Going beyond the Kidney Disease Outcomes Quality Initiative: Hemodialysis Access Experience at Kaiser Permanente Southern California

In 1996, as part of Kaiser Permanente Southern California’s participation in the Medicare End-Stage Renal Disease Managed Care Demonstration Project, a multidisciplinary continuous quality improvement (CQI) committee was formed, which included nephrologists, vascular surgeons, interventional radiologists, care managers, a renal quality-improvement nursing director, and renal program administrators. The goal of this report was to analyze the impact of this CQI program on hemodialysis outcomes within the organization. Kaiser Permanente is a national, integrated, nonprofit, staff model health maintenance organization with 8 million members. The southern California region has 3.1 million members and currently manages the health care of 3,700 hemodialysis patients, 300 peritoneal dialysis patients, and 1,000 kidney transplant patients. Thirty-one vascular surgeons and 29 interventional radiologists provide for their hemodialysis access needs. The Kidney Disease Dialysis Outcomes Quality Initiative (K/DOQI) guidelines were adopted, as well as measures to perform more venous transpositions and less common arteriovenous fistulas (AVFs) before graft placement. The outcomes assessed included incidence and prevalence of AVFs, grafts, and catheters; replacement access with AVFs; and combined AVF and graft thrombosis episodes per patient per year. Primary AVF incidence rates increased from 27% in 1997 to 88% in 2003. AVF prevalence rates increased from 30% in 1997 to 62% in 2003. Replacement access which is an AVF increased from 26% in 1998 to 58% in 2003. Yearly thrombosis episodes/patient decreased from 0.62 in 1998 to 0.34 in 2003. Catheter usage as of 2003 comprised an incidence of 65% and prevalence (≥90 days) of 13%, which was essentially unchanged from 1999, despite improvements in fistula usage and thrombosis rate. The rate of AVF prevalence can be increased dramatically, exceeding the 40% K/DOQI recommendation, by using the CQI process. Increased prevalence of AVF is associated with a lower yearly incidence of thrombosis episodes/patient. Reducing excessive catheter usage appears to be a more difficult problem. Presented at the Twenty-second Annual Meeting of the Southern California Vascular Surgical Society, San Diego, CA, May 1, 2004.     

Idiopathic Hypertrophie Pyloric Stenosis : Our Experience

Background

A typical infant with idiopathic hypertrophic pyloric stenosis is described as a male child, first in the order of birth with a positive family history. However our experience suggests otherwise which is presented in this report. Methods : A retrospective analysis of medical records of 8 infants, who were diagnosed to be suffering from idiopathic hypertrophic pyloric stenosis and subjected to surgical treatment, was undertaken.

Results

There were 5 (62.5%) males and 3 (37.5%) females. There was no family history and only one child (12.5%) was first born in the order of birth. One infant was preterm and one case (12.5%) had associated congenital anomaly (single kidney). Definitive diagnosis was established in 6 (75%) babies at admission whereas, other 2 cases (25%) required further evaluation. All the infants were in a state of moderate dehydration and in a varying state of hypochloremic alkalosis. The pH and serum chloride levels ranged from 7.52 to 7.67 and 86-94 mmol/L respectively. All were subjected to traditional Ramstedt''s pyloromyotomy after having undergone vigorous correction of fluids and electrolytes for 24-48 hours. Intraoperatively, there was one iatrogenic mucosal perforation, which was closed with an omental patch. Postoperative feeding was initiated 12 hrs after surgery in 6 (75%) babies.

Conclusion

Our series suggests a clinical profile of hypertrophic pyloric stenosis in our subset of patients which is different from what is described in literature.Key Words: Idiopathic hypertrophic pyloric stenosis, Pyloromyotomy     

Differentials and Determinants of Syndrome ‘X’ and its Role as Coronary Risk among Healthy Middle Aged Indian Army Personnel

Background

Syndrome ‘X’, a clustering of impaired glucose tolerance (IGT), raised blood pressure, raised serum triglycerides and low HDL-cholesterol, occurring under the influence of insulin resistance and resultant hyperinsulinaemia, has been hypothesised to be a major risk factor for ischaemic heart disease (IHD). However, there is a lack of research based evidence in this field, in our country.

Methods

The study was a cross-sectional analytical epidemiological design of 614 healthy Indian Army personnel, aged 35 years and above, selected by random sampling.

Results

The study indicated that there is a statistically significant (p < 0.001) clustering between fasting hyperinsulinaemia, raised blood pressure, IGT, raised triglycerides and low HDL. The prevalence of syndrome ‘X’ was 8.47% (95% CI 6.27% to 10.47%). Initial univariate and subsequent multivariate analysis using multiple logistic regression method, indicated that predictors of syndrome ‘X’ were increasing age, overweight, increasing central (abdominal) obesity, lack of adequate physical exercise and low level of physical fitness. Presence of syndrome ‘X’ increased the risk of resting ECG changes suggestive of coronary insufficiency (OR = 6.29, p < 0.001).

Conclusion

Based on the findings, recommendations for prevention of this syndrome have been submitted.Key Words: Syndrome ‘X’, Insulin resistance syndrome, Ischaemic heart disease, Coronary Risk factors, Military personnel     

MRSA in urology: a UK hospital experience

OBJECTIVE: Methicillin-resistant Staphylococcus aureus (MRSA) infection appears to be increasing, the UK has one of the worst MRSA rates in Europe. As urological patients are at high risk, the aim of this study was to determine the number of newly diagnosed cases of MRSA detected in a urology ward. PATIENTS AND METHODS: The urology department serves an annual local population of greater than 500,000 with 30 inpatient beds and a tertiary population of 1 million. Over a five year period, we retrospectively recorded all patients with a new diagnosis of MRSA. We also determined colonization site and if the diagnosis of MRSA was made in an elective surgical patient or a patient admitted as an emergency. RESULTS: The mean number of newly diagnosed cases of MRSA was 20.6 per year. The percentage of patients with a new diagnosis of MRSA was less than or equal to 1% per year with no significant difference of new cases of MRSA over five years. Emergency patients had a trend towards a mean higher rate of MRSA. The commonest site of MRSA colonization was from catheters (32%) and open wounds (18%). DISCUSSION: MRSA is of concern, as compared to methicillin-sensitive staphylococcus aureus, because it is associated with high rates of clinically relevant infection, increased hospital stay and cost, greater mortality and high vancomycin usage. Mandatory reporting has shown a steady increase in the number of cases of MRSA infection over the past four years. We found that the number of newly diagnosed cases of MRSA was low, at less than or equal to 1% of patients per year. Furthermore, the number of new cases of MRSA remained constant over five years suggesting low acquisition rates in a busy UK urology ward.     

Characteristics of false-negative ThinPrep cervical smears in women with high-grade squamous intraepithelial lesions

OBJECTIVE. To examine the cellular characteristics and other possible factors affecting the correct prediction of ThinPrep cervical smears from patients with high-grade squamous intraepithelial lesions. DESIGN. Retrospective study. SETTING. Private anatomical pathology service, Hong Kong. PATIENTS. Patients (n=98) with biopsy-confirmed high-grade squamous intraepithelial lesion of the uterine cervix encountered between 2004 and 2006. MAIN OUTCOME MEASURES. Correct prediction of the cervical ThinPrep Papanicolaou tests. RESULTS. There were no significant differences in age, hormonal status, degree of inflammation, and the presence or absence of endocervical/metaplastic cells between the true-positive and false-negative groups. There was a significant difference in the number of abnormal cells present and the screening time between the two groups. Approximately 79% (34/43) false-negative smears had 100 or less abnormal cells, while only 11% (5/45) true-positive smears had 100 or less abnormal cells (P<0.001). The true-positive smears were also more likely to contain koilocytic cells and abnormal cells with hyperchromatic nuclei. CONCLUSIONS. The number of abnormal cells present, the presence or absence of koilocytic cells, and the presence or absence of abnormal cells with nuclear hyperchromasia appeared to be independent factors affecting the correct prediction of smears from patients with high-grade squamous intraepithelial lesions.     

Oral desmopressin treatment of central diabetes insipidus in children

To assess the efficacy of treatment with oral desmopressin (DDAVP), 20 patients, aged 5–20 y, with central diabetes insipidus were studied during 3 d of hospitalization and for 3 months at the outpatient clinic. At baseline the median rate of diuresis was 12. 7 ml kg^-1 h^-1. Urinary output decreased significantly under treatment with an increase in urinary osmolality, normalization of plasma osmolality and absence of nocturia. Patients were discharged from hospital with a median dose of 500μg d^-1 (100–1200μg d^-1). An adjustment in dosage was necessary in seven patients during follow-up, resulting in a final dose of 600μg d^-1. Body weight and DDAVP doses ( r = 0. 75, p = 0. 001) and body surface and DDAVP doses ( r = 0. 72, p < 0. 001) were significantly correlated. The average dosage was 474 ± 222μg m^-2 d^-1 (mean ± SD). The oral DDAVP treatment remained effective during the 3 months of follow-up. This therapy offers an alternative for the treatment of central diabetes insipidus in children.     

Esophageal intubation with duodenoscope in the presence of pharyngeal pouch by a guidewire and catheter-guided technique

Esophageal perforation can occur during blind intubation with a side-viewing duodenoscope during endoscopic retrograde cholangiopancreatogram (ERCP) in patients with pharyngeal or esophageal anomalies. We describe a case of difficult intubation during an ERCP due to an asymptomatic and unsuspected pharyngeal pouch (Zenker's diverticulum). The side-viewing duodenoscope was withdrawn once resistance was encountered during intubation, and a forward-viewing gastroscope was inserted carefully under direct vision to evaluate the upper esophagus. After the diagnosis was made, intubation of the duodenoscope was performed by exchanging scopes over a guidewire. Subsequent ERCP with sphincterectomy and stone removal was uneventful. We caution that a side-viewing duodenoscope should be withdrawn once resistance is encountered during blind intubation during ERCP. Our technique minimizes patient discomfort and is rapid and easy to perform. In addition, no extra device such as an overtube is required.