End-of-life care beliefs among Hindu physicians in the United States.

Several studies from the United States and Europe showed that physicians' religiosity is associated with their approach to end-of-life care beliefs. No such studies have focused exclusively on Hindu physicians practicing in the United States. A 34-item questionnaire was sent to 293 Hindu physicians in the United States. Most participants believed that their religious beliefs do not influence their practice of medicine and do not interfere with withdrawal of life support. The US practice of discussing end-of-life issues with the patient, rather than primarily with the family, seems to have been adopted by Hindu physicians practicing in the United States. It is likely that the ethical, cultural, and patient-centered environment of US health care has influenced the practice of end-of-life care by Hindu physicians in this country.

Role of sodium restriction and diuretic therapy for "resistant" hypertension in chronic kidney disease.

In patients with chronic kidney disease, an impaired capacity of the kidney to excrete sodium is a major contributor to hypertension. We discuss the role of sodium restriction and diuretic therapy for resistant hypertension in chronic kidney disease. Independent of increasing blood pressure, a sustained high sodium intake also may affect the progression of renal disease adversely. Consequently, dietary sodium restriction and appropriate diuretic therapy are the foundation for the treatment of resistant hypertension. Thiazide-like diuretics have decreasing effectiveness in patients with advancing renal disease; however, they may augment the effectiveness of the more potent loop diuretics. Increasing evidence suggests that spironolactone is an effective adjunct for the treatment of resistant hypertension. Inclusion of other classes of antihypertensive agents to the treatment regimen generally is necessary to counterbalance other mechanisms contributing to resistant hypertension. The effectiveness of these agents is enhanced by dietary sodium restriction and diuretic therapy.

Peritoneal dialysis versus hemodialysis: risks, benefits, and access issues.

Peritoneal dialysis (PD) and hemodialysis (HD) are dialysis options for end-stage renal disease patients in whom preemptive kidney transplantation is not possible. The selection of PD or HD will usually be based on patient motivation, desire, geographic distance from an HD unit, physician and/or nurse bias, and patient education. Unfortunately, many patients are not educated on PD before beginning dialysis. Most studies show that the relative risk of death in patients on in-center HD versus PD changes over time with a lower risk on PD, especially in the first 3 months of dialysis. The survival advantage of PD continues for 1.5-2 years but, over time, the risk of death with PD equals or becomes greater than with in-center HD, depending on patient factors. Thus, PD survival is best at the start of dialysis. Patient satisfaction may be higher with PD, and PD costs are significantly lower than HD costs. The new reimbursement system, including bundling of dialysis services, may lead to an increase in the number of incident patients on PD. The high technique failure of PD persists, despite significant reductions in peritonitis rates. Infection also continues to be an important cause of mortality and morbidity among HD patients, especially those using a central venous catheter as HD access. Nephrologists' efforts should be focused on educating themselves and their patients about the opportunities for home modality therapies and reducing the reliance on central venous catheter for long-term HD access.

Blood Loss through AV Fistula: A Case Report and Literature Review.

Little has been written about acute blood loss from hemodialysis vascular access. We describe a 57-year-old Caucasian male with an approximately 7 gm/dL drop in hemoglobin due to bleeding from a ruptured aneurysm in his right brachiocephalic arteriovenous fistula (AVF). There was no evidence of fistula infection. The patient was successfully managed by blood transfusions and insertion of a tunneled dialysis catheter for dialysis access. Later, the fistula was ligated and a new fistula was constructed in the opposite arm. Aneurysm should be considered in cases of acute vascular access bleeding in chronic dialysis patients.

Malignant transformation of actinic keratoses to squamous cell carcinoma in an albino.

A 25-year-old male, who was a known case of oculocutaneous albinism presented to us with right inguinal swellings of six months' duration. He gave a preceding history of a similar lump in the right thigh, which was excised at the Chennai Government Hospital. He was diagnosed to have oculocutaneous albinism with actinic keratoses, with multiple squamous cell carcinomas (with metastatic deposits in the right inguinal region) and cutaneous horns. The case is reported to highlight preventive aspects in the management of albinos.