Canadian survey of clinical status at dialysis initiation 1998-1999: a multicenter prospective survey.

AIMS: The current growth in end-stage kidney disease populations has led to increased efforts to understand the impact of status at dialysis initiation on long-term outcomes. Our main objective was to improve the understanding of current Canadian nephrology practice between October 1998 and December 1999. METHODS: Fifteen nephrology centers in 7 provinces participated in a prospective data collection survey. The main outcome of interest was the clinical status at dialysis initiation determined by: residual kidney function, preparedness for chronic dialysis as measured by presence or absence of permanent peritoneal or hemodialysis access, hemoglobin and serum albumin. Uremic symptoms at dialysis initiation were also recorded, however, in some cases these symptom data were obtained retrospectively. RESULTS: Data on 251 patients during 1-month periods were collected. Patients commenced dialysis at mean calculated creatinine clearance levels of approximately 10 ml/min, with an average of 3 symptoms. 35% of patients starting dialysis had been known to nephrologists for less than 3 months. These patients are more likely to commence without permanent access and with lower hemoglobin and albumin levels. Even of those known to nephrologists, only 66% had permanent access in place. CONCLUSIONS: Patients commencing dialysis in Canada appear to be doing so in relative concordance with published guidelines with respect to timing of initiation. Despite an increased awareness of kidney disease, a substantial number of patients continues to commence dialysis without previous care by a nephrologist. Of those who are seen by nephrologists, clinical and laboratory parameters are suboptimal according to current guidelines. This survey serves as an important baseline for future comparisons after the implementation of educational strategies for referring physicians and nephrologists.

Evidence-based medicine and the practicing clinician.

OBJECTIVE: To assess the attitudes of practicing general internists toward evidence-based medicine (EBM-defined as the process of systematically finding, appraising, and using contemporaneous research findings as the basis for clinical decisions) and their perceived barriers to its use. DESIGN: Cross-sectional, self-administered mail questionnaire conducted between June and October 1997. SETTING: Canada. PARTICIPANTS: Questionnaires were sent to all 521 physician members of the Canadian Society of Internal Medicine with Canadian mailing addresses; 296 (60%) of 495 eligible physicians responded. Exclusion of two incomplete surveys resulted in a final sample size of 294. MAIN RESULTS: Mean age of respondents was 46 years, 80% were male, and 52% worked in large urban medical centers. Participants reported using EBM in their clinical practice always (33, 11%), often (173, 59%), sometimes (80, 27%), or rarely/never (8, 3%). There were no significant differences in demographics, training, or practice types or locales on univariate or multivariate analyses between those who reported using EBM often or always and those who did not. Both groups reported high usage of traditional (non-EBM) information sources: clinical experience (93%), review articles (73%), the opinion of colleagues (61%), and textbooks (45%). Only a minority used EBM-related information sources such as primary research studies (45%), clinical practice guidelines (27%), or Cochrane Collaboration Reviews (5%) on a regular basis. Barriers to the use of EBM cited by respondents included lack of relevant evidence (26%), newness of the concept (25%), impracticality for use in day-to-day practice (14%), and negative impact on traditional medical skills and "the art of medicine" (11%). Less than half of respondents were confident in basic skills of EBM such as conducting a literature search (46%) or evaluating the methodology of published studies (34%). However, respondents demonstrated a high level of interest in further education about these tasks. CONCLUSIONS: The likelihood that physicians will incorporate EBM into their practice cannot be predicted by any demographic or practice-related factors. Even those physicians who are most enthusiastic about EBM rely more on traditional information sources than EBM-related sources. The most important barriers to increased use of EBM by practicing clinicians appear to be lack of knowledge and familiarity with the basic skills, rather than skepticism about the concept.

HLA-Dr expression by tumor cells compared with survival in high grade astrocytomas.

Frozen samples from 78 high grade astrocytomas were reacted with a monoclonal antibody directed against HLA-Dr invariant chain. Survival data was obtained for all 78 cases. HLA-Dr was expressed by a proportion of tumor cells in 65/78 (83%). Comparison of the survival of positive and negative cases showed that the difference was not statistically significant (p = 0.4). The relevance of the finding is discussed in the context of the immunoreaction to brain tumors.

Spinal cord compression due to thoracic disc herniation: results of microsurgical posterolateral costotransversectomy.

Fifteen consecutive patients with thoracic disc herniation treated by posterolateral microsurgical costotransversectomy are described. With appropriate modifications to the standard technique, costotransversectomy was found to be a suitable approach even for calcified central discs, and discs which had eroded intradurally. All patients had evidence of spinal cord compression preoperatively with varying degrees of leg weakness. The results of surgery are discussed. Ten patients who were disabled but ambulant showed marked improvement in symptoms and signs. Of the remaining five, all of whom were severely disabled and nonambulant preoperatively, four demonstrated significant improvement. Most patients mobilised rapidly, 13 being able to walk unaided within 24 hours. One patient developed an intrathoracic meningocoele postoperatively, which resolved after multiple percutaneous aspirations. Otherwise there were no serious pulmonary complications. We believe that costotransversectomy is the approach of choice for central as well as centrolateral and lateral thoracic disc herniations.

Two unusual pathological reactions to nitrofurantoin: case reports.

Idiosyncratic pulmonary reactions to nitrofurantoin are not unusual, often presenting as eosinophilic pneumonia. We report two cases of uncommon pathological reactions, one resembling a hypersensitivity pneumonitis and the other mimicking a giant cell interstitial pneumonia.

Marijuana-produced impairments in coordination. Experienced and nonexperienced subjects.

The effects of marijuana and a placebo on perceptual-motor coordination, motor ability, and visual perception were compared in cannabis-experienced and naïve subjects. Impairments in coordination were observed in both groups. However, the impairment was greater in the experienced than in the naïve group.

Marijuana-produced changes in pain tolerance. Experienced and non-experienced subjects.

The effect of marijuana and placebo on pain tolerance was compared in cannabis-experienced and naive subjects. A statistically significant increase in tolerance was observed after smoking marijuana. Although there was no statistically significant interaction between the drug effect and having had previous cannabis experience, there was a definite trend towards a greater increase for the experienced (16%) compared to the naive group(8%).

Protection against induction of supersensitivity to catecholamines by cocaine.

1. Adrenaline, noradrenaline, isoprenaline, tyramine, phentolamine, pronethalol, histamine and acetylcholine were each tested for their ability to prevent cocaine from causing supersensitivity to catecholamines in cat spleen strips in vitro. A high concentration of one of these drugs was added to the bath 5 min before cocaine hydrochloride (10 mug/ml). The effect on subsequent responses to catecholamines was compared with the effect of cocaine in control strips in the absence of an interfering drug.2. Phentolamine completely abolished the potentiating effect of cocaine. Large doses of adrenaline or noradrenaline reduced, but did not completely prevent, potentiation. Tyramine, isoprenaline, pronethalol, histamine and acetylcholine did not prevent potentiation.3. The ability of these drugs to interfere with potentiation does not correlate well with their ability to interfere with uptake of noradrenaline. Interference with uptake by cocaine is therefore unlikely to account fully for potentiation.