Results of implementation of a contemporary model for ambulance diversions in an integrated healthcare delivery system.

This brief report contains a description of a contemporary, coordinated new system for ambulance diversions, which was implemented in Edmonton area's Capital Health Region in January 1999. The development of this new system was precipitated by the combination of increasing pressures within the acute care system especially being felt within our emergency departments, and mounting evidence that the existing system for ambulance diversions was ineffectual in providing temporary relief of these pressures. The nature of the previous and the new system are compared and contrasted, and data are included to demonstrate that the new system has led to marked reductions in the number of ambulance diversions experienced regionally.

The last critical care bed in Western Canada.

This Brief Report provides an assessment of various factors contributing to the widely publicized emergency department overflow and bed availability crisis that occurred last spring in Edmonton area's Capital Health Region. We were able to divide the factors contributing to the crisis into those of a general nature, those related specifically to health care restructuring, and factors related even more specifically to the nature of Capital Health's Integrated Delivery System. Strategies that we have developed to deal with each of these factors are described.

Public-private partnerships in the Canadian environment: options for hospital pharmacies.

This brief report explores the direction being pursued by hospitals interested in outsourcing non-core activities within the pharmacy department. Private sector logistics companies are looking to position themselves in the drug product supply chain to facilitate seamless transfers of drug products, ordering information and payments between drug manufacturers and hospitals. Opportunities for implementing consolidated purchasing, unit dosing, just-in-time inventory and electronic commerce systems are discussed.

Public-private management partnerships in the Canadian environment: options for medical imaging.

Health services restructuring demands that hospitals consider innovative ways of providing patient care, including services within the clinical support departments such as medical imaging, diagnostic laboratories and pharmacy. This Brief Report describes the result of work carried out a St. Michael's Hospital to explore options for public-private management partnerships within the Department of Medical Imaging. Various partnership models and opportunities for cost containment, revenue generation and strategic positioning are discussed.

An analysis of predictors of long-term cadaveric renal allograft survival.

To determine factors predictive of long-term graft function in patients treated prophylactically with an antilymphocyte antibody, 670 first cadaveric adult renal transplant procedures performed between 1985 and 1991 were reviewed. The actuarial 1- and 5-year patient survival in this group was 95% and 87% respectively, and graft survival was 84% and 70% respectively. The final analysis was based on a study group of 635 patients which excluded 28 patients who lost grafts to early technical failures and 8 patients who were not induced with an antilymphocyte preparation. Multivariate analysis showed that 5-year graft survival was lower in patients with delayed graft function (p = 0.0001), in those who had an acute rejection episode in the first 6 months post-transplant (p = 0.0001), recipients greater than 55 years of age at the time of transplant (p = 0.0001), in patients who were highly sensitized at the time of transplant (p = 0.0331) and, finally, in those who received a graft from an older donor (p = 0.044). The 209 patients with delayed graft function had a 16% lower long-term graft survival than 425 patients with early graft function (62% vs. 78% respectively at 5 years). One or more rejection episodes in the first 6 months post-transplant (329 patients) reduced long-term graft survival by 13% compared to those who did not have a rejection episode (67% vs. 80% respectively at 5 years).(ABSTRACT TRUNCATED AT 250 WORDS)

A comparison of rabbit antithymocyte serum and OKT3 as prophylaxis against renal allograft rejection.

A total 166 first cadaveric renal allograft recipients were randomly assigned to receive either rabbit antithymocyte serum (RATS) (n = 83) or OKT3 (n = 83) for 10 to 14 days after transplant as prophylaxis against rejection. Both groups were similar with respect to age, sex, donor age, diabetes, time on dialysis, panel-reactive antibody, HLA matching, and transfusion before transplantation. All patients were followed for 1 year after transplantation. A comparison of the rejection rates between the 2 groups of patients showed that patients receiving OKT3 had a rate of first rejection 1.87 times higher than those receiving RATS (95% confidence interval 1.18-2.8, P = 0.007). Twenty-five steroid-resistant rejections occurred in OKT3-treated patients as compared with 12 in the RATS-treated group (P < 0.05). There was no significant difference in early or late renal function between the 2 groups of patients. Actuarial 1-year graft survival for the RATS group was 78% and for the OKT3 group, 80.7% (P = NS). Actuarial 1-year patient survival was similar: 89.5% in the RATS group and 94.6% in the OKT3 group (P = NS). Total hospitalization time was 29.8 +/- 19.9 days for RATS vs. 39.5 +/- 22.1 days for those treated with OKT3 (P < 0.006). A number of infections were observed but there were no significant differences between the groups. We conclude that RATS provides better prophylaxis than OKT3 in first cadaveric renal transplants because it is associated with fewer rejection episodes, less hospitalization, and no additional morbidity or mortality.

Treatment of hyponatremia: a quantitative analysis.

The bulk of clinical and experimental evidence seems to support the view that a catastrophic outcome can accompany rapid correction of chronic hyponatremia. However, the dilemma that faces the clinicians is controlling the rate at which the serum sodium concentration is increased during the treatment of hyponatremia. We present a case of severe hyponatremia and hypokalemia to illustrate, in a quantitative fashion, that the increase in serum sodium concentration will be determined not only by the tonicity of infused fluids, but also, and to a major degree, by the rate of excretion of free water by the kidney. A rapid increase in serum sodium concentration would occur if antidiuretic hormone (ADH) release is inhibited and water diuresis ensues. We suggest that the administration of potassium chloride (orally or via a central line) would have been the appropriate therapy for this patient.

Cementless total hip arthroplasty in renal transplant patients.

Twenty-seven cementless total hip arthroplasties were performed in 17 steroid-dependent renal transplant patients. The average age at operation was 39 years, and the average daily dose of prednisone was 10.9 mg. At a mean of 48 months post-surgery, all patients had good to excellent hip ratings on clinical examination and the results compared favorably with 235 non-steroid-dependent age-matched patients using the identical prosthetic hip system. The results of this study suggest that long-term immunosuppression does not prevent bone ingrowth. Noncemented total hip arthroplasty appears to be a reasonable therapeutic option for end-stage osteonecrosis in steroid-dependent renal transplant patients.

Long-term benefits of therapy with cyclophosphamide and prednisone in patients with membranous glomerulonephritis and impaired renal function.

Long-term follow-up data are provided for a previously reported study of patients with membranous glomerulonephritis (MGN), nephrotic syndrome, and renal function impairment. Nine patients were treated with cyclophosphamide (1 to 2 mg/kg) and six of these received concurrent prednisone; they are compared with 17 concurrent controls (14 of whom had received prednisone at some time). The mean follow-up is 83 +/- 13 months in the treated patients and 64 +/- 7 months in the controls. Of the nine treated patients, four achieved a complete remission from the nephrotic syndrome (proteinuria less than 0.5 g/d), and five a partial remission (proteinuria decreased by at least 50% and to less than 3.5 g/d). One of the nine treated patients and 10 of the 17 controls have reached end-stage renal disease (ESRD) (P less than 0.05). Nine of the controls reaching ESRD had persistent nephrotic syndrome, whereas of the seven controls who have not yet reached ESRD, only two have persistent nephrotic syndrome (chi 2, P less than 0.02). There have been four relapses in three treated patients, and three of the four have responded to repeat therapy. One patient refused full therapy and remains nephrotic. Life-table analysis demonstrates significantly increased survival from ESRD in treated patients as compared with controls (P = 0.04).

Urine electrolytes and osmolality: when and how to use them.

The purpose of this review is to provide an update on the use of the urine electrolyte and osmolality measurements in patients with disorders of fluid, electrolytes, and/or acid-base metabolism. It is critical to appreciate that there are no 'normal values' for these parameters, only 'expected values' relative to clinical situations. Pitfalls in the interpretation of each electrolyte in the urine are also provided. To detect a mild to moderate degree of reduction of the 'effective' intravascular volume, both urine sodium (Na) and chloride (Cl) concentrations should be measured. Pitfalls in this assessment are abnormal renal and adrenal function and the use of diuretics. Insights into the etiology of the low 'effective' intravascular volume can be deduced by comparing the urine Na, potassium (K), and Cl concentrations. The urine net charge (Cl vs. Na + K) is the most reliable way to estimate the urine ammonium concentration short of its direct measurement, an assay that is not provided by most laboratories. This measurement is important in the differential diagnosis of hyperchloremic metabolic acidosis. To examine the renal response to hypokalemia or hyperkalemia, the two components of K excretion (K secretion and urine flow rate) should be examined separately. The former is evaluated using the transtubular K, concentration gradient. The urine osmolality is used to assess antidiuretic hormone action and the osmolality of the renal medulla and to determine the etiology of polyuria and/or hypernatremia. The urine osmolality can also be used to assess the ammonium concentration, using the urine osmolal gap, and to detect unusual urine osmoles.

Early function as the principal correlate of graft survival. A multivariate analysis of 200 cadaveric renal transplants treated with a protocol incorporating antilymphocyte globulin and cyclosporine.

We examined the factors determining graft survival in 200 consecutive cadaveric renal transplants managed on a quadruple-therapy protocol: Minnesota antilymphoblast globulin, cyclosporine, azathioprine, and low-dose prednisone. Perioperative central venous pressure monitoring and volume expansion were emphasized. To avoid CsA nephrotoxicity in the early posttransplant period, patients were treated with ALG until renal function was established (a mean of 7 days). Therapeutic CsA levels were achieved before ALG was discontinued. Azathioprine was used to supplement CsA in patients with nephrotoxicity or rejection. Twelve-month graft survival was 85% (first transplants 86%, retransplants 79%), with patient survival of 95%. ALG was not associated with excessive clinical cytomegalovirus infections, which occurred in 5% of patients, or with malignancy. When 3 technical failures were excluded, an analysis of numerous factors in the pretransplant and peritransplant period revealed that the strongest correlate of one-year graft survival was early renal function. Grafts with delayed function (DF) had 75% survival, compared with 91% for grafts with good early function (EF). A multivariate analysis confirmed this association: the relative risk of graft loss was increased 2.86 times for DF compared with EF. The mechanism of the deleterious effect of DF was apparently multifactorial: the DF group, by definition, contained all the kidneys that never functioned, but some risk also persisted in kidneys that achieved function. One reason for this may be that DF kidneys that achieved function had higher mean serum creatinine values at 1 month: elevated serum creatinine values at 1 month were strongly associated with increased risk of graft loss regardless of initial function. There was also a higher number of rejection episodes diagnosed in the DF group. These observations suggest that early renal function is a major determinant of graft outcome and should be a target for efforts to further improve renal graft survival.

The urine osmolal gap: a clue to estimate urine ammonium in "hybrid" types of metabolic acidosis.

The urine osmolal gap is defined as the difference between measured urine osmolality and the sum of the concentrations of sodium, potassium, chloride, bicarbonate, urea and glucose. Normally, this gap is 80-100 mosmol/kg H2O. A determination of the urine osmolal gap may be useful to ascertain the etiology of metabolic acidosis which is of the mixed wide and normal plasma anion gap type ("hybrid" metabolic acidosis). For example, with "hybrid" metabolic acidosis, a low urine osmolal gap will suggest the absence of excessive organic aciduria (ketoacidosis) and the basis of the normal anion gap type of acidosis will be determined by the urine anion gap or "net charge". Where "hybrid" metabolic acidosis has occurred due to wide anion gap metabolic acidosis with loss of organic acid anion in the urine, the urine osmolal gap will be high and can be used in a semi-quantitative fashion to estimate the sum of urinary ammonium plus ketone body anion concentrations.

Myeloma-like cast nephropathy associated with acinar cell carcinoma of the pancreas.

Obstruction of renal collecting tubules by protein cats inciting a giant cell reaction is usually characteristic of myeloma cast nephropathy. Rarely other causes of proteinuria may result in a similar morphology. We report a rare case of 'myeloma-like' tubular casts in the kidney of a patient who was subsequently found at autopsy to have acinar cell carcinoma of the pancreas with peritoneal carcinomatosis. Only two similar reports could be found in the English literature.

A controlled trial of cyclophosphamide in patients with membranous glomerulonephritis.

Patients with membranous glomerulonephritis (MGN), impaired renal function and the nephrotic syndrome are at high risk of developing renal failure. Twenty-six such patients were studied with serum creatinine concentrations exceeding 135 microM, and 24-hour urine protein excretion of at least 3.5 g/day to determine the potential benefit of cyclophosphamide therapy. Cyclophosphamide (mean 1.5 mg/kg/day) was given to nine patients for 23 +/- 4 months. These patients were compared with 17 concurrent controls. The two groups did not differ in clinical or laboratory features at the time of biopsy or start of treatment or its equivalent. Six of the nine cyclophosphamide treated patients and 15 of the 17 controls had received prednisone therapy. The total follow-up was 49 +/- 10 months in the treated group and 50 +/- 6 months in the controls. At last observation, serum creatinine values exceeded 400 microM in eight controls (4 on dialysis) and in none of the treated patients. The mean serum creatinine level was significantly lower (P less than 0.02) in the treated group (173 +/- 24 microM) than in controls (433 +/- 71 0.02) in the treated group (173 +/- 24 microM) than in controls (433 +/- 71 microM). The mean serum albumin level and 24-hour urine protein excretion both improved significantly with treatment as compared with controls. There were four complete remissions, five partial remissions and no patient with persistent nephrotic syndrome after treatment. In the controls, there were no complete remissions, six partial remissions and 11 patients had persistent nephrotic syndrome (P less than 0.001). Thus, cyclophosphamide therapy appears to be of benefit in patients with MGN, the nephrotic syndrome and impaired renal function.