Dialysis adequacy at two haemodialysis units in Jamaica.

A prospective study on adequacy of dialysis was conducted at the haemodialysis units of Kingston Public Hospital (KPH) and the University Hospital of the West Indies (UHWI). Dialysis adequacy was better at KPH and morbidity, as measured by patient admission days, was increased at UHWI. Diabetics had a lower mean serum albumin and urea reduction ratio (URR) than non-diabetics. Multiple regression analyses revealed that age of patient (F = 5.30; p = 0.0241) and hospital (F = 7.85; p = 0.007) were the variables significantly associated with serum albumin level when the effect of other variables was controlled (F = 2.12; p = 0.34). Similar analyses showed that the hospital at which dialysis was done was the only factor which accounted for significantly higher URR, with KPH having higher rates (F = 13; p = 0.006). The differences between hospitals necessitate further investigations, explanations and intervention strategies. The study provides opportunities for improving patient care and for dialysis health care professionals to assess clinical performance measures and reduce variation between dialysis centres.

Dialysis adequacy at two haemodialysis units in Jamaica

A prospective study on adequacy of dialysis was conducted at the haemodialysis units of Kingston Pubic Hospital (KPH) and the University Hospital of the West Indies (UHWI). Dialysis adequacy was better at KPH and morbidity, as measured by patient admission days, was increased at UHWI. Diabetics had a lower mean serum albumin and urea reduction ratio (URR) than non-diabetics. Multiple regression analyses revealed that age of patient (F = 5.30; p = 0.241) and hospital (F = 7.85; p = 0.007) were the variables significantly associated with serum albumin level when the effect of other variables was controlled (F = 2.12; p = 0.34). Similar analyses showed that the hospital at which dialysis was done was the only factor which accounted for significantly higher URR, with KPH having higher rates (F =13; p = 0.006). The differences between hospitals necessitate further investigations, explanations and further intervention strategies. The study provides opportunities for improving patient care and for dialysis health care professionals to assess clinical performance measures and reduce variation between dialysis centres.(Au)

The impact of a community-wide vascular access program on the management of graft thromboses in a dialysis population of 495 patients.

BACKGROUND: The unpredictability of prosthetic vascular access thrombosis precludes the scheduling of elective graft thrombectomy. This results in inconsistent dialysis for patients, as well as logistical challenges for dialysis clinics and surgeons, and increased cost. In an effort to solve this problem a community-wide, prospective vascular access program (VAP) was established. This study evaluates the impact of the VAP by comparing the operative procedures and outcomes of vascular access surgery performed in the community before and after establishment of the program. METHODS: All 17 surgeons who perform vascular access, representing five independent practice groups in Greenville, South Carolina, formed a VAP in November 1996. Dialysis patients were pooled, and all graft thrombectomies were managed on a rotational basis by a surgeon assigned daily to a specifically designated access thrombectomy operating room. The hospital records of all patients undergoing vascular access procedures from November 1, 1995, through October 31, 1996 (pre-VAP), and November 1, 1996, through October 31, 1997 (post-VAP), were reviewed. RESULTS: Comparison of the pre-VAP and post-VAP groups showed no significant difference in the number of patients undergoing vascular access procedures (391 versus 378), number of vascular access procedures performed (1034 versus 1,048), or average number of vascular access procedures performed per patient (2.64 versus 2.79). There was no statistical difference in the number of thrombectomies and revisions (786 versus 765; P = 0.114) or thrombectomies alone (248 versus 283; P = 0.114) in the pre-VAP and post-VAP groups. There was a significant increase in the number of procedures performed on an outpatient basis in the post-VAP group (757; 73%) compared with the pre-VAP group (575; 56%); P <0.001. There was also a significant difference in the percentage of cases performed after 6:00 PM in the pre-VAP group (262; 25%) compared with the post-VAP group (48; 4.5%; P = 0.001). CONCLUSIONS: Dialysis graft thrombosis, occurring in 75% of our patients annually, represents a substantial logistical dilemma necessitating the incorporation of 1,000 additional operations into a busy elective surgery schedule. An organized VAP reduces inpatient hospitalization, minimizes expensive after hours surgery, and enhances patient and physician convenience while providing a mechanism to monitor clinical outcomes and assure timely dialysis.

Dialysis adequacy at two haemodialysis units in Jamaica

A prospective study on adequacy of dialysis was conducted at the haemodialysis units of Kingston Public Hospital (KPH) and the University Hospital of the West Indies (UHWI). Dialysis adequacy was better at KPH and morbidity, as measured by patient admission days, was increased at UHWI. Diabetics had a lower mean serum albumin and urea reduction ration (URR) than non-diabetics. Multiple regression analyses revealed that age of patient and hospital were the variables significantly associated with serum albumin level when the effect of other variables was controlled (F=2.12; p=0.34). Similar analyses revealed that the hospital at which dialysis was done was the only factor which accounted for significantly higher URR, with KPH having higher rates (F=13; p=0.006). The differences between hospitals necessitate further investigations, explanations and intervention strategies. The study provides opportunities for improving patient care and for dialysis health care professionals to assess clinical performance measures and reduce variation between dialysis centres (AU)

Results and complications of arteriovenous access dialysis grafts in the lower extremity: a five year review.

Virtually no objective data exist regarding the natural history of arteriovenous (AV) dialysis access grafts placed in the lower extremity for routine hemodialysis. From March 1988 until October 1993, 45 consecutive lower extremity AV dialysis access grafts were placed in 39 patients (16 males; 23 females; mean age 58 years) at a large teaching community hospital. All 39 patients had long-standing end stage renal disease and had required chronic hemodialysis from 7 to 237 months mean, 72 months) prior to leg graft placement. Polytetrafluorethylene (n=39) or bovine (n=6) loop lower extremity dialysis grafts were placed after multiple upper extremity dialysis graft failures (mean, 2.7 previous grafts with 9.6 thrombectomies and/or access revisions per patient). There were no operative deaths; however, in follow-up (1-132 months; mean 20 months; median 18 months), 33 percent of the patients had died from systemic complications of their renal disease, and only 20 (44%) leg grafts are currently patent [correction of patient] . Graft complications, excluding graft thromboses, occurred in 20 grafts including graft infection (n=8; 18%), severe ipsilateral leg ischemia (n=7; 16%), graft aneurysmal degeneration requiring revision (n=3; 7%), fistula-induced congestive heart failure (n=2; 4%), and major lower extremity amputation (n=3; 7%). Primary patency by life-table analysis was 47 percent at 24 months. Fifteen (33%) grafts thrombosed at least once, and all but one were salvaged with thrombectomy. The need for lower extremity AV dialysis access appears to be a significant marker for late mortality in this group of chronically ill patients. They are associated with multiple complications and should probably be placed only if significant patient morbidity can be accepted and justified.

Doppler cerebrovascular examination: improved results with refinements in technique.

Doppler ultrasonic assessment of extracranial carotid occlusive disease has been modified to decrease the incidence of false positive and negative diagnoses. The technique, which assessed directional flow in the frontal artery and the influence of sequential compression of each temporal, infraorbital, facial and common carotid artery, was performed on 152 vessels visualized by contrast arteriography. Presence or absence of significant (greater than 50%) stenosis or occlusion of the internal carotid artery was identified correctly in 150 vessels (98.7%). Inasmuch as the classic temporal artery compression test only detected 39 of the 61 abnormal Doppler studies (64%), the more complete examination is recommended for screening patients for significant carotid artery obstruction.

Sequential circulatory changes in the circumferentially burned limb.

To assess the hemodynamic alterations in the circumferentially burned extremity, Doppler arterial examinations and Xenon-133 washout determinations of muscle blood flow (MBF) were obtained in 27 limbs. In this laboratory normal resting MBF was 2.82+/-0.86 cc/min/100 gm (mean +/- S.E.M., N=26) with no value less than 1.60 cc/min/100 gm. In 27 circumferentially burned limbs, the maximum decrement in MBF occurred by 36 hours following thermal injury. The lowest MBF value in the 11 extremities not requiring escharotomy was 1.50cc/min/100gm. Escharotomy was done in 16 extremities. Mean MBF immediately prior to escharotomy was 1.30+/-0.26cc/min/100gm and improved to 4.43+/-0.52cc/min/100gm following escharotomy (p less than 0.01). Correlation between MBF and Doppler examinations was present in 63% of all studies and in 88% of studies performed immediately before or after escharotomy. The diagnostic sensitivity of Doppler examination required audible recognition of abnormal velocity signals as well as absent velocity signals. Because the intial MBF determination or Doppler examination is not helpful in predicting which extremities will eventually require escharotomy, sequential studies should be done during the first 36-48 hours following thermal injury.

Accuracy of Doppler ultrasound in clinically suspected venous thrombosis of the calf.

Doppler ultrasonic examinations and contrast phlebography were performed on 55 limbs of 43 patients with a clinical diagnosis of venous thrombosis of the calf and without phlebographic evidence of thrombosis above the knee. There was diagnostic concurrence of Doppler and venographic evaluations in 46 of 55 limbs studied. There was only one instance of a false-negative diagnosis by Doppler examination. Of the eight false-positive Doppler examination findings, an alternate clinical diagnosis affecting venous flow in the calf was evident in six patients. The diagnostic importance of augmentation of flow velocity of the posterior tibial vein upon release of compression of the calf is emphasized. A normal Doppler examination finding may accurately exclude significant deep venous disease in a patient with clinical manifestations of venous thrombosis in the calf.

Primary small bowel plasmacytoma with intracellular fibrils.

This is a report of a rare plasma cell tumor, an extramedullary plasmacytoma arising in the small bowel. The tumor first occurred in the jejunum without evidence of multiple myeloma. One year later, classical signs of multiple myeloma appeared. The rarity and unusual course of this tumor plus the finding of intracellular fibrils make the case worthy of note.

Sterility of intestinal transudate during aortic reconstructive procedures.

In 119 patients undergoing intra-abdominal arterial reconstructions, the small intestines were retained in plastic bags and the fluid that passed from the small intestine into the intestinal bag was cultured for bacteria to search for enteric organisms as a source of prosthesis infection. No enteric organisms were recovered from these 119 cultures. Three cultures did yield bacterial growth; in two cases Staphylococcus epidermidis was found and in one instance S aureus was cultured. Under the conditions of this study, which included intravenous administration of cephalothin sodium preoperatively, intraoperatively, and postoperatively, the small intestinal transudate did not harbor enteric bacteria.