Helping patients to face the challenges of renal failure. Opportunities to improve compliance

Hippokratia 2006; 10(2): 51-59

P.N Ziroyannis, P Vamvakari
Nephrology Dpt, General Hospital of Athens, Athens, Greece

Abstract

Opportunities to improve compliance.Opportunities to improve compliance. It is well known that efficacy of a specific treatment may be evaluated only when there is compliance with the treatment. The term compliance is customarily used to refer to the degree to which patients follow the therapeutic recommendations of a health care provider. Recently there has been renewed interest in this area due to technical advances and a new appreciation of its importance as assessed by outcomes research. In fact, research has shown that the rates of non-compliance are often high, ranging from 30 to 60 percent for all types of medical therapies - even among those patients who are seriously ill. Despite the lack of uniform criteria for measuring compliance in the interpretation of reported rates, there is little doubt that overall compliance with prescribed regimens is suboptimal. Noncompliance among ESRD patients undergoing renal replacement therapy is a clinical challenge. Studies have reported noncompliance rates as high as 86% with ESRD patients’ full regimen, including medications, fluid restrictions, dietary restrictions and consistency in returning/staying for treatments. To evaluate adherence to treatment, it should be possible to measure it simply and repeatedly. Outcomes researchers have rediscovered the importance of compliance, and have been able to demonstrate in long-term studies, including the Beta-Blocker Heart Attack Trial, the Medical Research Council Trial in the Elderly, and the Acute Infarction Ramipril Efficacy Study, that compliance with therapy is a major determinant of a beneficial outcome. The study of compliance has been improved by the implantation-based memory chips that are inserted into the caps of medication containers, which “remember” the times and dates when the container is opened, presumably to dispense a pill. This has provided a new gold standard for the estimation of compliance, which formerly was based on pill counting or other less accurate measures.

Read PDF

Read more...

Vascular calcification

Hippokratia 2006; 10(2): 60-67

G. Efstratiadis, E Tsirou, E Mantziari
Renal Dpt, Hippokratio General Hospital, Thessaloniki, Greece

Abstract

Calcification is a process that results to calcium deposition in non-bone tissue. The present study focuses on the molecular mechanisms and the clinical significance of vascular calcification in accordance with atherosclerosis and diabetes mellitus. The clinical significance of calcification in atherogenesis should be estimated in terms of its ability to affect the plaque stability. In diabetes, calcification seems to be an independent predictor of cardiovascular mortality correlated with the complications of diabetic patients, initially those concerning the autonomic system. These two pathological conditions seem to have important similarities and differences in their molecular pathways. The identification of hydroxyapatite and the detection of all kinds of bone-tissue cells in the wall of the calcified arteries reveal that calcification, either in atherosclerosis or in diabetes, differs from the dystrophic deposition of calcium minerals, which is observed during chronic inflammation and tissue necrosis. Vascular calcification uses all the mechanisms of embryonic osteogenesis, concerning the chondrogenic or osteogenic differentiation.

Read PDF

Read more...

Insulin-like Growth Factor-1 and the cardiovascular system

Hippokratia 2006; 10(2): 68-74

G Efstratiadis, G Tsiaousis, Ch Manes, D Karagianni, A Giannakou-Darda
Renal Dpr, Hippokratio General Hospital, Thessaloniki, Greece
Diabetes Unit, "G. Papageorgiou" General Hospital, Thessaloniki, Greece
Immunology Dpt, "G. Papageorgiou" General Hospital, Thessaloniki, Greece

Abstract

The insulin-like growth factor -1 axis has been extensively studied at the molecular level, where IGF-1 seems to play a protective role against atherosclerosis and insulin resistance. Thus, low levels of IGF-1 in healthy populations have been prospectively associated with increased occurrence of cardiovascular disease and diabetes mellitus. In diabetic patients, IGF-1 concentrations appear reduced, probably contributing in part to the elevated cardiovascular morbidity of this group of patients. Herein we review the experimental research that has elucidated the molecular actions of IGF-1, as well as the relevant clinical studies, confirmatory or not of the above. Whether IGF-1 can play a role in cardiovascular risk stratification is discussed.

Read PDF

Read more...

The Outcome of Patients with Renal Dysfunction,after Coronary Artery Bypass Grafting (CABG).Comparison Between the two Methods, On-Pump and Off-Pump CABG

Hippokratia 2006; 10(2): 75-79

M Toumbouras, D Grekas, C Voucharas, P Spanos
Dpt Cardiac Surgery, Renal Unit and 1st Medical Department University Hospital AHEPA, Thessaloniki, Greece

Abstract

Renal dysfunction is known to be a major predictor of in-hospital and remote mortality among patients with coronary artery disease (CAD), who undergo coronary artery bypass grafting (CABG). The aim of this study was to investigate the outcome of patients with non-dialysis-dependent renal dysfunction, who underwent on - pump and off-pump CABG.
Methods. Between October 1, 1996 and September 30, 2000, a total of 1723 consecutive patients underwent isolated CABG. Fifty-nine of 1723 patients with CAD had also renal dysfunction (serum creatinine ?2 mg/dl). On-pump CABG was performed in 43/59 and off-pump CABG in 16/59 patients. The causes of renal dysfunction were diabetes mellitus (49.2%), hypertension (18.6%), atherosclerosis(13.6%), chronic glomerulonephritis (8,5%) and others(10.1%) of unknown etiology. In on-pump CABG we maintained the perfusion pressure above 60 mmHg. Furocemide or mannitol were given during the heart surgery. Off-pump CABG was performed using initially a compression type of coronary stabilizer and after mid-1999 a suction type of stabilizer.
Results. The hospital mortality rate was 3 / 43 (7.0%) in on -pump and 1 / 16 (6.3%) in off-pump group. The Intensive Care Unit (ICU) stay was significantly shorter in off-pump group than the on-pump group (p < 0.05), and the length of postoperative stay was two-thirds of that in the on-pump group. No significant differences were found in terms of the long-term survival of cardiac event-free rate between the two groups. Postoperative hemodialysis was performed in 8 / 59 patients.
Conclusions. Patients with renal dysfunction carry significant operative risks and require prolonged hospital care. Off-pump CABG strategy in these patients is safe and contributes to the improvement of both postoperative and remote results. The long-term results were not different between the two groups in this study.

Read PDF

Read more...

Oral versus inhaled bronchodilators in pediatric practice at a rural health care setting

Hippokratia 2006; 10(2): 80-84

Ch Zavos, D Vini, J Kountouras, N Zavos, E Trivara
Dpt Pediatrics, Health Centre, Gonni, Larissa, Greece
2nd Medical Clinic Hippokratio General Hospital, Thessaloniki, Greece
Dpt Pediatrics, Infectious Diseases Hospital, Thessaloniki, Greece

Abstract

The majority of pediatric asthma cases are managed entirely within general practice; selecting the appropriate type of therapy for the wheezy infant with no previous asthma history often becomes a dilemma for clinicians.
Aim: To compare the improvement in asthma exacerbations, after administration of oral or inhaled bronchodilator therapy, in children with newly diagnosed mild to moderate asthma.
Material and methods: A total of 128 children aged 6 months to 14 years with asthma symptoms were referred at a rural health care setting. Detailed case history was obtained and peak flow monitoring was performed when feasible. Group A, 58 children aged 2.94??2.57 years, received oral and Group B, 70 children aged 8.26??4.43 years, inhaled therapy. All children were re-examined 3 days and 7 days from onset of treatment.
Results: Improvement was noticed in 43/58 (74.1%) and 67/70 (95.7%) patients of groups A and B respectively (p?0.001) 3 and 7 days after the onset of treatment. Treatment was changed in 10 and 8 patients of each group respectively (p>0.05). Compliance was better in Group A (p?0.001). Fifty-two patients of Group B and no patients of Group A required further training (p?0.001). Inhaled bronchodilator therapy has led to a significant remission of asthma exacerbations compared to oral bronchodilator therapy.
Conclusions: Although there has been better compliance and no need for additional education in the patients receiving the oral therapy, the latter should be reserved only for children usually less than 2-3 years of age with mild occasional asthma, or for older children who seem not to be competent using the inhaled therapy on their first visit. Parents should be encouraged and trained to use inhaled rather than oral regimens in all age groups of children.

Read PDF

Read more...

Anaesthetic management of an educational laparoscopic radical prostatectomy: a case report

Hippokratia 2006; 10(2): 85-87

Z Kanonidou, D Iordanidou, G Karistianou, H Giannakos, E Saridakis, M Davlis
3rd Anesthesiology Dpt, Hippokratio General Hospital, Thessaloniki, Greece

Abstract

Laparoscopic radical prostatectomy is a relatively new surgical procedure, which combines the advantages of a laparoscopic surgery with the special considerations of radical prostatectomy. Unique issues that affect the anesthetic management are pneumoperitoneum, surgical position and the duration of the surgery. The purpose of this case report is to share our experience and difficulties we had to face during the first procedure of a laparoscopic radical prostatectomy in our hospital, to present the anesthesiologist’s considerations about the effects of this procedure on patient’s vital functions, as well as the methods followed to solve the problems. Our final target is the favorable outcome of emerging surgery and for that, thorough preoperative planning both from the urologists and the anesthesiologists is essential.

Read PDF

Read more...

A case report of acute leukemia and pregnancy

Hippokratia 2006; 10(2): 88-89

V Karagiannis, A Daniilidis, N Klearhou, A Mamopoulos, V Garipidou, S Vakalopoulou, P Stamatopoulos, N Paisios, H Zaboulis
3rd Dpt Obstetrics and Gynaecology, Hippokratio Hospital,
2nd Dpt Internal Medicine, Hippokratio Hospital, Thessaloniki, Greece

Abstract

We are presenting a case of a pregnant woman who was diagnosed to have acute leukemia at 20 weeks of gestation. She was started in multi-agent chemotherapy and was delivered at 28 weeks and 4 days by caesarian section due to severe intrauterine growth restriction. A live male infant was born with apgar score (appearance, pulse, gesture, activity and rate of breathing) 6 at 1 minute and 8 at 5 minutes and excellent progress the following days. She recovered from the caesarian section uneventfully and is currently following her treatment.

Read PDF

Read more...

Munchausen syndrome by PROXY

Hippokratia 2006; 10(2): 90-91

V Kola, E Kola, A Koroshi
Dpt Psychiatry, Dpt Pediatrics, Dpt Nephrology, University Hospital Centre "Mother Teresa", Tirana, Albania

Abstract

We report a case of Munchausen syndrome by proxy, which includes the description of three different clinical situations of the child, sustained all by her parents(mainly the mother). Munchausen by proxy syndrome, in which a mother seeming apparently careful and preoccupied who at the same time injures her own child, takes origin in a deep feeling of earlier negligence of mother during her own childhood. This way of understanding such relationships, extends the definition of perversions. In this sadistic-masochistic interaction, the child gets dehumanized and used as a fetish object to control the relationship. This syndrome is mostly observed in children under the age of 6, but it can be developed even later.

Read PDF

Read more...

Alveolar haemorrhage in a patient with Leptospirosis

Hippokratia 2006; 10(2): 92-93

C Katsanoulas, H Mouloudi, C Lampiri, M Assimaki, N Gritsi-Gerogianni
General Intensive Care Department, Hippokratio Hospital, Thessaloniki, Greece

Abstract

Alveolar haemorrhage due to pulmonary vasculitis in the course of leptospirosis, although not uncommon, is rarely included in the differential diagnosis of pulmonary haemorrhagic syndromes. We present a case of a patient, treated in the ICU for leptospira infection, with a late onset of diffuse alveolar haemorrhage. A 68-year-old man was transferred in the ICU after a progressive CNS impairment. His lab tests were indicative for a severe hepatic dysfunction and renal impairment in need of intermittent haemodialysis. A presumptive diagnosis of leptospirosis was done, confirmed later by positive serologies. At the end of the icteric phase and while weaning from mechanical ventilation, multiple episodes of haemoptysis started, resulting in severe deterioration of oxygenation. Chest X-ray showed new bilateral patchy infiltrates and a High Resolution Computed Tomography scan revealed diffuse airspace disease with bilateral ground-glass opacities. Methylprednisolone 1g daily for 3 days, followed by prednisolone, 20 mg every 6 hours, was given. The patient responded with bleeding cessation and successful weaning. Twelve days later he was discharged to the ward improved. Haemorrhagic alveolitis usually occurs at the after the “leptospiremic” period of the disease. The case presented is suggestive of a delayed, post-”immune” onset of symptoms responding well to high dose steroid therapy.

Read PDF

Read more...

Current Issue 20 (3)