Stress, burnout and hardiness in R.T.s.

This article reports results of a survey assessing the relationship among occupational stress, "personality hardiness" and burnout in 95 radiographers employed in Connecticut hospitals. Regression analyses indicated a positive correlation between burnout and occupational stress, and an inverse relationship between personality hardiness and burnout. Personality hardiness had a beneficial effect at all stress levels.

A randomized comparison of intradermal and intramuscular vaccination against hepatitis B virus in incident chronic hemodialysis patients.

Hepatitis B virus (HBV) remains a threat to hemodialysis patients. Nevertheless, the vaccination rate against this virus is low, perhaps because of the low conversion rate. Although intradermal (ID) vaccination has been proven to be effective (even in patients nonresponsive to intramuscular [IM] vaccination), the duration of immunity was short. The impact of vaccination route and a greater peak antibody (Ab) titer on conversion rate and duration of immunity after ID or IM vaccination was compared in incident hemodialysis patients. Forty-nine patients were randomly assigned to treatment with 5 microgram of recombinant hepatitis B vaccine (Engerix B; Smith Kline Beecham Pharma Inc, Oakville, ON, Canada) ID every 2 weeks up to either a peak Ab titer of 1,000 IU/L or greater or 52 doses, whereas 48 patients were administered 40 microgram IM at 0, 1, 2, and 6 months. Group demographics were similar. Conversion was achieved in 97.6% of the ID group and 90.5% of the IM group (P: = 0.16). There was no difference between ID and IM groups in time required to convert, peak Ab titer reached, and proportion of patients with a peak Ab titer of 1,000 IU/L or greater. Overall, the duration of immunity was not different after ID or IM vaccination (P = 0.683), and patients in the IM group with a peak Ab titer of 1,000 IU/L or greater had a longer duration of immunity (P = 0.001). In conclusion, a high conversion rate and long duration of immunity against HBV can be achieved cost-effectively in the end-stage renal disease population using the ID or IM route and aiming for an Ab titer exceeding 1,000 IU/L. Based on these data, we provide recommendations for vaccination and surveillance in this population.

Comparative hospitalization of hemodialysis and peritoneal dialysis patients in Canada.

BACKGROUND: Most comparisons of hemodialysis (HD) and peritoneal dialysis (PD) have used mortality as an outcome. Relatively few studies have directly compared the hospitalization rates, an outcome of perhaps equal importance, of patients using these different dialysis modalities. METHODS: Eight hundred twenty-two consecutive patients at 11 Canadian institutions with irreversible renal failure had an extensive assessment of comorbid illness and initial mode of dialysis collected prospectively immediately prior to starting dialysis therapy. The cohort was assembled between March 1993 and November 1994. The mean follow-up was 24 months. Admission data were used to compare hospitalization rates in HD and PD. RESULTS: Thirty-four percent of patients at baseline and 50% at three months used PD. Twenty-five percent of HD and 32% of PD patients switched dialysis modality at least once after their first treatment (P = NS). Nine percent of HD patients and 30% of PD patients switched modality after three months (P < 0. 001). Total comorbidity was higher in HD patients at baseline (P < 0. 001) and at three months (P = 0.001). The overall hospitalization rate was 40.2 days per 1000 patient days after baseline and 38.0 days per 1000 patient days after three months. When an adjustment was made for baseline comorbid conditions, patients on PD had a lower rate of hospitalization in intention-to-treat analysis according to the type of dialysis in use at baseline (RR 0.85, 95% CI, 0.82 to 0.87, P < 0.001), but a higher rate according to the type of dialysis in use three months after study entry (RR 1.31, 95% CI, 1.27 to 1.34, P < 0.001). In analyses based on the amount of time actually spent on each treatment modality, PD was associated with a higher rate of hospitalization when analyzed according to the type of dialysis in use at baseline (RR 1.10, 95% CI, 1.07 to 1.13, P < 0.001) and according to the type of dialysis in use three months after study entry (RR 1.26, 95% CI, 1.23 to 1.30, P < 0.001). CONCLUSIONS: Conclusions regarding comparative hospitalization rates are heavily dependent on the analytic starting point and on whether intention-to-treat or treatment-received analyses are used. When early treatment switches are accounted for, HD is associated with a lower rate of hospitalization than PD, but the effect is modest.

Comparative mortality of hemodialysis and peritoneal dialysis in Canada.

BACKGROUND: Comparisons of mortality rates in patients on hemodialysis versus those on peritoneal dialysis have been inconsistent. We hypothesized that comorbidity has an important effect on differential survival in these two groups of patients. METHODS: Eight hundred twenty-two consecutive patients at 11 Canadian institutions with irreversible renal failure had an extensive assessment of comorbid illness collected prospectively, immediately prior to starting dialysis therapy. The cohort was assembled between March 1993 and November 1994; vital status was ascertained as of January 1, 1998. RESULTS: The mean follow-up was 24 months. Thirty-four percent of patients at baseline, 50% at three months, and 51% at six months used peritoneal dialysis. Values for a previously validated comorbidity score were higher for patients on hemodialysis at baseline (4.0 vs. 3.1, P < 0.001), three months (3.7 vs. 3.2, P = 0.001), and six months (3.6 vs. 3.2, P = 0.005). The overall mortality was 41%. The unadjusted peritoneal dialysis/hemodialysis mortality hazard ratios were 0.65 (95% CI, 0. 51 to 0.83, P = 0.0005), 0.84 (95% CI, 0.66 to 1.06, P = NS), and 0. 83 (95% CI, 0.64 to 1.08, P = NS) based on the modality of dialysis in use at baseline, three months, and six months, respectively. When adjusted for age, sex, diabetes, cardiac failure, myocardial infarction, peripheral vascular disease, malignancy, and acuity of renal failure, the corresponding hazard ratios were 0.79 (95% CI, 0. 62 to 1.01, P = NS), 1.00 (95% CI, 0.78 to 1.28, P = NS), and 0.95 (95% CI, 0.73 to 1.24, P = NS). Adjustment for a previously validated comorbidity score resulted in hazard ratios of 0.74 (95% CI, 0.58 to 0.94, P = 0.01), 0.94 (95% CI, 0.74 to 1.19, P = NS), and 0.88 (95% CI, 0.68 to 1.13, P = NS) at baseline, three months, and six months. There was no survival advantage for either modality in any of the major subgroups defined by age, sex, or diabetic status. CONCLUSIONS: The apparent survival advantage of peritoneal dialysis in Canada is due to lower comorbidity and a lower burden of acute onset end-stage renal disease at the inception of dialysis therapy. Hemodialysis and peritoneal dialysis, as practiced in Canada in the 1990s, are associated with similar overall survival rates.

Prediction of early death in end-stage renal disease patients starting dialysis.

Demand for dialysis for patients with end-stage renal disease is growing, as is the comorbidity of dialysis patients. Accurate prediction of those destined to die quickly despite dialysis could be useful to patients, providers, and society in making decisions about starting dialysis. To determine whether age and comorbidity accurately predict death within 6 months of first dialysis for end-stage renal disease, a prospective cohort study of 822 patients starting dialysis at one of 11 Canadian centers was performed. Patient characteristics were recorded at first dialysis. Follow-up continued until death or study end (at least 6 months after enrollment). One hundred thirteen of 822 (13.7%) patients died within 6 months. Although an existing scoring system predicted prognosis, adverse scores greater than 9 were found in only 9.7% of those who died; only 52% of those who scored higher than 9 died within 6 months. No score cutoff point combined high true-positive and low false-positive rates for predicting early death. Age, severity of heart failure or peripheral vascular disease, arrhythmias, malnutrition, malignancy, or myeloma were independent prognostic factors identified in multivariate models. However, the best fit discriminant and logistic models were also unable to accurately predict death within 6 months. Clinicians were very accurate in assigning patients to prognostic groups up to a 50% risk of death by 6 months, above which they tended to overestimate risk. However, clinicians were only marginally better than the predictive models in determining whether a given high-risk patient would die. The inability of a scoring system or clinical intuition to accurately predict death soon after starting dialysis for end-stage renal disease suggests that limiting access to dialysis on the basis of likely short survival may be inappropriate in Canada.

The benefits and side effects of ramped hypertonic sodium dialysis.

The effectiveness of ramped hypertonic sodium dialysis (RHSD) is controversial because of the prevalence of side effects (weight gain and hypertension). Standard dialysis (SD) was therefore compared with RHSD in a double-blind controlled crossover trial. Eleven patients who suffered from symptoms attributable to water shifts from extracellular fluid to intracellular fluid (headaches or hangover) or extracellular-fluid volume contraction (cramps or lightheadedness) and five asymptomatic patients were enrolled in the study. RHSD was individually tailored to each patient (to minimize thirst) during a 2-wk run-in period. Patients then received RHSD and SD for a period of 3 wk in randomized sequence. Outcome measures were both objective and subjective ratings on questionnaires. Significant differences were found between the two treatments, with RHSD improving specific problems (70% of lightheadedness/cramps, 100% of headaches/hangover) versus SD. Weight gain and hypertension were not different between the two treatments despite increased thirst sensation reported by 14/16.94% of patients preferred RHSD. Long-term studies in 20 different patients demonstrated the lack of increase in blood pressure or weight gain after 3 and 6 months of therapy.

Successful vaccination with intradermal hepatitis B vaccine in hemodialysis patients previously nonresponsive to intramuscular hepatitis B vaccine.

Seventy-seven chronic hemodialysis patients were vaccinated against hepatitis B virus with an intramuscular (im) hepatitis B vaccine (HBV), 40 micrograms at 0, 1, 2, and 6 months. Fifty-seven patients (74%) developed antibodies (anti-HBs). The im-responsive patients were significantly younger than the nonresponsive patients (P < 0.05). Nineteen of the 20 im nonresponders received HBV intradermally (id), 5 micrograms every 2 wk until anti-HBs developed; the 20th patient died before receiving the id vaccine. Three patients were lost to follow-up. Fifteen (94%) of the 16 developed anti-HBs after 5.2 +/- 4.7 months. The peak anti-HBs titers were 726 +/- 426 (im) and 211 +/- 260 (id) IU/L (P < 0.05). Twelve (21%) of the 57 im-responsive patients and 8 (53%) of the 15 id-responsive patients had anti-HBs less than 20 IU/L at 18 and 8 months postvaccination, respectively (P < 0.05). Further preliminary data indicate that more prolonged id vaccination can increase both the titer and the duration of anti-HBs in im-nonresponsive patients.

Myocardial alterations during hemodialysis: insights from new noninvasive technology.

Eighteen patients with chronic renal failure had their cardiac status monitored during hemodialysis (HD). Ten studies were carried out using an ambulatory nuclear vest to assess ejection fraction (EF), heart rate (HR), relative end-systolic (ESV) and end-diastolic (EDV) volumes every 60 s. A total of 36 episodes of EF falls occurred in 9 patients, all asymptomatic. These EF falls were associated with a rise in ESV, while HR, BP, and EDV remained unchanged. The EF falls correlated best with the volume of ultrafiltrate removed. Ten patients had on-line ST-segment monitoring with sestamibi injection either at the time of ST depression (STD) or at the end of dialysis, if no STD occurred, in order to detect the presence of transient ischemia. Seven of ten patients had perfusion defects after dialysis, with STD occurring in 3 of 10 patients. Predialysis imaging was available in only 8 of 10 patients, and 6 of these patients had perfusion defects. Changes in perfusion defects were not significantly different in the 3 patients with STD compared with those without STD. EF falls and perfusion defects are common in HD patients even in the absence of known coronary artery disease; however, ST segment monitoring is not a sensitive tool for its detection. These changes in function and perfusion may represent myocardial ischemia and contribute to the high incidence of cardiovascular morbidity and mortality in this patient population.

Mathematical formulation to help identify the patient at risk of ischemic tissue necrosis--a potentially lethal complication of chronic renal failure.

Ischemic tissue necrosis (ITN) has been described as a complication of hyperparathyroidism (HPT) in patients with end-stage renal disease (ESRD) and is associated with a mortality rate of up to 80%. Early recognition of ITN is important but difficult. Optimal treatment is controversial. Based on an analysis of the English literature and a recent clinical experience, a mathematical expression to aid in the identification of high-risk patients (2 x [CaPO(4) - 5] x alkaline phosphatase x PTH ratio) was developed. The values for this expression were calculated in 3 recently reported cases and our case (n = 4). The values were compared with those of a group of 54 hyperparathyroid chronic hemodialysis patients (controls); the mean values were significantly different (p < 0.001). The expression, consisting of 4 easily measured laboratory values, appears to differentiate patients with this complication of ITN from patients with only severe HPT. Ten new additional cases were evaluated using the equation; the sensitivity of the equation was 80% and the specificity 92%, positive predictive value was 66% and the negative predictive value 96%. Long-term validation of this equation is required but it appears to be discriminatory and, thus, promising, given the potentially lethal consequences of ITN.

Canadian Hemodialysis Morbidity Study.

The objective of this study was to determine the probabilities of specific morbid events or death among patients with end-stage renal disease (ESRD) treated by hemodialysis. A prospective cohort study was performed between March 1988 and September 1989 in 18 hemodialysis centers in 13 Canadian cities, representing about one third of the hemodialysis population in Canada. The inception cohort consisted of 496 patients entering hemodialysis who had survived 1 month. The few new hemodialysis patients who received erythropoietin (EPO) in the last 3 months of the study were excluded. Survival curves were compared using the Cox proportional hazards regression model. Older age and history of cardiovascular disease were independently associated with a greater probability of death. Age and history of cardiovascular disease were also associated with a greater probability of nonfatal circulatory events (myocardial infarction, angina requiring hospitalization, or stroke), while a serum albumin level less than or equal to 30 g/L (3.0 g dL) was associated with an increased probability of pulmonary edema. The probability of surviving 12 months without receiving a blood transfusion was 47.2% for males and 27.5% for females. The incidence of non-A, non-B hepatitis, as estimated by unexplained elevations in serum aspartate aminotransferase (AST) values, was not different between patients receiving and not receiving blood transfusions. The probability of hospitalization for any cause was greater for patients with grafts for vascular access than for those with fistulae, for those with a history of cardiovascular disease, for those with a serum albumin level less than or equal to 30 g/L, and for those with renal disease due to diabetes or vascular disease. Hospitalization due to circulatory disease was more likely among those with a history of cardiovascular disease and among those with a lower serum albumin level. Hospitalization for infectious disease was more likely among those with a lower serum albumin level and less likely among those with a fistula for vascular access. Among all patients receiving hemodialysis treatment for more than 6 months, there were 14.8 hospital days per year.(ABSTRACT TRUNCATED AT 400 WORDS)

The politics of prevention: changing definitions of substance use/abuse.

Over the past decade there has been a significant shift in the language used by the Reagan and Bush administrations in the fight against youthful drug abuse. We believe this shift reflects a change both in the "moral climate" regarding drug use as well as a reconceptualization of the appropriate way to confront the issue--the "just say no" philosophy. This paper will first provide a brief sociological overview of the emergence of adolescent drug use as a major social problem. We will then document, through an examination of government-sponsored literature on drug use produced over the past 10 years, the changes in conceptual focus that have occurred and consider some of the potential negative consequences of these changes for education.

Prevention of hemodialysis subclavian vein catheter infections by topical povidone-iodine.

Subclavian catheter (SCC) related infections are a major cause of morbidity in hemodialysis patients, the vast majority due to staphylococci species. Povidone-iodine (PI) has proven anti-staphylococcal activity. Therefore, a randomized controlled trial of topical PI ointment was undertaken to evaluate the impact of this prophylactic intervention on the incidence of SCC related infections in hemodialysis patients. The role of S. aureus nasal carrier state in the acquisition of infection was also evaluated. Patients requiring SCC for temporary hemodialysis access were randomized to receive the treatment (T; N = 63) or sterile gauze dressings alone (C; N = 66). Catheter duration ranged from 2 to 210 days in both groups, with a mean of 38.6 days in T and 36.2 days in C (NS). Exit site (ES) infections were significantly less in T (5%) versus C (18%) (P less than 0.02); tip colonization (TC) was 17% in T versus 36% in C (P less than 0.01), while the incidence of septicemia (S) was also significantly less in T (2%) versus C (17%; P less than 0.01). S. aureus nasal carriers were at a threefold higher risk of SCC related septicemia (0.009/day) than noncarriers (0.003/day; P less than 0.05). The beneficial effect of PI ointment was most evident in this high risk group of S. aureus carriers: ES = 0% T versus 24% C, TC = 12% T versus 42% C, S = 0% T versus 29% C, P less than 0.05. There were no adverse effects of the treatment. The routine application of topical PI ointment to temporary hemodialysis catheter exit sites is effective in reducing SCC related infections.

The successful treatment of psychogenic polydipsia and water intoxication with propanolol. A case report.

Psychogenic polydipsia (PPD), which can lead to water intoxication (WI), is a problem with many psychiatric patients. The case history of one schizophrenic patient presented here shows that propanolol therapy can reduce PPD and WI, possibly decrease thirst, and improve schizophrenic symptoms and behavior. When combined with regular weight evaluation and behavioral treatment to restrict water intake, the therapy can further reduce the risk of developing life-threatening WI complications.