCNJ11, TCF7L2, SLC30A8, HHEX, CDKN2A, IGF2BP2, and CDKAL1 on the Risk of Type 2 Diabetes in 5,164 Indians

OBJECTIVE

Common variants in PPARG, KCNJ11, TCF7L2, SLC30A8, HHEX, CDKN2A, IGF2BP2, and CDKAL1 genes have been shown to be associated with type 2 diabetes in European populations by genome-wide association studies. We have studied the association of common variants in these eight genes with type 2 diabetes and related traits in Indians by combining the data from two independent case–control studies.

RESEARCH DESIGN AND METHODS

We genotyped eight single nucleotide polymorphisms (PPARG-rs1801282, KCNJ11-rs5219, TCF7L2-rs7903146, SLC30A8-rs13266634, HHEX-rs1111875, CDKN2A-rs10811661, IGF2BP2-rs4402960, and CDKAL1-rs10946398) in 5,164 unrelated Indians of Indo-European ethnicity, including 2,486 type 2 diabetic patients and 2,678 ethnically matched control subjects.

RESULTS

We confirmed the association of all eight loci with type 2 diabetes with odds ratio (OR) ranging from 1.18 to 1.89 (P = 1.6 × 10⁻³ to 4.6 × 10⁻³⁴). The strongest association with the highest effect size was observed for TCF7L2 (OR 1.89 [95% CI 1.71–2.09], P = 4.6 × 10⁻³⁴). We also found significant association of PPARG and TCF7L2 with homeostasis model assessment of β-cell function (P = 6.9 × 10⁻⁸ and 3 × 10⁻⁴, respectively), which looked consistent with recessive and under-dominant models, respectively.

CONCLUSIONS

Our study replicates the association of well-established common variants with type 2 diabetes in Indians and shows larger effect size for most of them than those reported in Europeans.Type 2 diabetes is a complex metabolic disorder with both genetic and environmental factors such as food habits and lifestyle contributing to its pathogenesis (1). Due to its complex etiology, the progress of discovery of genetic components for type 2 diabetes had been very slow until the advent of high throughput genome-wide association (GWA) studies (2). Until recently, only a few common variants in PPARG (3), KCNJ11 (4), and TCF7L2 (5) were shown to be associated with type 2 diabetes. With the advent of GWA studies, there are at least 20 loci identified today that are associated with the risk of type 2 diabetes (6). The first GWA study in the French population revealed SLC30A8 and HHEX as new loci for type 2 diabetes in addition to replicating the strong association with TCF7L2 (7). Further, GWA studies added several new genes including CDKAL1, CDKN2A, IGF2BP2, and FTO to the list of type 2 diabetes–associated loci and confirmed the associations for PPARG, KCNJ11, and TCF7L2 (8–12).India harbors the maximum number of diabetic patients, which is projected to double by the year 2030 (13). Indians are diagnosed with diabetes a decade earlier and at a lower BMI than Europeans, which may be partly explained by their excess central obesity (14,15). Hence, determination of genetic risk factors predicting the risk of type 2 diabetes in the Indian population is highly desirable. Recent evidence suggests that the genetic basis of several diseases in Indians might be different from that of Europeans (16,17), which could be due to differences in the risk allele frequency and pattern of linkage disequilibrium. A report from the Indian Genome Variation Consortium also suggested that most of the populations in the Indian subcontinent are distinct from HapMap populations (18). Hence, genes associated with a disease in other populations need to be assessed for their role in the Indian population. The present study evaluated the association of eight most replicated and well-established genetic variants of PPARG, KCNJ11, TCF7L2, SLC30A8, HHEX, CDKN2A, IGF2BP2, and CDKAL1 with type 2 diabetes and related quantitative traits in Indians. We also performed allele dosage analysis of these variants and investigated their influence on quantitative metabolic traits related to type 2 diabetes.