Specificity of Doppler echocardiography for the assessment of changes in valvular regurgitation: comparison of side-by-side versus serial interpretation.

OBJECTIVES: We sought to determine the specificity of two different methods for assessing change in aortic (AR), mitral (MR) and tricuspid (TR) valvular regurgitation. BACKGROUND: Echocardiographic imaging with Doppler is the standard noninvasive diagnostic tool for assessing valvular structure and function. Change can be assessed using either independent evaluations (serial) or using a side-by-side comparison. METHODS: Subjects were from the placebo arm of a randomized, double-blind, clinical trial. Three echocardiograms over 10 months were performed. An initial and three-month echocardiogram were read as independent groups, blinded to all parameters except sequence. The initial and 10-month echocardiograms were read side-by-side, blinded to all parameters including sequence. RESULTS: Two hundred nineteen predominantly healthy, obese, white, middle-aged women had initial and three-month echocardiograms (acquisition interval 105 +/- 28 days) evaluated by the serial method (mean 167 +/- 61 days between interpretations). The same subjects had the initial and 10-month studies (acquisition interval 303 +/- 27 days) compared side-by-side. The specificity of the serial versus side-by-side method for determining change in MR grade was 55.8% versus 93.2% (p < 0.001); TR: 63.8% versus 97.6% (p < 0.001) and AR: 93.7% versus 97.6 (p = 0.08). Notably, most of the change occurred in a range (none versus physiologic/mild) that has limited clinical significance. Furthermore, the percentage of echocardiograms interpreted as nonevaluable was lower with the side-by-side method for MR (5.0% vs. 16.0%, p = 0.06), TR (4.6% vs. 15.5%, p < 0.001) and AR (4.1% vs. 12.3%, p = 0.002). CONCLUSIONS: The side-by-side method of assessing change in valvular regurgitation appears to be the more reliable method with a higher specificity and minimal data loss.

A practical approach to TQI.

Total quality improvement (TQI) is a refreshing new approach to leadership that can be applied to a dialysis setting. The team approach to prospective data analysis is used for problem solution and reevaluation. Adapting theory to daily practical application can be successfully done using time, energy, and full senior management commitment. Staff education and involvement are essential to successful program implementation. Evaluation tools are easily adapted to analyze common dialysis problems. The initial time invested in education and data collection can be great but results in a streamlined process.

Weekly subcutaneous recombinant human erythropoietin corrects anemia of progressive renal failure.

PURPOSE: The purpose of this study was to analyze data retrospectively from our use of weekly subcutaneous recombinant human erythropoietin (rHuEPO) in predialysis and peritoneal dialysis patients with anemia. PATIENTS AND METHODS: All anemic patients with progressive renal failure (12 predialysis and seven home peritoneal dialysis) in whom subcutaneous rHuEPO therapy was begun at, or was reduced to, a weekly dose were studied retrospectively. Patients were not selected for, nor excluded from, these observations for any other reason. Hematocrit and endogenous creatinine clearance were monitored regularly, and no other new treatment for anemia was given except oral iron. Iron-deficiency anemia was considered improbable because of normal red blood cell mean corpuscular volume. Unfortunately, iron parameters were not monitored. RESULTS: The hematocrit increased 4 to 9 percentage points in 4 to 13 weeks in all but two patients who were initially treated with weekly doses, and a hematocrit of 31% was achieved in these patients within 6 to 12 weeks. The mean effective dose to accomplish this was 150 U/kg. All but three patients could be maintained on weekly doses at a hematocrit of 31% or higher. The mean effective dose was 75 U/kg. CONCLUSION: It is concluded that subcutaneous rHuEPO administered weekly can correct the anemia of predialysis and peritoneal dialysis patients. Weekly dosing is more convenient for patients and may be less costly for Medicare providers.

Seldinger technique for Tenckhoff catheter placement.

The Seldinger technique can be applied to the placement of chronic peritoneal dialysis catheters. With strict adherence to criteria identifying low risk patients, the procedure is comparatively safe, simple, usually better tolerated, and likely to be less costly than laparotomy placement. Using a straight Tenckhoff catheter with a subcutaneously placed single cuff, our one year catheter survival is similar to the multicenter data reported by The National CAPD Registry.

Role of catheter removal in therapy of bacterial peritonitis of continuous ambulatory peritoneal dialysis.

Bacterial peritonitis in Continuous Ambulatory Peritoneal Dialysis (CAPD) patients usually responds within a few days to intraperitoneal antibiotics. Catheter removal is rarely needed to resolve the episodes unless they are complicated by endogenous sources such as perforated diverticulitis or infections of the extraperitoneal catheter section. Recurrent peritonitis with the same organism has been attributed to bacterial colonization of the intraperitoneal section, making the decision for catheter removal more difficult. Catheter removal with substitution of hemodialysis may have greater morbidity than prolonged antibiotics. The authors retrospectively analyzed our incidence of and reasons for catheter removal during therapy for bacterial peritonitis for the period from October 1, 1980, to December 31, 1986. For uncomplicated peritonitis, that is, in the absence of infection of the extraperitoneal catheter section, endogenous sources, and episodes associated with catheter function problems per se, the authors were able to resolve the peritonitis without catheter removal in 99.2% of cases. It was concluded that the intraperitoneal catheter section plays a negligible role in thwarting therapeutic efforts in uncomplicated bacterial peritonitis of CAPD.