Renal replacement therapy in multiple myeloma and systemic amyloidosis

Renal failure frequently complicates both multiple myeloma and systemic amyloidosis. Renal replacement therapy (RRT) may be poorly tolerated and its role in such patients is not clearly defined. Of fifty patients (26 males and 24 females) referred to a single centre because of renal failure associated with multiple myeloma or systemic amyloidosis 37 progressed to end-stage renal failure and 30 of these patients received RRT. Nine patients have been treated by CAPD, 13 by haemodialysis, and 8 patients have required both forms of dialysis. Overall one year and two year survival rates were 66% and 57% respectively. The median duration on RRT was 7.5 months (range 1-96 months) with a 51% one year, and a 46% two year survival rate. Of 7 patients with amyloidosis who underwent renal transplantation, 3 died within 6 months of transplantation. Undiagnosed cardiac involvement contributed to this early mortality. We conclude that renal replacement therapy is appropriate for some patients with multiple myeloma and systemic amyloidosis who develop endstage renal failure. Careful assessment and selection of patients is necessary prior to renal transplantation.     

Renal replacement therapy for chronic renal failure patients in the Languedoc-Roussillon region in 1994

BACKGROUND: Unbiased and reliable data are presently required for health planning concerning end stage renal diseases (ESRD) in Languedoc-Roussillon region of France. METHODS: A comprehensive retrospective study has been carried out on patients with ESRD in 1994 in this area. Information was collected from medical and social documents by physicians. The present report describes the management of patients and their demographic and epidemiologic characteristics. Multiple correspondence analysis was carried out to estimate to what extent mode of renal replacement therapy is determined by patient characteristics. RESULTS: An incidence of 11.4 for new cases of renal replacement therapy was found per 100,000 inhabitants. This represents an increase of 4.8% in the total number of patients. The patients were found to be elderly (25% being over 72 years) and to present with multiple pathologies (32.5% severe cardiac pathology; 20.7% arteritis of the lower limbs; 15.1% diabetes; 11.2% manifesting malignant tumors). Only 57.5% received dialysis within a hospital setting; 30.1% received dialysis at home; 13% perform autodialysis; 1.2% were being trained for home dialysis in December. The renal transplantation rate was 5.5%. No significant relationship was found between choice of therapy and age, renal disease, comorbidities and place of dwelling. CONCLUSIONS: This study demonstrates the great variety in the modes of treatment used, the facilities provided and the evolutive trend, which together make programming planning difficult.     

Effects of thyroid hormone replacement therapy on nocturnal apnea in elderly patients with hypothyroidism

BACKGROUND AND STUDY AIMS: Dieulafoy's disease is a rare cause of upper gastrointestinal tract hemorrhage. The aim of the study was to evaluate the efficacy of endoscopic hemostasis and to analyze the mortality of patients with hemorrhage due to Dieulafoy's disease. PATIENTS AND METHODS: The retrospective analysis included patients from our institution who had undergone urgent endoscopic examination of the upper digestive tract and hemostatic interventions in the period between January 1994 and December 1996. RESULTS: Twenty-five patients were examined (18 men and 7 women, average age 52.6, SD+/-15.3, range 25-78). In 20 patients endoscopic injection sclerotherapy was performed (diluted epinephrine 1:10,000 plus polidocanol 1%) and Nd:YAG laser photocoagulation in five patients. In all patients a total of 44 interventional endoscopies were carried out. Repeated endoscopic hemostasis did not prove successful in two patients (8%, 2 men), and they were treated operatively. During the postoperative period one patient died because of multiorgan failure. The total mortality rate of all patients in which endoscopic hemostasis was done was 16% (4/25). None of the 21 surviving patients had rebleeding on long-term follow-up (mean: 29.4 months). CONCLUSIONS: Endoscopic hemostasis is a major therapeutic advance in the management of Dieulafoy's disease hemorrhage. Interventional endoscopy has decreased the need for surgical management and significantly reduced mortality.     

Nicotine replacement therapy

The peptide hormones, prolactin (PRL) and growth hormone (GH), are known to regulate numerous target tissues. Among such targets are cells of the immune system, including T cells, B cells, macrophages and natural killer cells. We have cloned a panel of PRL- and GH-inducible T cell genes for use in studies to understand how these hormones through the expression of these genes modulate the biology of immune function cells. This article focuses on the signalling pathways emanating from the PRL receptor (PRL-R) and GH receptor (GH-R), and the expression of PRL-inducible target genes.     

Vitamin supplementation therapy in the elderly

Vitamin supplementation in large dosages is increasingly common in the older population. Often, such supplementation is used in an attempt to improve an individual's health status. There have been claims that the effects of vitamins halt the normal aging process or prevent and cure disease. However, several recent studies have failed to demonstrate the efficacy of vitamin supplementation in preventing several types of cancer. In moderate dosages, supplementation with vitamin E (tocopherols) shows promise as a lipid antioxidant, and may reduce the risk of coronary heart disease. However, before vitamin E becomes an accepted medical therapy, further long term studies must be undertaken to examine the safety and efficacy of such therapy. An adequate intake of vitamins should be ensured by adherence to a well balanced diet. However, the elderly are prone to circumstances that may prevent them from eating a balanced diet. In addition, there are several age-related medical conditions that may predispose individuals to dietary and vitamin deficiencies. To prevent vitamin deficiency diseases and their associated morbidity, modest vitamin supplementation may be necessary. However, supplementation should be reserved for individuals with documented deficiency or who are at risk of developing such deficiencies, especially those who are homebound or institutionalised. Vitamins taken in large dosages should be considered as drugs. These medicines, which are obtainable over-the-counter, should be carefully regulated to prevent toxicity.     

Characteristics of antibiotic therapy in the elderly

In the elderly, the morbidity and mortality rates of infections are significantly increased. Atypical or nonspecific symptoms or their absence often delay the diagnosis. When providing treatment, in addition to microbiological specifics of infections in the aged, consideration must also be given to pharmacokinetic aspects when choosing a suitable antibiotic. Furthermore, any existing medication must be taken into account in order to avoid interactions and undesirable drug effects. In view of the elevated mortality and multimorbidity rates, the early use of antibiotics is of considerable importance. If no specific etiological diagnosis is available, a broad-spectrum antibiotic should be administered.     

Future trends in renal replacement therapy

The authors report a case about relapsing corneal ulceration in a patient with rheumatoid arthritis. Treatment of such perforated and preperforated corneal ulcers is a difficult task. The poor visual outcome of an emergency penetrating keratoplasty leads to the use of other methods (conjunctival flaps, corneal graft, keratopatch, tissue adhesive). This case report stresses the importance of preserving the anatomy of the eye allowing in a record time the performance of corneal graft. The use of immunosuppressive drugs is also discussed because of the existence of a rheumatoid arthritis with eye involvement.     

Tianeptine therapy for depression in the elderly

PURPOSE: Data on patients with cancer of the larynx are analyzed using statistical models to estimate the effect of gaps in the treatment time on the local control of the tumor. METHODS AND MATERIALS: Patients from four centers, Edinburgh, Glasgow, Manchester, and Toronto, with carcinoma of the larynx and treated by radiotherapy were followed up and the disease-free period recorded. In all centers the end point was control of the primary tumor after irradiation alone. The local control rates at > or = 2 years, Pc, were analyzed by log linear models, and Cox proportional hazard models were used to model the disease-free period. RESULTS: T stage, nodal involvement, and site of the tumor were important determinants of the disease-free interval, as was the radiation schedule used. Elongation of the treatment time by 1 day, or a gap of 1 day, was associated with a decrease in Pc of 0.68% per day for Pc = 0.80, with a 95% confidence interval of (0.28, 1.08)%. An increase of 5 days was associated with a 3.5% reduction in Pc from 0.80 to 0.77. At Pc = 0.60 an increase of 5 days was associated with an 7.9% decrease in Pc. The time factor in the Linear Quadratic model, gamma/alpha, was estimated as 0.89 Gy/day, 95% confidence interval (0.35, 1.43) Gy/day. CONCLUSIONS: Any gaps (public holidays are the majority) in the treatment schedule have the same deleterious effect on the disease free period as an increase in the prescribed treatment time. For a schedule, where dose and fraction number are specified, any gap in treatment is potentially damaging.     

Bolus dispersal through the lungs in surfactant replacement therapy

A model is presented of surfactant replacement therapy. An instilled bolus is pushed into the lungs on the first inspiration, coating the airways with a layer of surfactant and depositing some in the alveoli. Layer thickness depends on the capillary number (muU/gamma, where mu, U, and gamma are bolus viscosity, advancing meniscus velocity, and surface tension, respectively). Larger capillary number leads to thicker layers, reducing alveolar delivery. Subsequently, surface tension gradients sweep surfactant into alveoli not receiving surfactant during the first inspiration. The effects on spreading of sorption kinetics, bolus viscosity, initial layer thickness, initial penetration of surfactant, gravity, and shear stress are examined. Sorption nearly eliminates surface tension gradients in central airways but produces a sharp transition at the leading edge of the exogenous layer. Local thinning of the liquid layer results, trapping 95% of the surfactant in the airways. Gravity and ventilation augment transport somewhat. Transport to the periphery takes 4-170 s for the leading edge but considerably longer for the bulk of the surfactant. The model demonstrates how the various physical parameters governing surfactant distribution might alter the response to surfactant replacement therapy.     

Renal disease in the elderly: distinctive disorders, tailored treatments

Many 40-year-olds would be surprised to learn that, as far as their kidneys are concerned, the aging process is already under way. The decreased blood flow and diminished regulatory capacity that come with age are not necessarily problems. However, when another factor is added (eg, fluid loss from diarrhea, depressed thirst mechanism from sedative use), serious fluid and electrolyte imbalances can result. Dr Ali discusses renal disorders for which older people are at risk, and he provides safety tips on drug choices and doses.     

Choice of renal replacement therapy

Renal replacement therapies (RRT) for acute renal failure patients consist of continuous or intermittent methods. Continuous renal replacement therapies (CRRT) are used in 54% of centers. Determinant for the choice of the continuous versus intermittent method is the clinical status of the patients. Those who are hemodynamically unstable, who receive a large fluid intake, who are anuric, who present with severe and persistent metabolic disorders such as acidosis or hyperkaliemia, and who are in respiratory failure, are preferably treated with CRRT. Once the patient has improved, he can be switched to intermittent RRT (IRRT). Thus CRRT and IRRT are complementary approaches. Dialysis material should be biocompatible; the RRT method used should guarantee stable hemodynamics. Coping with these two requirements reduces the time duration of renal recovery, diminishes the need for catecholamines and may improve the survival rate.     

Menopause and hormone replacement therapy

Menopause is a normal part of life of most women and can be made easier with appropriate information about the events that occur. For those women who desire help for bothersome menopausal symptoms, effective therapy can be offered. The use of HRT for prevention is more complex. Several large randomized clinical trials, including the Women's Health Initiative (WHI) and the Heart and Estrogen Replacement Therapy Study (HERS) in the United States, are currently underway. These trials, which have as end points clinical events such as myocardial infarction, sudden death, fractures, and cancer, will provide answers to many of the questions raised in this discussion. Until the results of these trials are available, clinicians must be prudent in their recommendations and should keep their patients apprised of the relevant uncertainties of preventive HRT.     

Endometrial cytology in postmenopausal hormone replacement therapy

INTRODUCTION: The purpose was to examine whether health-promotion programs offered by California health plans are a serious attempt to improve health status or a marketing device used in an increasingly competitive marketplace. The research examined differences in the coverage, availability, utilization, and evaluation of health-promotion programs in California health plans. METHODS: A mail survey was done of the 35 HMOs (86% response) and 18 health insurance carriers (83% response) licensed to sell comprehensive health insurance in California in 1996 (some plans sell both HMO and PPO/indemnity products). The final sample included 30 commercial HMOs and 20 PPO and indemnity plans. The 1996 California Behavioral Risk Factor Survey (BRFS) of 4,000 adults was used to estimate population participation rates in health-promotion programs. RESULTS: California's HMOs in 1996 offered more comprehensive preventive benefits and health-promotion programs compared to PPO and indemnity plans. HMOs relied on a more comprehensive set of health-education methods to communicate health information to members and were more likely to open their programs to the public. HMOs are also more likely to have developed relationships with community-based and public health providers. Participation in health-promotion programs is low (2%-3%), regardless of plan type, and most health plans limit evaluations to assessment of member satisfaction and utilization. Only 35%-45% of HMOs, and no PPO/indemnity plans, assess the impact of health-promotion programs on health risks and behaviors, health status, or health care costs. CONCLUSION: For the majority of California's PPO and indemnity plans, health promotion is not an integral part of their business. For the majority of HMOs, health-promotion programs are offered primarily as a marketing vehicle. However, a substantial minority of HMOs offer health-promotion programs to achieve other organizational goals of health improvement and cost control.     

Principles of renal replacement therapy in children

Much has changed in pediatric renal replacement therapy during the past decade. Even the smallest critically ill patients can be temporarily supported, and chronic peritoneal and hemodialysis in young children has become routine. Although improved technical capabilities often may raise difficult ethical dilemmas, the health care team must know that such therapeutic modalities are available for the pediatric patient.     

Hormone replacement therapy, other reproductive variables and symptomatic hip osteoarthritis in elderly white women: a case-control study

BACKGROUND: Recent epidemiological studies suggest that post-menopausal hormone replacement therapy might reduce the risk of hip osteoarthritis (OA) in women. However, the association of the disorder with other reproductive variables is controversial. We addressed this issue in a population-based case control study among 413 female cases and 413 age- and sex-matched controls. METHODS: A total of 413 women listed for hip replacement because of primary OA over an 18 month period were compared with an equal number of controls selected from the general population and individually matched for age and general practice. Information about reproductive variables was obtained by questionnaire administered at interview. RESULTS: The risk of hip OA was significantly elevated among women who had had an oophorectomy (OR = 1.9, 95% CI 1.0-3.7). After adjustment for body mass index, the presence of Heberden's nodes, previous hip injury and past leisure sporting activity (all independent risk factors for hip OA), and for other reproductive variables, there was a non-significant, protective effect of long-term hormone replacement therapy, such that > or =5 yr of use was associated with a 40% reduction in risk (OR = 0.6, 95% CI 0.2-1.8). Paradoxically, short-term HRT use (up to 5 yr duration) was associated with an excess risk of hip OA (OR = 1.7, 95% CI 0.9-3.3). There was no association between the risk of hip OA and use of oral contraceptives, parity or hysterectomy. CONCLUSIONS: These data are consistent with previous studies suggesting a protective effect of long-term hormone replacement therapy on the risk of hip OA. By contrast, an elevation of risk in short-term users was demonstrated. Our results also suggest that risk is increased among women who have undergone unilateral or bilateral oophorectomy. Studies are required to investigate the mechanisms underlying these associations.