Outcome of renal replacement therapy in the very elderly.

BACKGROUND: In a retrospective case-note and computer database analysis we assessed the outcome of very elderly patients (> or = 75 years old) with end-stage renal disease (ESRD) on renal replacement therapy (RRT). METHODS: Fifty-eight individuals aged 75 or over (group 1) commenced RRT between 1 January 1991 and 31 December 1995. Comparisons were made with other patients commencing RRT who were divided into two groups: group 2 (201 individuals 65-74 years old) and group 3 (379 patients <65 years old). All subjects were followed up until the point of assessment (30 June 1998), the time of death, or withdrawal from dialysis. Survival rates in the three groups were compared using Kaplan-Meier method. The number of hospital admissions, length of in-patient stay, and complications rate on RRT were assessed for group 1. RESULTS: One-year survival rates in groups 1, 2 and 3 were 53.5, 72.6, and 90.6% respectively and the 5-year survival rates were 2.4, 18.8, and 61.4% respectively. The very elderly spent 20% of their time in hospital, 46% had two co-morbid factors at the outset, and 26% developed multiple complications while on RRT. Withdrawal from dialysis remained the most common cause of death in this group of individuals (38%), followed by cardiovascular causes (24%) and infections (22%). CONCLUSION: Very elderly ESRD patients on RRT have a very poor outcome and, since they are the largest growing group of RRT patients, this has important implications for future health policies.

Reproducibility and automatic measurement of QT dispersion.

This study investigated interobserver (two observers) and intrasubject (two measurements) reproducibility of QT dispersion from abnormal electrocardiograms in patients with previous myocardial infarction, and compared a user-interactive with an automatic measurement system. Standard 12-lead electrocardiograms, recorded at 25 mm.s-1, were randomly chosen from 70 patients following myocardial infarction. These were scanned into a personal computer, and specially designed software skeletonized and joined each image. The images were then available for user-interactive (mouse and computer screen), or automatic measurements using a specially designed algorithm. For all methods reproducibility of the RR interval was excellent (mean absolute errors 3-4 ms, relative errors 0.3-0.5%). Reproducibility of the mean QT interval was good; intrasubject error was 6 ms (relative error 1.4%), interobserver error was 7 ms (1.8%), and observers' vs automatic measurement errors were 10 and 11 ms (2.5, 2.8%). However QTc dispersion measurements had large errors for all methods; intrasubject error was 12 ms (17.3%), interobserver error was 15 ms (22.1%), and observers' vs automatic measurement were errors 30 and 28 ms (35.4, 31.9%). QT dispersion measurements rely on the most difficult to measure QT intervals, resulting in a problem of reproducibility. Any automatic system must not only recognize common T wave morphologies, but also these more difficult T waves, if it is to be useful for measuring QT dispersion. The poor reproducibility of QT dispersion limits its role as a useful clinical tool, particularly as a predictor of events.

Automated measurement of QT interval dispersion from hard-copy ECGs.

Increased "dispersion" of the QT interval of the electrocardiogram has been proposed as a marker for increased risk of cardiac arrhythmias, but definitive identification of its independent predictive value requires accurate and reproducible measurement in large numbers of cases. A personal computer-based technique for (1) converting hard-copy electrocardiograms to digital records and (2) automatically measuring QT interval dispersion from the digitized records has been developed and validated. Hand measurements of the RR interval from the original tracing and cursor or automated measurements from digitized waveforms correlated to within 1%. QT intervals measured by cursor on digitized waveforms were a mean of 14 ms (95% confidence interval, 10-19 ms) longer than manual measurements on original tracings. Automatic QT interval measurements were a mean of 5 ms longer than cursor measurements (95% confidence interval, 3-7 ms). Automated measurements were observer independent and repeatable (coefficient of variation for repeat measurements, 0.137% RR and 0.370% QT). Estimates of QT dispersion (expressed as coefficient of interlead QT variation) were made for 14 patients with documented recurrent ventricular and 15 control subjects. The median coefficient of interlead QT variation was 8.8% (range, 4.4-12.4%) for arrhythmia patients and 3.6% (range, 2.7-6.3%) for the control group (P < .001). The automatic measurements were more conservative and less likely to give spuriously large values for QT dispersion than manual measurements. Automated QT dispersion measurements should facilitate future studies on predicting the risk of ventricular arrhythmias.

Selective noninvasive electrode to study myoelectric signals.

The paper describes the design and construction of a selective surface electrode for use in a clinical environment. The main criterion of the design was to enable the recognition of individual motor unit action potential trains (MUAPTs) at moderate force levels. The main features of the electrode are, first, a small concentric bipolar arrangement to avoid electrode/muscle fibre alignment problems and to allow measurements within a small, well defined probed volume; secondly, the non-requirement for conducting paste or gel; and thirdly, the casing acting as an earth plate. All of these simplify its use. The results of tests undertaken with the electrode showed that it was able to pick up individual MUAPTs at up to 20 per cent of maximum voluntary contraction from the first dorsal interosseous muscle. Tests were carried out on the small hand muscles to further demonstrate the usefulness of the electrode. A computer program was written to calculate the shift in frequency of the power spectrum of the recorded myoelectric signal with muscle fatigue and hence indirectly to demonstrate the ability of the electrode to detect the reduction in muscle fibre conduction velocity.