[The course and outcome of acute kidney failure in patients treated by hemodialysis]. / Techenie i iskhody ostroi pochechnoi nedostatochnosti u bol'nykh, lechennykh gemodializom.

In 1989-1995 229 patients with acute renal failure were treated by hemodialysis. A total of 1470 procedures have been performed, 8.8 +/- 1.5, on the average. 61 patients (26.6%) died. There is no significant relation between duration of oliguria, maximum BUN, creatinine level and lethality. The latter is associated with the patient's age, acute respiratory failure, sepsis, coma, hyperbilirubinemia and hypoproteinemia. Lethality was higher at failure of two and more organs and poor prognosis defined by a simplified acute physiology score (SAPS). 10 patients (5.9%) were discharged with increased creatinine level. Conventional hemodialysis is recommended as a basic technique of dialysis for patients with mono-organ failure and relatively good prognosis according to SAPS scale.

[Hemodialysis in the treatment of acute kidney failure in hemorrhagic fever with renal syndrome]. / Gemodializ v lechenii ostroi pochechnoi nedostatochnosti pri gemorragicheskoi likhoradke s pochechnym sindromom.

The results of hemodialysis therapy given in 1988-1994 to 57 patients with acute renal failure at the age of 17-62 years in hemorrhagic fever with renal syndrome (HFRS) are provided. A total of 306 procedures were performed. Hemodialysis was initiated early, before clinical presentation of uremia. The indications for hemodialysis were: oliguria, BUN above 20 mmol/l, serum creatinine level above 0.6 mmol/l. For 11 (19.3%) patients hemodialysis was started because of hyperhydration, for 2 patients (3.5%) it was performed because of hyperkalemia. Infectious complications occurred in 7 (12.3%) patients. One (1.7%) patient died. Hemodialysis induced no complications that could negatively influence the disease. All the patients with severe HFRS need inpatient treatment in hospitals with hemodialysis facilities.

"The responsibility to inform, the power to act": a conference for New England college newspaper editors on the role of the campus press in addressing substance use issues.

College newspapers are a powerful but underutilized medium for educating students on health issues, including those related to drug and alcohol use on campus. Editors of these publications are in a position to wield significant influence among their readers. In addition to communicating factual information about the prevalence and impact of substance use among college students, editors can use the press to advocate changes in students' attitudes and behaviors and in college or community policies that affect substance use. A pilot conference was held to help New England college newspaper editors perceive the importance of their role in educating their peers about substance use and other health-related issues, and to offer concrete suggestions as to how they can incorporate these topics into an "activist" campus press.

The illusion of futility in clinical practice.

The claim that a treatment is futile is often used to justify a shift in the physician's ethical obligations to patients. In clinical situations in which non-futile treatments are available, the physician has an obligation to discuss therapeutic alternatives with the patient. By contrast, a physician is under no obligation to offer, or even to discuss, futile therapies. This shift is supported by moral reasoning in ancient and modern medical ethics, by public policy, and by case law. Given this shift in ethical obligations, one might expect that physicians would have unambiguous criteria for determining when a therapy is futile. This is not the case. Rather than being a discrete and definable entity, futile therapy is merely the end of the spectrum of therapies with very low efficacy. Ambiguity in determining futility, arising from linguistic errors, from statistical misinterpretations, and from disagreements about the goals of therapy, undermines the force of futility claims. Decisions to withhold therapy that is deemed futile, like all treatment choices, must follow both clinical judgments about the chance of success of a therapy and an explicit consideration of the patient's goals for therapy. Futility claims rarely should be used to justify a radical shift in ethical obligations.

Long-term follow-up of prosthetic joint replacement in hemophilia.

We evaluated the outcome of seven severe hemophilic patients who underwent four total hip and four total knee arthroplasties since 1976. These patients have been followed at regular intervals over a period of 2.5-9.5 years (mean 5.8). Of the four total hip replacements, one had to be removed because of loosening and secondary infection 3 years after the initial surgery but was salvaged by pseudoarthrosis; the other three are pain-free and radiologically stable and have an excellent range of motion 2.5, 5, and 7 years postoperatively. Of the four total knee replacements, one had to be removed because of infection but was successfully salvaged by arthrodesis; one patient has loose components, but the prosthesis is still functional; and the final patient with bilateral knee prostheses is pain-free with limited but functional range of motion. Clotting-factor replacement therapy was effective in controlling intraoperative bleeding, even in a patient with an inhibitor, and only one procedure was complicated by hematoma formation. We conclude that prosthetic joint replacement may be safely performed in hemophilic patients but should be reserved for those who have limited function because of severe pain, joint destruction, and deformity. Total hip arthroplasty is as successful in these patients as in nonhemophiliacs. Total knee arthroplasty provides relief of pain, reduces the frequency of hemarthroses, and corrects most of the deformity, but it is usually associated with a limited range of motion.