The Self-Locating Catheter: Review and Cost Analysis

The self-locating catheter invented by Nicola Di Paolo has been increasingly used in Italy and elsewhere since 1994, with about a thousand patients currently implanted every year. Twelve grams of tungsten inserted in the tip of the conventional Tenckhoff catheter during extrusion do not significantly change its form, but suffice to keep the tip firmly in the Douglas cavity.

The validity of the new catheter is confirmed by a multicentric controlled study in a large population of peritoneal dialysis patients. This trial showed that patients with the new catheter have fewer episodes of peritonitis, tunnel infection, cuff extrusion, catheter malfunction, obstruction and leakage.

This paper outlines the present situation and reports a comparative analysis of the costs of Tenckhoff and self-locating catheters.

Accidental Death Due to Erroneous Intravenous Infusion of Hypertonic Saline Solution for Hemodialysis

The case of a continuous hemodialysis patient who died shortly after erroneous infusion with undiluted hypertonic solution is reported. Autopsy showed small parenchymal hemorrhages in all organs. Although producers take measures to prevent such errors by hospital staff, further steps are suggested for types of dialysis requiring reinfusion of large quantities of reinfusion hemodialysis solution.

Topical prostaglandin E2 and chemo- and radio-induced oral mucositis

Oral mucositis is a frequent complication of specific antineoplastic treatments. Mouth lesions have a great impact on the quality of life of cancer patients. Current topical and systemic therapies have not yet achieved completely satisfactory results. We studied the effect of topical use of prostaglandin E2 (PGE2) 2.25 mg/day on oral mucositis of 15 chemo- or radio-treated cancer patients. Absolute mean VAS value on mouth pain decreased from 71.2 at TO, to 34.1 at T3 (p<0.001) and to 14.1 at T6 (p<0.001). Objective evaluation according to Miller scale showed significant improvement at day 3 and 6, as well. We suggest that PGE2 could be a useful additional therapeutic agent to palliate oral symptoms.

Evaluation of exercise testing for subjects with isolated proteinuria and/or hematuria of unclear significance

BACKGROUND

A frequent problem that family doctors face is the meaning of small quantities of blood or protein in urine samples. Patients with this problem are often either neglected or referred to specialists for complex, expensive, and often invasive diagnostic procedures. Exercise testing has never been considered in nephrology, except for some attempts in diabetic patients.

METHODS

We report on a study conducted over 12 years with patients referred for slight hematuria and/or proteinuria to determine whether exercise testing could be a diagnostic aid in some or all of them. We performed exercise testing using a treadmill preceded and followed by urine analysis, with a kidney biopsy within 10 days. Of the 94 patients enrolled in the study, only those with a positive exercise test turned out to have parenchymal nephropathy. At the end of the study, we simplified the quantification of exertion, dispensing with the treadmill and drastically reducing the number of urinary parameters considered.

RESULTS

In patients with histological evidence of kidney damage, most of the variables increased significantly after the test. Statistical analysis also showed that determination of proteinuria and hematuria alone guaranteed maximum predictability. We found that it is also possible to simplify the quantification of effort/exertion and to drastically reduce the number of urinary parameters and still obtain significant results.

CONCLUSIONS

Exercise testing provides useful information about the significance of microhematuria and proteinuria, reducing the number of cases that need to be referred to specialists. The method needs to be validated in other studies, but our results suggest that family doctors could use simple dipsticks to screen the many cases of microhematuria or proteinuria observed in daily practice. The method seems useful in eliminating doubts and unnecessary diagnostic costs.

Prevention of peritoneal sclerosis: a new proposal to substitute glucose with carnitine dialysis solution (biocompatibility testing in vitro and in rabbits)

AIM

Commercial glucose peritoneal dialysis solutions expose the peritoneum to hyperosmolar glucose containing variable amounts of non-enzymic breakdown products of glucose. These solutions are toxic for the peritoneum. The aim of the present study is to compare in vitro and in vivo characteristics of a new dialysis solution containing carnitine, a naturally occurring compound, as substitute of glucose.

MATERIAL AND METHODS

We compared in vitro and in the rabbit a new peritoneal dialysis solution containing carnitine, with two standard bicarbonate glucose peritoneal dialysis solutions and a solution containing icodextrin.

RESULTS

In vitro and in vivo the solution containing carnitine seems to be more biocompatible than standard glucose solutions and those containing icodextrin.

CONCLUSIONS

In our study the peritoneal dialysis solution containing carnitine seems to prevent the mesothelial changes observed with solutions containing glucose. Since carnitine has been extensively studied and seems to be well tolerated by hemodialysis patients, even at high doses for long periods, clinical trials in humans may be planned in the near future.

Experimental Evaluation of Transport Force in the Rabbit Ureter

Background

Cleaning the urinary tract by so-called “wash-out effect” and promoting high diuresis has long been advocated but has had very little scientific backing and few prospective studies in international journals.

Aim

To verify whether the physical laws describing the transport force of water in rivers and pipes are also valid for urinary outflow.

Methods

A laboratory model for measuring transport force, given liquid and solid capacity, was adapted to create an in vivo model based on the rabbit urinary tract.

Results

Fluid flow in the rabbit renal pelvis and ureters was found similar to flow in pipes, obeying the physical laws of water transport to some extent. When the quantity of liquid flowing in the urinary tract in unit time was doubled, the transport force increased by various orders of magnitude. When the liquid increased by a larger factor, the transport force became enormous.

Conclusions

The results confirm the utility of maintaining high diuresis in patients with renal calculus, but stress the utility of drinking 1–2 liters of hypotonic water in a short time to obtain an enormous increase in transport force which increases the probability of a cleansing effect.

The specialist palliative care team in Forlì, Italy

A specialist palliative care team (SPCT) for the care of terminal cancer patients was established at Forli in 1986. Over the years, its staff and the patients cared for have been increasing in numbers up to the present levels of importance. For 12 years the service was supplied by a private institution, Istituto Oncologico Romagnolo (IOR). The National Health Service (NHS) has since stepped in and is now supplying home care directly, leaving the IOR with a cultural, supporting, role and with the promotion of volunteer recruitment. The care provided by the specialist group active in the patients' homes is integrated into the primary care provided by the family doctors. A plan is being realized to establish a palliative care unit (PCU) within the city hospital. The group has also been engaged in research for many years, giving special attention both to prognostic factors in very advanced cancer patients and to the organization and evaluation of the service costs. Moreover, two training courses in palliative care are organized biennially, one for all health workers in the region and one for volunteers co-operating with the medical teams.

High-dose loperamide in the treatment of 5-fluorouracil-induced diarrhea in colorectal cancer patients

Thirty-seven colorectal cancer patients with grade 1-4 diarrhea (NCICTC) caused by chemotherapy with 5-FU-containing regimens, received oral loperamide at the initial dose of 4 mg followed by 4 mg every 8 h (total dose 16 mg/24 h). Twenty-five patients (69%) were diarrhea-free and were considered to be treatment responders. Eight-four percent of the patients with grade 1 or 2 diarrhea achieved a response, but only 52% of those with grade 3-4 diarrhea. These data seem to suggest that high-dose loperamide is effective in patients with moderate diarrhea and can be regarded as the treatment of choice. The patients with more severe diarrhea did not respond so well, and should, perhaps, be given first-line treatment with more effective drugs, such as somatostatin analogues (e.g., octreotide).

Ovarian cancer: natural history and metastatic pattern

Ovarian cancer begins at a molecular level, however to date, our knowledge of genetic changes and mechanisms of ovarian tumorigenesis is limited. The natural history of ovarian cancer may depend on different anatomo-clinical and biological factors. In the life history of ovarian cancers the stage, histology, tumor grade, age of the patient and gene abnormalities, both oncogenes (c-myc, H-ra, new) and oncosuppressor genes (p53, in particular), DNA ploidy and steroid receptor status have important prognostic significance. Residual disease, when less than 1 cm, is another important prognostic factor, being significantly associated to the survival and, progression free, improvement in the survival. In the low stage ovarian cancer (Stage IA, IB, IAII,IBII,IC,IIA,IIB,IIC), adjuvant treatment seems not to influence Disease Free Survival (DFS) or Overall Survival (OS) The exception to this rule is when cisplatin regimen is assessed, as it can highly reduce the relapse rate while the survival is not significantly influenced. Ovarian cancers disseminate, primarily by continuity. Lymphatic dissemination to the pelvic and para-aortic lymph nodes (40% of patients at stage III-IV disease) as well as to the peritoneum is common. At the time of diagnosis, bone or brain metastases are rarely present and their presence is not related to the histology or grading of the tumor.

Phosphatidylcholine and peritoneal transport during peritoneal dialysis

Peritoneal effluent of patients on chronic ambulatory peritoneal dialysis (CAPD) contains a surface-active material (SAM) made up of phospholipids and showing phosphatidylcholine on thin-layer chromatography. This substance drastically lowers surface tension, helps to repel water and has a lubricating effect. The presence of stratified phosphatidylcholine on the peritoneum might narrow the stagnant dialysate fluid layer and situations which can alter the quantity or composition of SAM may affect peritoneal transport and also, perhaps, the formation of adherences. This led us to verify, experimentally, the presence of phospholipids in basal conditions, after CAPD and during peritonitis and to check if addition of phosphatidylcholine to dialysis liquid is able to modify water transport in patients with low ultrafiltration and peritonitis. Phospholipids in the dialysis effluent of patients who have been on CAPD for a long time are lower than observed in the first days of peritoneal dialysis. A more drastic, significant decrease in phospholipids was observed in patients with low ultrafiltration and in patients with peritonitis. Mean ultrafiltration significantly increases in patients with low ultrafiltration and in those with peritonitis during dialysis exchanges containing phosphatidylcholine (50 mg/l) indicating that the latter is able to restore normal physiological conditions.