Dialysis of schizophrenic patients: a double-blind study.

The authors designed a double-blind hemodialysis protocol consisting of hemodialysis or sham dialysis twice weekly for 10 weeks, respectively. Four patients were carefully selected and evaluated clinically and on the Clinical Global Impression Scale. Three did not show any signs of improvement, and one patient demonstrated questionable improvement but decompensated after 12 additional weeks of hemodialysis. This preliminary study does not confirm the hypothesis that hemodialysis is effective in controlling psychotic symptoms. The authors consider other possibly beneficial treatments for schizophrenia.

Total parathyroidectomy and autotransplantation.

Total parathyroidectomy and autotransplantation of tissue to the forearm was practiced in 50 chronic renal failure patients as treatment for secondary hyperparathyroidism. Four hyperplastic glands were removed in all cases. Followup observation ranged from 3 to 42 months. Serum parathyroid hormone, alkaline phosphatase, calcium and phosphorus levels decreased significantly following the procedure (P less than 0.005) and remained stable during the period of observation. Significant bone pain present in 26 patients improved or ceased in 19; pruritus, present in 39 patients, universally improved. Strong radiographic suggestion of secondary hyperparathyroidism, present in 38 patients, improved or disappeared in 17. Three patients remained functionally hyperparathyroid, requiring further tissue removal. Autograft function 3 to 7 days after transplantation was demonstrated in 3 cases by differential parathyroid hormone concentration determinations. Essentially all patients experienced symptomatic improvement after surgery and most showed objective evidence of improved calcium-phosphorus metabolism and bone healing.

Visual function in diabetic patients undergoing dialysis: comparison of peritoneal and hemodialysis.

A prospective, uncontrolled study was designed to evaluate the changes in visual efficiency among insulin-requiring diabetic patients undergoing peritoneal and hemodialysis. Of the 112 patients (63% adult onset and 37% juvenile onset diabetics) studied chronologically, 63% were treated with hemodialysis and 37% with peritoneal dialysis. The mean distribution of sex, age, observation period and initial visual function were the same in the peritoneal and hemodialysis subpopulations, but more juvenile onset diabetics were treated with peritoneal dialysis. Preservation of vision correlated well with overall blood pressure control in all dialysis groups. Loss of vision was independent of the dialysis modality, of glucose control, and of the type of onset of diabetes.

The influence of peritoneal dialysis on the outcome of transplantation.

The Authors' series of 44 patients transplanted after peritoneal dialysis suggests that the results of renal transplantation are comparable to those on hemodialysis.

Results of in situ subtalar arthrodesis for late sequelae of calcaneus fractures.

A retrospective review was performed on all patients who had an in situ subtalar arthrodesis for painful sequelae of calcaneus fractures between 1989 and 1994. Nineteen feet were available for evaluation, with a mean follow-up of 27 months (range, 12-62 months). Lateral calcaneal wall decompression was performed in seven feet. Although loss of ankle dorsiflexion was associated with anterior ankle tenderness, loss of ankle dorsiflexion was not correlated with either talar declination angles or talar height differences. There was no correlation between American Orthopaedic Foot and Ankle Society hindfoot score and talar declination, talar height, or calcaneal width. Peroneal tendon/subfibular impingement, ankle tenderness, sural nerve injury, and patient smoking were all statistically associated with lower scores. The calcaneocuboid joint was frequently involved in the fracture but was not painful at follow-up. Late pain after a calcaneal fracture is not caused by only subtalar arthrosis. Radiographic criteria alone cannot be relied upon for surgical decision making. Careful physical evaluation should be used to determine sources of pain. Distraction arthrodesis should be considered only if findings of anterior ankle impingement are present. If sural nerve symptoms are present, a sural neurectomy may be added to the procedure. Pain localized to the plantar fat pad should be managed nonoperatively. Radiographic changes in the calcaneocuboid joint rarely require surgical intervention. Based on these results, in situ subtalar arthrodesis with lateral wall decompression is the procedure of choice in most cases of subtalar traumatic arthritis with lateral wall impingement.

Osteomyelitis associated with Crohn's disease. A case report and literature review.

The case of a patient with pelvic osteomyelitis in association with Crohn's disease is presented. A review of the literature is discussed. The location most frequently affected is the right ileum, but other sites may be involved. The osteomyelitis usually develops as a result of direct extention of internal fistulae, with enteric flora being the infecting organisms. The importance of resecting the diseased segment of bowel is discussed. Many patients do not require bony resection. The possibility of pelvic osteomyelitis must be considered in patients with Crohn's disease who present with suggestive symptoms and radiographic evidence of osteomyelitis. Patients who initially present with pelvic osteomyelitis should be suspected of having intraabdominal pathology.

Tibial eminence fracture with meniscal entrapment.

Controversy has existed regarding the treatment of tibial eminence fractures in children. It has been widely assumed that closed manipulation of the knee resulting in radiographic reduction of the fragment is acceptable. We present a case report of a trapped medial meniscus, even after apparent successful closed reduction of an incompletely displaced tibial eminence fracture. The integrity of meniscii cannot be inferred radiographically. Arthroscopic evaluation allows reduction of a trapped meniscus and suture fixation of the fragment is easily accomplished.

Intraperitoneal infusion of non-absorbable steroids in the treatment of ascites and sterile peritonitis.

The experience with intraperitoneal infusion of non-absorbable steroids (triamcinolon hexacetonide) in the treatment of intractable hemodialysis-associated ascites and severe sterile peritonitis is presented. All patients uniformly responded to therapy with prolonged periods of remission and no significant complications. We conclude that intraperitoneal steroidal administration offers an effective modality of therapy in the treatment of these complications.

Continuous cyclic peritoneal dialysis: a preliminary report.

Continuous cyclic peritoneal dialysis (CCPD) was designed to reduce the high incidence of peritonitis and eliminate the multiple interruption created by dialysis exchanges during the day needed for CAPD, while maintaining the quality of dialysis. Three nocturnal cycles with 2 liters of dialysate lasting 3 hours each are provided by an automated cycler while the patient sleeps. Two liters are left in the abdomen in the morning. Only one daily connection and one disconnection are required between the peritoneal catheter and the cycler line. Our 84 patient months experience with 14 patients reveals a low incidence of peritonitis (1 per 42 patient months), satisfactory ultrafiltration rates and clearances that compare favorably with those of CAPD (Curea 67, Ccreatinine 58, and CB12 45 L/wk). Blood pressure control has been excellent while most patients enjoy liberal diets. This preliminary study suggests that CCPD may indeed reduce the rate of peritonitis, provide excellent clearance and ultrafiltration, allow more free time to the patient and maintain a steady physiological state.

Control of post renal biopsy hemorrhage by Gelfoam embolization.

A patient with severe and protracted post renal biopsy hemorrhage is presented. The bleeding site was identified by renal arteriography and the hematuria was promptly controlled by Gelfoam embolization of the artery leading directly to the bleeding site. This aggressive approach should be considered early to control hematuria and expanding perirenal hematomas in selected cases of protracted post renal biopsy hemorrhage.

Experience with intermittent peritoneal dialysis and continuous cyclic peritoneal dialysis.

Acceptance of peritoneal dialysis as a standard modality of therapy for end-stage renal disease (ESRD) was initially slow due to various technical problems and the difficulty of quantitating peritoneal membrane function. Development of reliable, permanent access to the peritoneum and the availability of dependable automated equipment stimulated the development of intermittent peritoneal dialysis (IPD), which demonstrated initial success. However, the failure rate was noted to increase with time, primarily due to insufficient dialysis and malnutrition. The introduction of continuous ambulatory peritoneal dialysis (CAPD) allowed better clearances and the maintenance of a more physiologic steady state. However, the twin problems of inconvenience and frequent infections proved to be significant. Continuous cyclic peritoneal dialysis (CCPD) was then developed to allow exchanges at night on a more convenient basis, reduce the rate of peritonitis by circumventing some of the technical disadvantages of CAPD, and decrease the stress on any helpers who may be involved. Experience with CCPD has demonstrated acceptable control of nitrogenous waste products, fluid balance, adequate maintenance of nutrition in the great majority of patients, and satisfactory maintenance of hemoglobin and acid-base balance. CCPD also offers flexibility of prescription accomplished by varying the frequency and length of nocturnal automated cycles. The preliminary experience with peritoneal kinetic modeling suggests that quantitation of peritoneal function will be significantly improved in the future and that standards of adequacy of dialysis will be more precisely defined.

Restrospective correlation of clinical and histologic findings of 189 exchanged kidneys.

Tissues samples from 189 unsuccessful renal allografts, 47 recovered at autopsy and the others removed surgically, were examined histologically by light microscopy. Tissues samples were obtained from cadaver kidneys that had been exchanged regionally for transplantation. Each allograft tissue sample was rated as to extent of pathologic changes denoting rejection and was classified accordingly. Surgical and autopsy reports, as well as clinical data, were then obtained and these were compared with the retrospective pathologic findings of this study. Our pathologic findings agreed with the original pathologic diagnosis as to presence or absence of rejection changes in 180 cases, but disagreed with the clinical diagnosis of rejection in 28 of the 63 cases with minimal or no histologic evidence of rejection. There was less disagreement with the clinical diagnosis for the 87 cases with histologic evidence of rejection which had been judged as sufficient to cause allograft loss, 70 having been clinically diagnosed as rejected. Disagreement occurred most often where the allograft had never functioned or had been lost within 3 months. Retrospective analysis did not disclose any association between rejection histology and preformed antibodies or length of kidney perfusion time. Sufficient allografts appeared to have been lost for reasons other than rejection to cast doubt on the validity of interpreting renal allograft data only by graft survival statistics.