Iron therapy in patients undergoing maintenance hemodialysis

Studies were conducted of the effect of temperature and humidity, variant of plague microbe, frequency and duration of feeding and specificity of the host on the blockformation in the souslik fleas C. tesquorum and N. setosa infected with plague. 28 tests on the effect of temperature and humidity on the blockformation were undertaken, for which 14411 fleas of the above species were used. A temperature of 16 to 22 degrees proved to be optimal; at this temperature the number of blocked fleas (C. tesquorum) varied from 21.2 to 42.7% and that of N. setosa--from 41.9 to 54.2%. Marmot variant of plague microbe caused the formation of the "block" in 53.3 to 55.1% of fleas of N. setosa in 3-4 days and in 28.0 to 42.7% of C. tesquorum in 10-14 days after the infection. In C. tesquorum the process of blockformation is affected by the frequency of feeding, in N. setosa--by the duration of each feeding.     

Morbidity and mortality on maintenance haemodialysis

Despite the many technical advances in medical care and dialysis delivery, mortality and morbidity remain high in end-stage renal disease (ESRD) patients. A number of factors seem to contribute. Cardiovascular diseases are the leading cause of death: volume overload, anaemia, hypertension, arteriovenous fistula, uraemia-related myocardial cell injury all contribute to the development of ischaemic heart disease and congestive heart failure. The underlying disease is determinant for prognosis, with diabetics displaying an excess cardiovascular mortality. Elderly are also more likely to experience intercurrent medical conditions, vascular disease and diabetes, thus increasing the risk of death. Protein-energy malnutrition and wasting also contribute to the higher mortality in renal replacement therapy. Although nowadays high-risk patients are dialysed too, the rate of acceptance of ESRD patients still varies widely in different countries, possibly because of hidden selection criteria. The patients in the registries with a higher acceptance rate are more likely to be affected by co-morbid conditions and greater disease severity; the assessment of these co-morbid conditions is extremely important when comparing outcomes in different haemodialysis populations. Dialysis adequacy, obtained by means of longer duration of the treatment, is also of paramount importance; it allows minimizing the clinical effects of ultrafiltration and ensure that correct dry weight is reached. This means decreasing the incidence of intradialytic hypotensive episodes, but also improving blood pressure control, a strong predictor of survival. Family and social support, together with adequate medical care, greatly affect the quality of life of patients and can improve compliance to dialysis, diet and drugs and therefore survival.     

Impaired kidney function in lithium therapy

Long-term therapy with lithium may be associated with a broad spectrum of functional and structural side-effects in the kidney. Among these features, nephrogenic diabetes insipidus is the most frequent and it can be expected to occur in 20-70% of the patients. Diabetes insipidus is the result of a lithium induced resistance of collecting ducts to antidiuretic hormone. Additional functional disturbances are represented by renal tubular acidosis and consequences of hypercalcemia. Structural alterations of the kidney have a rare occurrence. In the literature, there are accounts of chronic tubulo-interstitial nephritis, acute tubular necrosis and few cases of glomerulopathies. Our report of a patient with chronic interstital nephritis is supplemented by a brief discussion of the diverse picture of the nephrotoxicity of lithium.     

Salmeterol xinafoate as maintenance therapy compared with albuterol in patients with asthma

OBJECTIVE: To compare the efficacy and safety of inhaled salmeterol xinafoate, a long-acting beta 2-adrenoceptor agonist, with that of albuterol, a short-acting inhaled beta 2-agonist, in the treatment of asthma. DESIGN: Randomized, double-blind, placebo-controlled, parallel-group study. SETTING: Eleven outpatient clinical centers. SUBJECTS: A total of 322 male and female patients at least 12 years of age with chronic symptomatic asthma requiring daily therapy. INTERVENTION: Patients were treated with salmeterol xinafoate (42 micrograms inhaled twice daily), albuterol (180 micrograms inhaled four times daily), or placebo (four times a day) for 12 weeks; patients in all three groups could use inhaled albuterol as backup medication for breakthrough symptoms. MAIN OUTCOME MEASURES: Serial 12-hour forced expiratory flow in 1 second (FEV1), peak expiratory flow (PEF), asthma symptoms, nocturnal awakenings due to asthma, episodes of asthma exacerbations, and electrocardiography. RESULTS: The mean area under the curve for FEV1 throughout each 12-hour period was consistently greater after a single dose of salmeterol than after two doses of albuterol administered 6 hours apart (P < .001), with the difference ranging from 3.1 to 4.3 L.h. Salmeterol produced an average increase in morning and evening PEF of 26 and 29 L/min, respectively, over pretreatment values compared with decreases of -13 and -3 L/min, respectively, in the albuterol group and -2 L/min both in the morning and evening in the placebo group (P < .001). Patients in the salmeterol group had significantly fewer days and nights with symptoms than did either the albuterol or placebo group (P < .001). Responses to salmeterol were similar at day 1 and at week 12. Adverse events in all treatment groups were equally infrequent, and no clinically significant change in cardiac rhythm was observed with salmeterol treatment. CONCLUSION: Salmeterol inhaled twice daily is more effective than albuterol inhaled four times a day (or as needed) in patients with asthma requiring maintenance therapy. No deterioration of asthma control was observed with the use of salmeterol over a 3-month period.     

Suicide in head and neck cancer patients

PURPOSE: It has been well documented that patients with a diagnosis of cancer are at an increased risk of committing suicide. However, there is a paucity of literature on the risk of suicide in the head and neck cancer patient. The purpose of this investigation was to determine the incidence of suicide and expressed suicidal intent in a series of such cancer patients. PATIENTS AND METHODS: A retrospective chart review of 241 patients who were diagnosed with head and neck cancer at the University of Maryland Oral and Maxillofacial Surgery Oncology Division was done. RESULTS: Three patients were identified who committed suicide, 1.2% of the series. Two patients expressed suicidal intent, and four patients refused all treatment and counseling, preferring to die of their disease. CONCLUSIONS: Head and neck cancer patients have many of the same risk factors for suicide as patients with other forms of cancer. To reduce this risk, it is essential that the surgeon maintain good rapport with the patient, because this serves as a foundation for all other aspects of their therapy. In addition, these patients need to be fully evaluated for depression, hopelessness, pain, and other factors important in raising the possibility of suicide, and appropriate, aggressive management must be provided.     

Long-lasting remission of cytomegalovirus retinitis without maintenance therapy in human immunodeficiency virus-infected patients

Seven AIDS patients who were receiving suppressive therapy for previously diagnosed cytomegalovirus (CMV) retinitis were offered treatment with protease inhibitors (PIs). Secondary prophylaxis for CMV was discontinued after 3 months of therapy with PIs if patients had >150 CD4 cells/mm3 and a human immunodeficiency virus (HIV) load of <200 copies/mL and if they were negative for CMV as determined by qualitative CMV polymerase chain reaction (PCR). Ophthalmologic exams were done periodically. After a median follow-up of 9 months (range, 9-12), no new episodes of CMV retinitis were observed. CD4 cell counts were >150 cells/mm3 in all cases, HIV loads were <200 copies/mL, and results for qualitative CMV PCRs remained negative. These observations suggest that for selected patients with healed CMV retinitis who have immunologic and virologic evidence of a clinical response to potent combination antiretroviral therapy, temporary discontinuation of a chronic anti-CMV suppressive therapy may not result in further retinal necrosis. However, the long-term immunologic benefit of PIs and hence the safety of prolonged withdrawal of anti-CMV therapy is unknown.     

Effects of the rate of discontinuing lithium maintenance treatment in bipolar disorders

BACKGROUND: Gradual discontinuation of lithium may reduce high risk of early morbidity in bipolar disorder patients discontinuing successful long-term maintenance on lithium, but previous small samples have limited analyses of subgroups. METHOD: DSM-IV bipolar disorder patients (N = 161) were pooled from similar samples maintained on lithium for 4.2 +/- 3.1 years. Effects of discontinuing treatment abruptly (1-14 days) or gradually (15-30 days) were compared by survival analysis in clinically closely similar groups. RESULTS: After gradual versus rapid discontinuation, the overall median time to recurrence +/- SE differed by 5.0-fold (20.0 +/- 5.8 vs. 4.0 +/- 0.7 months; p < .0001). After rapid discontinuation, the median time in remission was 2.3 times shorter than the mean cycling interval before lithium (6.3 vs. 14.6 months; p < .0001). The proportion of subjects falling ill/month (recurrence rate) was much higher in the first year after rapid discontinuation (6.5% vs. 2.3%), but similar thereafter (0.4% vs. 0.6%); patients remained stable for 3 years when off lithium treatment 20 times more frequently after gradual than rapid discontinuation (37% vs. 1.8%; p < .0001). Ratios of median survival times after gradual/rapid lithium discontinuation were similar for a first recurrence of mania and depression (4.4 vs. 3.4-fold), insignificantly higher (34%) with rapid or continuous cycling before lithium, and greater in Type II than Type I disorder (9.8- vs. 4.0-fold). The polarity of first off-lithium and first lifetime episodes matched in 70% of cases. CONCLUSION: These pooled results strengthen the concept or a pharmacodynamic stress factor in early relapse after stopping lithium maintenance and support the conclusion that early recurrence risk can be minimized by discontinuing maintenance treatment gradually in both Type I and II bipolar disorders.     

Abrupt lithium discontinuation in manic-depressive patients

Prophylactic lithium was abruptly discontinued (under double-blind conditions and using placebo) in 18 manic-depressive patients for 15 days. Following lithium withdrawal tremor of hands, polyuria, general muscular weakness, polydipsia and dryness of mouth were significantly reduced. No withdrawal symptoms were noted. Three patients relapsed within 4 days of lithium discontinuation. The questions arising from these findings are discussed and the possibility of a rebound phenomenon produced by lithium is considered.     

Abdominal surgery for patients on maintenance hemodialysis

PURPOSE: To evaluate the performance of the new perimetric threshold strategy SITA relative to older methods. METHOD: Thirty-two patients with either glaucoma or ocular hypertension performed two threshold visual field tests with each of three threshold strategies, SITA, Humphrey Full Threshold, and Fastpac. Testing was distributed over three visits, and testing order was balanced between strategies to control for order effects. RESULTS: SITA tests consumed 54% of the time taken by Full Threshold tests on average, and 85% of Fastpac tests; SITA's test times were significantly shorter than those of Full Threshold (p<0.0001) and Fastpac (p=0.0008). Test-retest threshold variability did not differ significantly between strategies. Intertest variability of the pattern deviation analysis was lowest in SITA (p<0.01) relative to both Full Threshold and Fastpac. Both SITA and Fastpac showed higher than expected average sensitivities relative to Full Threshold. SITA and Fastpac showed approximately the same amount of visual field loss. There was a significant relationship between Mean Deviation and the SITA function used to shorten stimulus sequences at points where measurement errors are small (p<0.0001). CONCLUSION: Our results suggest that SITA matches the precision of older thresholding methods, consuming considerably and significantly less test time. This indicates that SITA could replace Full Threshold as the standard clinical test used in glaucoma management, without decreasing the quality of test results.     

Discontinuation of maintenance therapy in patients with quiescent cytomegalovirus retinitis and elevated CD4+ counts

OBJECTIVE: To determine whether maintenance therapy can be discontinued safety in patients with quiescent cytomegalovirus retinitis (CMVR) and increased CD4+ counts after treatment with highly active antiretroviral therapy (HAART). DESIGN: A prospective observational case series. PARTICIPANTS: Eight human immunodeficiency virus (HIV)-positive patients with quiescent CMVR who were taking HAART and had CD4+ counts above 100 cells/microliter elected to discontinue anti-CMV maintenance treatment. INTERVENTION: Biweekly-to-monthly indirect ophthalmoscopy and fundus photographs, monthly-to-quarterly CD4+ counts, and quarterly HIV viral loads were ordered. MAIN OUTCOME MEASURES: Twelve previously affected eyes were examined for evidence of recurrent retinitis, which was defined as any retinal whitening, border opacification, or expansion of areas of retinal pigment epithelial (RPE) atrophy greater than 750 microns. Four previously unaffected fellow eyes were observed for new CMVR. RESULTS: There was no reactivation or progression of retinitis in any patient during the mean follow-up interval of 11.4 months (range, 3-16 months). No previously unaffected eye developed CMVR. CD4+ remained elevated in all patients (range, 70-725; mean, 255). The HIV viral load ranged from undetectable to 139,000 copies. CONCLUSION: Discontinuation of maintenance therapy may be considered in patients with HAART-induced elevated CD4+ counts above 100 cells/microliter, prolonged relapse-free intervals during the reconstitution period before CD4+ counts rise above 100 cells/microliter, and completely quiescent retinitis characterized by RPE scarring only. Reduced risks of drug toxicity and drug-resistant organisms are potential benefits. Close observation for evidence of recurrent retinitis is indicated.     

Effects of lipid-lowering therapy on total and coronary mortality

The results of several lipid-lowering randomized trials were released during the past year. The Scandinavian Simvastatin Survival Study has contributed significantly to the understanding of lipid-lowering on all-cause and coronary mortality outcome. An approximate 25% net difference in cholesterol between the simvastatin and placebo group produced a 30% reduction in total mortality in the simvastatin group (P < 0.01). No increase in noncardiovascular mortality or nonfatal diseases was observed. Although angiographic trials that study atherosclerosis are not designed to show the effect on clinical outcome, several new trials such as the Asymptomatic Carotid Artery Progression Study, the Multicentre Anti-Atheroma Study, the Canadian Coronary Atherosclerosis Intervention Trial and the Stanford Coronary Risk Intervention Project all add information that is consistent with the results from the Scandinavian Simvastatin Survival Study. The meta-analysis of randomized cholesterol-lowering trials also indicates that no excess of all-cause mortality is present when the degree of cholesterol reduction and treatment modality is adjusted. It is probable that the excess mortality from noncardiovascular causes found in unadjusted analyses is due to specific effects of hormones and fibrate drug treatments to reduce cholesterol. It is concluded that the lipid hypothesis is confirmed more solidly than ever before.     

Effects of beta-blocker therapy on mortality in patients with heart failure. A systematic overview of randomized controlled trials

The zeta potential of human enamel is of physiological importance for interactions between enamel surfaces and the surrounding aqueous medium of saliva. The zeta potentials of both enamel and hydroxyapatite (HA) have been examined previously by various techniques. In this study, we examined the zeta potential of human enamel and HA using the Coulter DELSA 440, which, by a laser, makes independent Doppler shift measurements of moving particles in an electric field at 4 different angles, providing advantages over previous techniques. The enamel and HA particles were suspended directly in different phosphate buffers, or first incubated for 2 hrs in parotid (PS) or whole saliva (HWS) and then suspended in the same buffers. The enamel and HA particles exhibited an overall net surface potential of -15 to -30 mV, depending on the buffer content. Incubation in PS and HWS gave less negative potentials of -8 to -14 mV. In our previous studies, the salivary micelle-like structures (SMSs), seen in TEM of parotid saliva, were observed to have a zeta potential of -9 mV (Rykke et al., 1996). The zeta potential determinations in this study support the concept of an adsorption of mostly SMSs to the enamel surfaces, with a change of the zeta potential of the enamel and HA toward that of the SMSs.