Subject(s)
Child Health Services , Child Mortality , Community Medicine , Social Class , Socioeconomic Factors , Child , Child Advocacy/economics , Child Advocacy/education , Child Advocacy/history , Child Advocacy/psychology , Child Health Services/economics , Child Health Services/history , Child Mortality/ethnology , Child Mortality/history , Child Welfare/ethnology , Child Welfare/history , Child Welfare/psychology , Community Medicine/economics , Community Medicine/education , Community Medicine/history , Death , England/ethnology , History, 19th Century , Humans , Records , Residence Characteristics , Social Class/history , Social Conditions/economics , Social Conditions/historyABSTRACT
Vascular calcification (VC), which is described in the elderly and in diabetics, is frequently seen in uraemia. It is usually regarded as having little significance. We studied the roentgenological appearance of VC in a homogeneous group of 38 long-hours haemodialysis patients whose longevity on dialysis allowed sustained (10-25 years) follow-up, including annual skeletal surveys and thrice-yearly clinical examinations and biochemical profiles. We compiled a dossier of clinical and laboratory parameters from the start of dialysis to the present day. We were able to analyze the natural history of VC and to determine which clinical parameters were linked with progression. We found that VC became steadily more prevalent-at dialysis onset present in 39% of the patients, but in 92% after an average dialysis duration of 16 years, with a mean onset 9.7 years after starting dialysis. As well as becoming more prevalent, the calcification became progressively more severe in most patients. There were two patterns of VC: axial (aorta and iliac and femoral arteries), seen alone in 32% of the patients, and peripheral (digital arteries), seen alone in 3% of patients. Most patients (65%) had evidence of both types. Calcification was scored for site and severity. Patient age (r = 0.57, p < 0.001), systolic blood pressure (r = 0.54, p < 0.001), hyperparathyroidism (reduced progression after parathyroidectomy), plasma phosphate (r = 0.34, p = 0.042), and vitamin D concentrations (r = 0.53, p < 0.001) were the principal determinants of severity and rate of progression of VC in this population. There was a weak negative association between progression and serum ferritin (r = -0.33, p = 0.046). The reduced vessel compliance that results from VC is likely to be cardiovascularly deleterious. In severe cases, tissue perfusion or vascular access for haemodialysis can be compromised. VC and accelerated cardiovascular mortality are common to uraemia, diabetes, and systolic hypertension in the elderly. Better understanding of these pathological processes may permit intervention and possibly lead to a reduction in cardiovascular mortality.
Subject(s)
Calcinosis/etiology , Renal Dialysis/adverse effects , Uremia/complications , Vascular Diseases/etiology , Calcinosis/complications , Calcinosis/pathology , Diabetes Complications , Disease Progression , Female , Humans , Kidney/pathology , Kidney Transplantation/physiology , Long-Term Care , Male , Middle Aged , Peritoneal Dialysis, Continuous Ambulatory/adverse effects , Retrospective Studies , Uremia/therapy , Vascular Diseases/complications , Vascular Diseases/pathologyABSTRACT
Nine cases of severe sepsis following percutaneous or endoscopic procedures for upper urinary tract stones are reported. The mortality rate was 66%. Despite the fact that approximately 700 procedures were carried out in males and females in roughly equal proportions, a striking but inexplicable feature was that all 9 patients in the study group were female. Severe systemic sepsis has a high mortality rate and any procedure that may put patients at risk of this complication should not be undertaken lightly (and certainly not as an out-patient procedure). Recovery is possible with a high index of suspicion, early intervention and intensive treatment.
Subject(s)
Nephrostomy, Percutaneous , Postoperative Complications , Sepsis/etiology , Urinary Calculi/surgery , Adolescent , Adult , Aged , Aged, 80 and over , Endoscopy , Female , Fever/etiology , Hemodynamics/physiology , Humans , Hypotension/etiology , Hypothermia/etiology , Lithotripsy , Middle Aged , Sepsis/physiopathology , Sex FactorsABSTRACT
In a series of 51 patients with prostate cancer and obstructive uropathy, unilateral or bilateral obstruction was identified in 22 (43%) and 29 (57%) respectively. This included a non-functioning kidney in 12 patients. In 86% of patients the T category was advanced. Bone metastases were present in 36 cases (71%); 19 patients (37%) had chronic retention. All patients with metastatic disease underwent hormonal manipulation and 43 underwent transurethral resection of the prostate. External beam radiotherapy, percutaneous nephrostomy and ureteric reimplantation were performed in 4, 5 and 1 patient respectively. Actuarial survival of all 51 patients was 57 and 25% at 2 and 5 years. Presentation with bilateral or non-function did not predict a worse prognosis in comparison with patients with unilateral hydroureteronephrosis. Raised alkaline phosphatase and prostatic acid phosphatase were of no prognostic value, while creatinine reached marginal significance. A positive bone scan and raised urea were strongly predictive of a poor outlook. It was concluded that prostate cancer and obstructive uropathy should not uniformly imply a terminal event, and interventional therapy is justified with a 25% 5-year survival rate.
