Pre-tertiary hospital care of patients with chronic kidney disease in India.

BACKGROUND & OBJECTIVES: There is paucity of data available on how chronic kidney disease (CKD) is treated before referral to a tertiary hospital. This study was conducted to assess pre-tertiary hospital care of patients with CKD 5 at their presentation to nephrology services at a tertiary care hospital. METHODS: Over a period of 8 months, consecutive patients with CKD 5 presenting at the Nephrology services at Christian Medical College, Vellore, Tamil Nadu, and their relatives were interviewed to assess the pre-tertiary hospital care and knowledge about CKD 5 and its treatment. RESULTS: A total of 561 patients with CKD 5 were enrolled. The mean duration (months) of known CKD was 12.4 +/- 23.1 and known CKD 5 was 3.2 +/- 3.5. Of these, 369 patients (65.8%) had been under the care of a nephrologist; 305 patients had CKD 5 as the initial presentation of renal illness. Vaccination against hepatitis B had been initiated in only 133 patients (23.7%). Only 172 patients(38%) had an adequately controlled blood pressure. Care under a nephrologist was more likely to result in appropriate investigation, treatment and patient education though blood pressure control did not differ. INTERPRETATION & CONCLUSION: Paucity of symptoms in the initial stages of certain forms of CKD probably led to 50 per cent of patients presenting with CKD 5 as the initial presentation of renal disease. Inadequate vaccination against hepatitis B infection highlights the need for appropriate vaccination. Prevention of CKD and its progression are important targets which requires physician awareness at all levels. Early referral to a nephrologist's care is more likely to result in appropriate investigations and treatment.

Acute abdomen in patients receiving chemotherapy.

OBJECTIVE: To assess the incidence of acute abdomen in patients receiving chemotherapy and to evaluate the factors affecting the clinical decision-making. MATERIAL AND METHODS: Retrospective analysis of surgical oncology references for the patients developing acute abdomen while receiving chemotherapy was carried out. A surgical oncologist reviewed each referral and a full work-up was carried out. Surgical interventions were carried out as and when deemed necessary. Response to treatment, whether surgical or conservative, was used as main outcome variable. RESULTS: Mean age of the patients was 37 years (7-58 years). Half of the patients were receiving chemotherapy for lymphoproliferative disorders, 13 for haematological malignancies and 3 for ovarian cancer. Clinical diagnosis was of acute appendicitis in 13, paralytic ileus in 9, typhilitis in 3 and intestinal perforation in 2, acute intestinal obstruction in 3, and obstructed hernia and intussception in one each. Six patients underwent surgery. Two patients expired postoperatively of progressive septicaemia and multi-system organ failure. CONCLUSION: Evaluation of cancer patients on chemotherapy is difficult. Tenderness, presence of peritoneal signs and absence of exaggerated bowel sounds are most important clinical signs, however they may be blunted by progressive neutropenia or corticosteroid administration. Decision to operate, should be made with extreme caution as mortality and morbidity after surgery is high.

Non invasive evaluation of patients with ventricular septal defect after surgical correction

The present work is planned to study the cause of any residual cardiac murmur after surgical closure of ventricular septal defect and to evaluate cardiac function using Doppler echocardiography. Twenty cases of isolated VSD who underwent trans-atrial surgical closure of VSD were studied. They were 14 males and 6 females. Their age ranged between 3 and 20 years with a mean of 8. 5 +/- 4 years. Preoperative data were collected from patients files as cardiac catheterization data. Operative details were recorded during operation. Post operative study was also conducted and included clinical examination for any residual cardiac murmur. ECG, chest X-ray and Doppler echocardiography were performed to assess closure of the defect. Patients were classified into two groups. Group I included 8 patients with RV pressure < 50 mm Hg. Group 2: included 12 patients with RV pressure > 50 mm Hg. Doppler examination revealed 14 cases of 20 [70%] proved to have no residual shunt. 4 cases had mild shunt [20%], 2 cases had moderate shunt [10%] and no case showed large shunt. The shunt occurred along the suture line. Left ventricular function was assessed by the EF% which ranged between 47% and 63%. RV pressure decreased significantly in both groups postoperatively, post operative echo evaluation has also showed that 9 patients had TR 45%, 1 patient had pericardial effusion [5%], 1 showed vegetation on the patch [5%] and I patient had right atrial thrombus [5%]. We conclude that Doppler echocardiography is highly sensitive in the early post operative detection of VSD shunt, as well as other postoperative complications as pericardial effusion, vegetation on the patch and myocardial dysfunction. Results showed also that RV pressure decreased significantly after closure of the defect in both groups, however, in patients with VSD and at least moderate pulmonary hypertension, pulmonary artery pressure was not returning to normal therefore, it is advisable to operate on individuals with VSD and moderate pulmonary hypertension before there is the any increase of pulmonary vascular resistance