First hemodialysis access selection varies with patient acuity.

Timely placement of a reliable permanent vascular access is essential for hemodialysis care quality; National Kidney Foundation Dialysis Outcomes Quality Improvement (NKF-DOQI) guidelines emphasize native arterio-venous (AV) fistulae as preferred access for incident patients. As part of Network One's Vascular Access Quality Improvement Project (QIP) we investigated whether patients' course to end-stage renal disease (ESRD) influenced vascular access selection. Baseline information was obtained for incident (1998) dialysis patients from 6 centers participating in the Network QIP. Patients were subdivided into 3 predefined clinical groups: KNOWN (known chronic renal disease, seen by a nephrologist, with predictable progression to ESRD), CRISIS (KNOWN but with unanticipated medical crisis precipitating ESRD), and UNKNOWN (not known to have chronic renal insufficiency or never seen by a nephrologist before developing ESRD). Two hundred forty patients were identified (median age 69.9, 42% diabetic). Only 43% of the entire population experienced an orderly progression to renal insufficiency. The most frequent initial access was a catheter (54%), followed by a fistula (29%) and a graft (16%), but selection of initial access differed significantly by patient group, with 46% of KNOWN patients receiving a fistula (P <.001). After 2 months of dialysis, the initial access supported dialysis in only 53.7% of the KNOWN patients, and in 59.4% and 45.7% of the CRISIS and UNKNOWN patients, respectively. We conclude that unpredicted, new ESRD patients are common and are less likely to receive a fistula as initial hemodialysis access. Studies should define optimum access management when dialysis requirement is unforeseen.

Prospective sonographic evaluation of interleukin-2-induced changes in the gallbladder.

PURPOSE: To describe the changes in the gallbladder induced by interleukin-2 (IL-2) therapy and to correlate the findings with the clinical course. MATERIALS AND METHODS: Twenty-five men with human immunodeficiency virus (HIV) infection were examined prospectively with right upper quadrant ultrasonography (US) before and after receiving IL-2 therapy. Four patients also underwent US after a second course of IL-2. The gallbladder was evaluated for wall thickening, echotexture, and intramural and pericholecystic fluid. Correlation was made between the clinical signs and symptoms, IL-2 dose, CD4 cell count, and the US appearance of the gallbladder. RESULTS: There was significant correlation between symptoms of right upper quadrant pain during IL-2 therapy and US abnormalities of the gallbladder, including an increase in wall thickening (P = .012) and the development of intramural (P = .015) and pericholecystic (P = .006) fluid. More severe abnormalities were seen with higher IL-2 doses. All symptoms resolved with cessation of IL-2 therapy. In patients who underwent repeat US, the gallbladder reverted to a normal appearance. No correlation was found between the CD4 cell count and the development of symptoms or the US appearance of the gallbladder. CONCLUSION: IL-2-induced changes resolve rapidly with cessation of therapy, and no surgical intervention is needed. These changes can be avoided or reduced by decreasing the IL-2 dose during subsequent cycles.

Initial clinical experience with a new model of mass transfer for peritoneal dialysis.

A clinical pilot study compared predictions of a new model of peritoneal dialysis mass transfer to measured weekly KT/V urea (KTu/V) and weekly creatinine clearance (Ccr) in liters per 1.73 m2 in 50 patients from five centers (40 CAPD, 10 CCPD). The Robertson et al. model is unique in that it does not require a 24-hour collection of dialysate. Instead, model predictions are based on the results of a standard 4-hour peritoneal equilibration test (PET) and appropriate demographic data. Analysis revealed 12 collection errors, 8 affecting the PET and 4 affecting 24-hour dialysate volume. PET drainage volume was low in six cases, excessive in two; 24-hour volume was incomplete in three, excessive in one. Similar errors were not found in the remaining 38 patients. In the 38 patients with correctly performed PET and dialysate collections, agreement between predicted and measured values was excellent.

Serving two masters: the interaction between Family and Medical Leave Acts and the ADA.

The complex interaction between family leave acts and the new Americans with Disabilities Act (ADA) is just coming to light as employers begin to analyze how to comply with both laws. Specifically, the ADA implicates the procedures set forth in most family leave acts for verifying an employee's need for a leave through mandatory medical examinations and doctor's certificates. Many employees who are entitled to a leave of absence under state law are defined as "disabled" under the ADA. The ADA protects these employees with disabilities by regulating medical examinations and inquiries, and protecting the confidentiality of information obtained in such inquiries. This article offers some practical guidance for employers in providing leaves of absence under state family leave acts, while verifying the need for leaves in compliance with the ADA.

Industrial hypertension program in a rural state. Efficacy and cost effectiveness.

A program was designed to evaluate the efficacy and cost of detecting and treating hypertension in an industrial population of a rural state. Original screening and evaluation was initiated by a trained blood-pressure technician team, but initiation of therapy was the responsibility of the private physician. Follow-up data were obtained at one year by rescreening in 83% and by telephone contact in 91% of the original hypertensive patients. Eighty-three percent of those patients with moderate or severe hypertension complied with physician visits. The condition of 60% of the treated patients was controlled, and the condition of 74% was improved. The total cost per patient treated for one year was 250 dollars; per patient with controlled hypertension, 446 dollars; and per patient with controlled or improved hypertension, $362.

Industrial hypertension control program in a rural state.

Many problems remain in attempting to improve the detection and management of hypertension in the United States. This study applied a previously established model community hypertension program to a wide geographic area in a rural state. In 47 industries in 18 communities, 15,689 subjects were screened for the presence of hypertension. Eight hundred five subjects were found to have an elevated blood pressure on three separate occasions and were classified for further management. Follow-up showed that 76% visited their physicians within six months, and of these 81% were being observed. Sixty-seven percent of the subjects who saw their physicians were receiving antihypertensive drug therapy. The cost of finding each subject with an elevated blood pressure was $80 and of identifying a subject who received drug therapy, $160.