Effect of early nephrology referral on the mortality of dialysis patients in Israel.

BACKGROUND: Late nephrology referral, before initiation of dialysis treatment, is associated with adverse outcome. OBJECTIVES: To investigate the implications of late nephrology referral on mortality among dialysis patients in Israel. METHODS: We retrospectively analyzed 200 incident dialysis patients. Patients were defined as late referrals if they started dialysis less than 3 months after their first nephrology consultation. Survival rates and risk factors for mortality were analyzed RESULTS: The early referral (ER) group comprised 118 patients (59%) and the late referral (LR) group 82 patients (41%). The mortality rate was 44.5% (53 patients) in the ER and 68% (n = 56) in the LR group. The 4 year survival rate was 41.1% in the ER and 18.7% in the LR group (P < 0.0001). The mortality rate increased with late nephrology referral (HR 1.873, 95% CI 1.133-3.094), with age (HR 1.043 for each year, 95% CI 1.018-1.068), with diabetes (HR 2.399, CI 1.369-4.202), and with serum albumin level (HR 0.359 for an increase of each 1 g/dl, 95% CI 0.242-0.533). The median survival time was higher for the ER group in women, in patients younger than 70, and in diabetic patients. A trend for longer survival time was found in non-diabetic patients. Survival time was not increased in early referred patients older than 70 and in male patients. CONCLUSIONS: Late nephrology referral is associated with an overall higher mortality rate in dialysis patients. The survival advantage of early referral may have a different significance in specific subgroups. The timing of nephrology referral should be considered as a modifiable risk factor for mortality in patients with end-stage renal disease.

Inspiratory muscle training and the perception of dyspnea in Parkinson's disease.

BACKGROUND: Pulmonary and respiratory muscle function impairment are common in patients with Parkinson's disease (PD). Inspiratory muscle training may improve strength, dyspnea and functional capacity in healthy subjects and in those with chronic obstructive pulmonary disease. This study investigated the effect of specific inspiratory muscle training (SIMT) on pulmonary functions, inspiratory muscle performance, dyspnea and quality of life, in patients with PD. PATIENTS AND METHODS: Twenty patients with PD (stage II and III Hoehn and Yahr scale) were recruited for the study and were divided into two groups: (a) ten patients who received SIMT and (b) ten patients who received sham training, for three months. Pulmonary functions, the respiratory muscle strength and endurance, the perception of dyspnea (POD) and the quality of life were studied before and within one week after the training period. All subjects trained daily, six times a week, each session consisting of 1/2 hour, for 12 weeks. RESULTS: Following the training period, there was a significant improvement, in the training group but not in the control group, in the following parameters: inspiratory muscle strength, (PImax, increased from 62.0 +/- 8.2 to 78.0 +/- 7.5 cm of H2O (p < 0.05), inspiratory muscle endurance (increased from 20.0 +/- 2.8 to 29.0 +/- 3.0 cm of H2O (p < 0.05), and the POD (decreased from 17.9 +/- 3.2 to 14.0 +/- 2.4 units (p < 0.05). There was a close correlation between the increase in the inspiratory muscle performance and the decrease in the POD. CONCLUSIONS: The inspiratory muscle performance may be improved by SIMT in patients with PD. This improvement is associated with a significant decrease in their POD.

[Chronic cough].

The discomfort caused by persistent cough compels a great number of patients to seek medical aid. Persistent cough interferes with the patient's sleep, professional and social activities. The pathogenic triad of asthma, post nasal drip syndrome and gastroesophageal reflux disease, alone or in combination, is responsible for the majority of cases of chronic cough. Investigation of chronic cough, according to a rational protocol leads to the identification of the cause for chronic cough in approximately 90% of the cases.