bluuebunny/crossref_metadata_2025 huggingface dataset:
Establishing a Home Nocturnal Hemodialysis Program: “Starting From Scratch”
Authors: Hryciw E. , Courtney M. , Herian N. , Wales L. , Bainey C. , Adams C. , Foster J.
Published: December 2004

Purpose:  In April 2001, the Northern Alberta Renal Program (NARP) in Edmonton, Alberta received a government grant to start a Home Nocturnal Hemodialysis program for 17 patients. At that time NARP did not have a home program, so the challenge was to develop and operationalize the program and to stay within the requirements related to the grant.

Methods:  We describe our experience with specific reference to funding, infrastructure, human resources, monitoring, and the target population.

Results:  Funding from the grant allowed space for one dialysis teaching station and clinic area. A multidisciplinary team of a nurse, technician, social worker, and dietitian were recruited. New procedures were written, and new manuals were prepared for teaching. Several new machines were evaluated. The Bellco Formula machine from Genpharm was chosen. This machine had very limited use in North America and had never been used in a home program or a nocturnal program with monitoring. Initiating the monitoring proved to be one of our main challenges. We initiated monitoring with Capital Health Link, the telephone health information line for our region, to provide the observers for the monitoring. Initially the program was intended to serve people who lived in remote areas not serviced by a satellite hemodialysis unit, but in a population of 600 dialysis patients we were having difficulty recruiting. We widened the criteria and expanded our marketing strategy. Based on a survey of other programs and a patient satisfaction survey, we discontinued the monitoring after one year as it did not prove clinically beneficial and patients viewed it as restrictive.

Conclusion:  Through perseverance and teamwork we were able to establish this innovative program “from scratch.” We received an award for innovation from our health authority in 2003. The program now has 15 patients at home enjoying the benefits of home nocturnal hemodialysis, and we are expecting to expand the program. The evaluation to date is encouraging with respect to this therapy being clinically more effective than conventional dialysis and an improved quality of life for the patients.
Long‐Term Transport Study of Bioartificial Tubule Devices in the Development of a Bioartificial Kidney
Authors: Saito A. , Aung T. , Terashima M. , Kakuta T.
Published: December 2004

Introduction:  A bioartificial kidney, which consists of a continuous hemofilter and a bioartificial tubule device using proximal tubular epithelial cells (LLC‐PK1), is desired to develop for preventing long‐term complications in hemodialysis patients. A bioartificial tubule device should function for a long duration in terms of the simplicity and the economy. Continuous hemofiltration with 10 L/day of filtrate could maintain plasma urea, creatinine and β2‐microglobulin in patients at low levels compared to those in standard hemodialysis patients.

Methods:  6 bioartificial tubule devices, in which LLC‐PK1 cells were grown on the inner surfaces of hollow fiber capillaries (membrane area: 0.4 m2, 1600 fibers), were used to evaluate the transport ability of H2O, glucose and Na+, and leak rates of urea and creatinine for 2 weeks when the medium containing 50 mg/dL of urea and 5.0 mg/dL of creatinine was perfused inside of the cell‐attached membranes and another medium containing 2.5 g/dL of albumin was perfused outside of the membranes. Scanning electron micrograph of cross‐sectional findings of the hollow fibers was taken at 6, 10, and 14 days after formation of confluence.

Results:  By conversion into 1 m2 of membrane area, transport of H2O, glucose, and Na+ was 6266 ± 995 mL/day, 22832 ± 7240 mg/day, and 941.3 ± 180 mEq/day, respectively at 6 days after confluence. Leak rates of urea and creatinine across the cell‐attached membranes were 22 ± 6.1% and 19.2 ± 4.9 with albumin addition, whereas 13.1 ± 1.9% and 12.2 ± 1.6 without albumin addition. Transport capacity of these components and the leak rates had continued for 10–13 days, and decreased thereafter because of the formation of the multilayers. Bioartificial tubule devices with membrane area 1.0 m2 can reach the targeted amounts of H2O, glucose, and Na+ transports when 6 L of 10 L/day of hemofiltrate has to be regenerated, substituting 4 L with meal and drinks.
Blood Compatibility and Filtration: Characteristics of Newly Developed Polyester Polymer Alloy Membrane
Authors: Yamashita A.C. , Tomisawa N. , Takesawa A. , Sakurai K. , Sakai T.
Published: December 2004

Many synthetic polymeric membranes have been widely used for blood purification therapies. Among them polyester polymer alloy (PEPA) membrane shows unique blood compatibility and filtration characteristics.

Objective:  To evaluate blood compatibility and filtration characteristics of 3 different PEPA membranes, including FLX (PEPA only), FDX (PEPA with polyvinylpyrrolidone, (PVP) as a hydrophilic agent), and FDY (PEPA with PVP) that has larger pore diameter.

Methods:  Ultrafilters with 3 PEPA membranes (FLX, FDX, FDY, Nikkiso, Tokyo) were compared with those with polysulfone (PS; NK‐PS, Nikkiso, Tokyo) for blood compatibility in vivo. Also, ultrafilters with PEPA, PS, and cellulose triacetate (CTA; FB‐110GA, Nipro, Osaka) membranes were also investigated for filtration characteristics of albumin in aqueous in vitro.

Results:  FDY, the latest version of the three PEPA, showed excellent small changes in C5a concentration during the treatment right after switching from PS membrane, leaving no significant changes in other biocompatible indices. First 60 min of the time course of s.c. for albumin were shown below taken under aqueous low albumin concentration, i.e., 2.42 × 10−3 kg/dm3. The time‐dependent patterns were totally different from each other in 5 filters. Generally speaking, PS takes a peak value 20–40 min after starting the experiment, depending on the flow conditions. Since PEPA is a hydrophobic material, it showed high s.c. for albumin in FLX (PEPA with no PVP) and never reached plateau. With a hydrophilic agent (PVP), the s.c. greatly reduced in FDX and showed little time‐dependent change. By enlarging the pore diameter in FDY, the s.c. increased in accordance with the enlargement.

Conclusion:  Newly developed PEPA with PVP has excellent blood compatibility and has unique separation characteristics for albumin.
Hepatocyte Growth Factor and Viral Load Variations in HD Session, Comparison with Molecular Absorbent Recirculating System (MARS) Therapy
Authors: Barril G. , Bartolomé J. , Ruiz M.P. , Sanz P. , Traver J.A. , Selgas R. , Carreño V.
Published: December 2004

A decrease in hepatitis C viral load in HD patients along HD sessions has been described. It has also been proposed that hepatocyte growth factor (HGF) stimulation by HD could have some protective effect in hepatitis C virus (HCV) liver disease outcome.

Aims:  (i) Measurement of HCV viral load variation and quantitation of HGF stimulation in CKD patients (HCV+ and HCV–) on HD, along the HD session. (ii) Study whether albumin HD (MARS) decreases HCV viral load and stimulates HGF, compared to HD sessions.

Methods:  We performed two MARS and two HD sessions in vitro by using an extracorporeal circuit with blood bag contaminated with HCV serum with a known HCV viral load. (We used only a single blood bag for each testing.) In vivo we performed three MARS sessions. The total number of treatments was 6 in 2 patients (3 treatments each) and one HD session in 2 HCV+ patients and 5 HCV– patients (included in HD program in our center), taking samples at the start of the following HD session, to compare the results with those obtained in vitro. We took samples at the beginning, middle, and at the end of MARS sessions in vivo and in vitro and starting (15 min) and at the end and before starting the following HD session in vivo. (The interval between 2 HD sessions in HCV+ patients was 2 days.) We determined HCV viral load using Amplicor (Roche) and HGF using ELISA (R&D System).

Results:  We found a decrease of viral load in vitro and in vivo both by MARS and HD. HD in vitro: ×decrease HCV viral load, 54.67%. HD in vitro × decrease viral load 30.6% × HD in vivo. We found a decrease of 30% in viral load, remaining 27.9% lower at the start of the following session. MARS in vitro: ×viral load decrease 3% (1 session in 2 experiments). MARS in vivo: ×viral load decrease of 44.5% (6 sessions in 2 patients). We did not find HCV viral load in ultrafiltrate or albumin from MARS procedure. Analyzing HGF stimulation we found the following:

MARS in vitro:
start, 1001; 15 min, 1537; final, 1981

HD in vitro:
start, 476; 15 min, 677; final, 1236

HD in vivo:
start, 2808.57; ×15 min, >8000; final,

  2605.28; ×start the following session, 2299.5

MARS in vivo:
HGF starting (first session, 4633; second session,   4390; third session, 4775); at 4 h (first session, 5443; second session, 4167; third session, 5178); final (first session, 4477; second session, 6167; third session, 5078).

Conclusions:  MARS and HD sessions decreased HCV viral load and stimulated HGF both in vitro and in vivo. It is necessary to confirm these results because it could offer protective effect for HCV chronic liver disease outcome. HD seems to be the best option for patients with HCV hepatopathy. On the other hand, patients with liver disease who need to be treated with MARS could obtain not only a good clearance of toxin binding to albumin, but also the positive effects described.
Prevalence of Hepatitis (A–E) and HTLV‐I/II Infection Markers in Hemodialysis Patients of Central Greece
Authors: Stefanidis I. , Zervou E.k. , Rizos C. , Liaskos C. , Zarogiannis S. , Liakopoulos V. , Kyriakopoulos G. , Dalekos G.n.
Published: December 2004

Objective:  The aim of this study was to assess the prevalence of serological and molecular markers of hepatitis (A–E) and human T‐lymphotropic viruses (HTLV) in hemodialysis (HD) patients of central Greece.

Methods:  370 patients (246 males, 60 ± 14 years) attending the renal units (RUs) of central Greece (n = 5) were tested for anti‐HAV IgG, hepatitis B virus markers, anti‐HCV, anti‐HEV, and anti‐HTLV‐I/II with ELISA. In 131 casual samples, regardless of anti‐HCV status, a sensitive, qualitative HCV‐RNA assay (Versant®, Bayer) based on transcription‐mediated amplification (TMA) was applied.

Results:  Previous HBV infection (anti‐HBc) was found in 48% and current HBV infection in 5.5% (HbsAg) of the patients. Anti‐HAV was detected in 94% while anti‐HDV and anti‐HTLV were negative. Anti‐HCV prevalence was 23% varying from 11 to 36% in the different RUs. Frequency of anti‐HEV (4.1%) was also highly varying (1.4–9.8%). There was no association between the infection markers and age, sex, or history of transfusion. Anti‐HCV correlated with duration of HD. HCV‐RNA was detected in 44/131 samples. In 15 cases results of anti‐HCV and TMA were contradicting. Two anti‐HCV negative samples were HCV‐RNA positive (2.3%).

Conclusion:  In RUs of central Greece, a high prevalence of HCV infection was found, associated with the duration of HD. The high prevalence of anti‐HEV found in 1 RU must be investigated further. In some of anti‐HCV‐negative patients viremia was detected. This result indicates that a considerable number of HCV infections are serologically occult. HCV‐RNA testing, regardless of the anti‐HCV status, has to be considered seriously in HD patients.
6 Month Experience with 1 Nurse Training 2 Patients Together for Nightly Home Hemodialysis
Authors: Pipkin M.F. , Lockridge R.S. , Spencer M.O. , Craft V.W. , Campbell D.L.
Published: December 2004

Objective:  To have 1 nurse successfully train 2 patients at a time for nightly home hemodialysis (NHHD) within a 7–10 week time period.

Methods:  Over the past 6 years, Lynchburg Nephrology Dialysis Inc. has evolved its NHHD program from 1 nurse training 1 patient during an average 6 week period to training 2 patients in a 7–10 week period. Patients came either from our in‐center population or directly from internal medicine. Our pre‐evaluation procedures and manual were revised. Patients were pre‐evaluated for literacy, manual dexterity, strength, hearing and visual deficits, substance abuse, psychiatric disorders, and compliance before being accepted into the program. A home visit was made to evaluate their environment, family interactions, and water source. Our training manual was rewritten to fifth grade level. Every patient was given index cards printed in 20 size font with step‐by‐step procedures for machine setup, put‐on and takeoff, re‐circulation, and power failure. Patients were dialyzed 4 days/week to improve cognitive function and ‘dialyzed the bucket’ 1 day, thus training 5 days/week. One nurse trained 2 patients, staggering their start dates 2 weeks apart to allow for both individual and group teaching. Fistula or IJ catheter was used for access. Patients were trained alone or with a partner. In the last week of training, patients were dialyzed for 7 h and were expected to complete all procedures independently.

Results:  From March 2003 to August 2003, 6 patients were trained for NHHD. 2 patients finished training in 7 weeks, 2 in 9 weeks, and 2 in 10 weeks.

Conclusion:  One nurse can successfully train 2 patients at a time for NHHD in a 7–10 week time period at a decreased cost to dialysis provider.
Hospital‐Based Nocturnal Hemodialysis—A Novel Approach to Solving Old Problems
Authors: Campbell J. , Hobbs D.
Published: December 2004

It is unlikely that there is a solitary hospital‐based dialysis unit that can claim an unlimited amount of available chronic spots. Many units, in fact, constantly face a problem of overcrowding, long patient waiting lists, and ongoing shortages of nurses trained in highly specialized areas such as dialysis. In addition, conventional dialysis does not afford the best outcomes to patients with lifestyle, fluid control, hypotension, or hypertension issues.

Objective:  We developed an in‐hospital nocturnal program with the goal of solving some of these issues related to wait lists, overcrowding, and shortages of trained hemodialysis nurses.

Method:  In the first year, a four‐bed room was converted into a 4 station unit. Nurses from the 24 bed in‐patient Nephrology/Urology/Ophthalmology unit were trained to perform hemodialysis. Stable, hospitalized dialysis patients or in‐center dialysis patients were selected if they met criteria drawn up by the medical director. Staffing for the unit was established at 3 : 1 or 4 : 1 patient to nurse ratio. Support staff included a hemodialysis‐trained ward nurse with an assignment of 5–6 hospitalized patients. Back‐up support included assistance with trouble‐shooting and break coverage for the nocturnal nurse.

Results:  We currently have 12 nurses from the ward trained to do hemodialysis. The nocturnal unit has been operating 3 nights/week, with plans to expand to 6 nights/week within the year. We have 3 patients on the program with plans to increase to 6–8 patients as more nurses are trained. Initiation of hospital‐based nocturnal hemodialysis has led to the opening of in‐center dialysis spots as well as shortening wait periods for patients in the Pre‐Renal Clinic, awaiting initiation of chronic dialysis. This model has also provided the in‐center dialysis unit with a greater pool of skilled hemodialysis nurses to draw from during shortages. Anecdotal reports from patients indicate that they feel much better, and 1 patient no longer requires antihypertensives for their blood pressure control.

Conclusion:  We conclude that hospital‐based nocturnal hemodialysis is a novel and extremely viable solution for many of the issues facing dialysis units today.
Role of Nitric Oxide, Endothelin‐1, Interleukin‐1, and Tumor Necrosis Factor‐α in Hemodialysis‐Induced Hypotension
Authors: Zaki A.m. , Kamel A.a.f , Ragab M. , Hassan M.y.
Published: December 2004

Serum level of nitrite plus nitrate (NO2 plus NO3), endothelin‐1 (Et‐1), interleukin‐1 (IL‐1), and tumor necrosis factor‐α (TNF‐α) have been estimated in 20 patients with end stage renal failure (ESRF) undergoing regular hemodialysis treatment in a trial to explain the hypotension occurring in some of these patients. According to the incidence of hypotension, patients were divided into GI (n = 10) hypotension prone patients and GII (n = 10) hypotension resistant patients (normotensive). Clinical examination with measurement of systolic and mean arterial blood pressure was performed in all cases before and after hemodialysis (HD) settings. After HD, GI showed significant increase in the serum levels of (NO2 plus NO3), IL‐1, and TNF‐α, whereas a significant decrease in serum Et‐1 level was noticed. GII showed no significant change in serum level of the 4 parameters mentioned above. In hypotensive patients, there was a significant positive correlation between (NO2 plus NO3) and the duration of dialysis, and a significant negative correlation between (NO2 plus NO3) and post dialysis systolic blood pressure, also between IL‐1 and Et‐1. From the previous results, it could be concluded that the vascular endothelial factors studied (NO and Et‐1) together with the inflammatory cytokines IL‐1 and TNF‐α contribute to the development of HD‐induced hypotension in ESRF subjects which is evidenced by: (1) the coupling of decrease of blood pressure and increase in NO2 plus NO3 level after HD in group I; (2) Et‐1, which is a powerful vasoconstrictor, showed a significant decrease postdialysis; and (3) levels of cytokines (IL‐1 and TNF‐α) (which are potent NO inducers) were found to be significantly increased postdialysis in group I.
Quality of Life in Chronic Hemodialysis Patients
Authors: Kirmizis D. , Belechri A.m. , Giamalis P. , Zolota A. , Karabatakis P. , Zabioglou G. , Memmos D.
Published: December 2004

Purpose:  Quality of life (QoL) is a well‐recognized important measure of therapy outcome, as it reflects what patients perceive as their health condition. The aim of this study was to estimate the QoL in patients on HD and to find the factors that mainly affect it.

Patients and Methods:  We studied 70 patients on HD (38 male, age 57.86 ± 14.63 years) with the use of kidney disease quality of life short form. Physical health (PH), mental health (MH), kidney disease issues (KDIs), and patient satisfaction (PS) were assessed, as well as Khan comorbidity index, adequacy of dialysis, nutrition, and epidemiologic and laboratory data.

Results:  PH was significantly correlated with comorbidity (p < 0001), age (p < 0001), duration of HD (p < 0001), serum albumin (Salb) (p < 0005), the existence of a living relative donor (p < 0001), Hb (p < 0.01), and CRP (p < 0.01). MH was significantly correlated to comorbidity (p < 0001), age (p < 0001), duration of HD (p < 0001), Salb (p = 0002), the existence of a living relative donor (p < 0001) and Hb (p < 0.01). KDI score was significantly correlated with comorbidity (p < 0001), age (p < 0001), duration of HD (p < 0001), and Hb (p < 0.05). The acceptance of the method was significantly lower in patients with AVF dysfunction (p < 0005). As much as 44.3% of patients presented inadequate compliance to dietary and fluid restrictions.

Conclusion:  Frequent QoL assessment in patients on HD is a useful tool for professionals involved in patients' care. Older age, long time on HD, malnutrition, elevated CRP, and comorbid conditions are correlated to lower QoL scores.
Health‐Related Quality of Life in Hemodialysis Patients in Taiwan
Authors: Chiang C‐K. , Peng Y‐S. , Chiang S‐S. , Yang C‐S. , He Y‐H. , Tsai T‐J. , Chen W‐Y.
Published: December 2004

Background:  Health‐related quality of life (HRQOL) is an important outcome of medical treatment effectiveness.

Objectives:  Thirty‐six item short‐Form (SF‐36) first has been used in hemodialysis (HD) patients in Taiwan.

Method:  HRQOL was measured by using SF‐36 in 497 HD patients in 5 hospitals.

Results:  Male sex, age less than 50 years, higher education level (EL), marriage, employed status (EPS), less comorbid medical condition (CMC), and non‐diabetic patients were all predicted a better physical component scale (PCS). Age less than 50 years, BMI greater than 18.5, HEL, EPS, and NDP were all predicted a higher mental component scale (MCS). Scales contributing to a summary measure of physical health, the PCS score, was significantly lower in women (35 ± 12.3) than in men (37.9 ± 12.3). There is no difference in MCS score between women and men. In multivariate analysis, age, CMC, diabetes, serum creatinine (SCr), and erythropoietin responsiveness were significant independent predictors of PCS. Diabetes, EL, SCr, and erythropoietic responsiveness were significant independent predictors of MCS. All of the individual scales, PCS and MCS scores were lower in the Taiwan HD patients than values for the US general population. Each of the individual scales and MCS scores were substantially lower in Taiwan HD group than in the US HD cohort. But the bodily pain of PCS was significantly higher in Taiwan HD group in spite of mean PCS scores for Taiwan HD group and US HD study participants were nearly equal at 36.3 and 36.1, respectively.

Conclusion:  Physical and mental aspects of quality of life are substantially reduced among Taiwan HD patients, but higher bodily pain tolerance. A number of demographic and clinical characteristics significantly impact on HRQOL in Taiwan HD patients. To our knowledge, this is the first time we demonstrate the HRQOL by using SF‐36 in Chinese HD patients.
Anaphylaxis in Association with Heparin‐Induced Thrombocytopenia
Authors: Azam N. , Douglas L.A. , McConnell S.W.
Published: December 2004

Heparin is almost universally used as an anticoagulant during hemodialysis. Rare but serious side effects of heparin therapy include heparin‐induced thrombocytopenia (HIT) and anaphylaxis, and these may lead to significant mortality and morbidity if left unrecognized. We are reporting a patient who developed HIT followed by an anaphylactoid reaction. This 8‐year‐old girl with Joubert's syndrome developed end‐stage renal disease secondary to nephronophthisis. She had a Permacath double‐lumen hemodialysis catheter placed in the right internal jugular vein and was started on hemodialysis using an Asahi B10 65 Dialyzer on 1/28/03. The platelet count at that time was 246 × 103/mL. Beef lung heparin was used for anticoagulation. She was admitted for living related donor renal transplant on 2/10/03 but was found to be thrombocytopenic with a platelet count of 49 × 103/mL. The transplant was postponed, a sepsis work‐up was performed, and she was started on antibiotics pending culture results. Hemodialysis was continued with heparin anticoagulation, and despite an improvement in the platelet count she had an acute anaphylactoid reaction 2 days later. The reaction occurred 20 min after starting her hemodialysis treatment and presented as acute onset of bronchospasm, agitation, and chest discomfort. She improved with nebulized albuterol and subcutaneous epinephrine. A review of her records revealed that she had received 6 hemodialysis treatments. The platelet count on 2/3/03, after 3 hemodialysis treatments, had been 242 × 103/mL and on 2/8/03 after 5 treatments the platelet count was 72 × 103/mL. HIT with anaphylaxis was suspected. Heparin was discontinued and the platelet count had returned to normal within 2 days. The diagnosis was confirmed by a positive heparin‐associated antibody test. While HIT is recognized as a complication in 1–5% of patients treated with heparin and has been well described in the literature, we could only find 2 reported cases of heparin‐induced anaphylaxis and in both cases there was accompanying thrombocytopenia. This patient further illustrates a possible linkage between these two phenomena. HIT is an important cause of thrombocytopenia in a patient on hemodialysis and continued exposure to heparin may induce anaphylaxis.
Use of Crit‐Line Delta H Access Blood Flow in a Vascular Access Management Program to Decrease Episodes of Thrombosis and Increase URR
Authors: Larson K. , Haglund L. , Carson R.
Published: December 2004

Substantial morbidity occurs within the hemodialysis population due to complications of vascular access, most frequently manifests as thrombotic events. An access management goal was the reduction of thrombotic events and associated morbidity. Intra‐dialytic vascular access blood flow (ABF) measurements using Crit‐Line Delta H ABF have been previously shown to provide objective and accurate access flow data and were our primary method of evaluating access function. A designated ‘access manager’ was assigned responsibility to track all issues related to vascular access. Each patient's ABF was measured monthly and the flow ‘trend’ was graphed using Crit‐Line Access Manager software. Additional data, including auscultation, cannulation difficulties, failing URR, and increased venous pressures were also recorded. These data and ABF trends were used to establish an angiography ‘hot list’. Following angioplasty, ABF was again measured to confirm a successful intervention. The ‘hot list’ led to 43 angiography referrals of which 83.7% (36/43) required subsequent intervention resulting in significant reductions of thrombosis events in PTFE grafts and native fistulae. The annual incidence of thrombotic events decreased from 1.6 to 0.4 events/patient year in grafts and 0.5–0.0 events in fistulae. Additionally, the percentage of URR's > 70 increased from 82.3 to 90.1% over the same time period. Use of the Crit‐Line Delta H ABF device in conjunction with a vascular access management program can significantly reduce the number of thrombotic events per patient year.
Sickle Cell Ulcer in Hand Attributable to Arterio‐Venous Fistula
Authors: Halker R. , Agraharkar M.
Published: December 2004

Introduction:  Sickle cell ulcers are a frequent dermatologic manifestation of sickle cell disease. They are almost exclusively described in the legs near the malleoli and are often bilateral. Such ulcers in the upper extremities are not described. We report a case of sickle cell ulcer in hand presumably related to arterio‐venous fistula in the forearm placed for hemodialysis in a patient with chronic kidney disease.

Case:  A 45‐year‐old African‐American man with a history of sickle cell disease, hypertension, and kidney failure treated with hemodialysis presented with a painful wound in his left hand near the base of his thumb, which had been present for 6 weeks prior to presentation. There was no history of trauma. 6 months prior to the development of the ulcer, the patient had an arterio‐venous fistula placed in the affected hand. The ulcer did not improve with use of antibiotics. Venous ultrasound of the left upper extremity showed occlusion of the cephalic vein and enlargement of the basilic vein. Subsequently, biopsy of the ulcer showed vascular proliferation with thickening of the vessel and obliteration of the vascular lumen. The blood vessels were plugged with sickled red blood cells, characteristic of sickle cell disease. Histological features of the lesion were indicative of vaso‐occlusive disease, suggesting sickle cell ulcer. Patient was treated with surgical débridement and skin grafting after hyperbaric oxygen therapy that only resulted in partial recovery of the lesion.

Discussion:  The pathogenesis of sickle cell ulcer is presumed to be related to a vaso‐occlusive process, leading to tissue necrosis resulting in skin ulcers. Ulcers can occur spontaneously or with local trauma. Low oxygen‐carrying capacity of the blood, impaired venous hemodynamics, and low hemoglobin are recognized contributing factors. The arterio‐venous fistula causing diversion of arterial blood probably contributed to the development of sickle cell ulcer.

Conclusion:  Sickle cell ulcers in the hand, although extremely rare, can occur in sickle cell patients with chronic kidney disease on hemodialysis with arterio‐venous fistula. This results from the altered local vascular hemodynamics that predispose to vaso‐occlusive conditions, eventually leading to ulceration.
Early Start of Dialysis Therapy is Beneficial for Patients with Acute Renal Failure following Cardiac Surgery
Authors: Sugahara S. , Suzuki H. , Okada H. , Nakamoto H. , Nemoto H. , Kanno Y.
Published: December 2004

Acute renal failure requiring dialysis therapy after cardiac surgery occurs in 1–5% of patients; however, the optimal timing for the initiation of dialysis therapy still remains undetermined. To assess the validity of early start of dialysis therapy, we studied the comparative survival between 14 patients who started to receive dialysis therapy with the timing of decrease of urine volume less than 30 mL/h and other 14 patients who waited to begin dialysis therapy until the level of urine volume of less than 20 mL/h during 14 days. Overall mortality of those patients was 50%. Twelve of 14 patients who received the early intervention survived. In contrast, only 2 of 14 patients in the other group survived. There was a significant difference of p < 0.01 between the two groups. Between the two groups, there were no significant differences in age, sex ratio, the score of APACHE (Acute Physiologic and Chronic Health Evaluation) II, and the levels of serum creatinine at the start of dialysis therapy (2.9 + 0.2 vs. 3.1 + 0.2 mg/dL) as well as in the levels of serum creatinine at admission. The start timing for the treatment of acute renal failure following cardiac surgery would be determined by the decrease of urine volume but not by the levels of serum creatinine. The early start of dialysis therapy might be preferable for the improvement of survival of the patients suffering from acute renal failure following cardiac surgery.
Comparative Study between Classic and Newer Methods for the Evaluation of Hemodialysis Adequacy
Authors: Kiriklidou P. , Memmos D. , Papadopoulou D. , Mitsopoulos E. , Sakellariou G.
Published: December 2004

Aim:  The comparative study of hemodialysis (HD) adequacy of Kt/V measurement between classic method (Daugirdas formula) and urea sensor monitor (online).

Patients and methods:  30 patients with end‐stage renal failure undergoing dialysis were studied. A comparative evaluation of HD adequacy during the same session was done with two different methods: (1) blood samples were drawn in the beginning and in the end of HD session for the measurement of blood urea nitrogen (BUN) and after measurement of HD adequacy by 3rd generation Daugirdas formula and (2) urea sensor monitor use for continuous HD adequacy measurement during HD session.

Results:  There was statistically significant correlation of Kt/V Daugirdas with Kt/V online (r = 0.8, p < 0.001). Also there was statistically significant correlation between solute removal index (SRI), Kt/V Daugirdas (r = 0.81, p < 0.001) and Kt/V online (r = 0.92, p < 0.001). From nutrition indices that were measured, the protein catabolic rate (PCR) had marginal negative correlation with the two compared adequacy indices, Kt/V Daugirdas (r = −0.24, p < 0.03), and Kt/V online (r = −0.17, p < 0.03) although the nPCR (normalized PCR) had marginal positive correlation (r = 0.35, p < 0.05) (r = 0.42, p < 0.05).

Conclusions:  The use of online urea sensor monitors contributes to the easy measurement of adequacy and nutrition indices and hence complicated mathematical formulas are not necessary. The results of these measurements are reliable and comparable with classic methods of HD adequacy evaluation.
Short Daily Hemodialysis vs. Short Daily Hemofiltration (Search for Optimal Prescription)
Authors: Galland R. , Traeger J. , Béné B. , Delawari E.
Published: December 2004

It has been shown that daily hemodialysis as well as convective transfer by hemofilitration improve the quality of extra renal treatment. Two following phases of treatment of three weeks each were tested in 2 patients: daily hemodialysis 2.5 h 6 times/week (HD*6) and daily hemofiltration 2.75 h 6 times/week (HF*6) performed according to the following modalities. Phase I, blood flow rates (QB): 300 mL/min, hemofilter 1.4 m2AN 69 dialysate flow 500 mL/min. Phase II, QB: 150 mL/min, hemofilter 1m2AN 69, exchange volume of 10 L/session; 5 L predilution and 5 L postdilution (conditions were limited by the device). We measured, during the third week of treatment of each phase, the weekly mass transfers and the predialysis plasma levels of urea (U), creatinine (C), phosphate (P), and B2 microglobulin (B2M). In the 2 phases, HD*6 and HF*6, respectively, the weekly urea Kt was: 120 vs. 60 L; std Kt/V: 3.30 vs. 2.0; npcr: 1.26 vs. 1.42 g kg–1 day–1.

Mass transfer/week
Predialytic levels/L

HD*6
HF*6
HD*6
HF*6

U (mmol)
 2366
 2204
 23.2
 38.5

C (µmol)
67240
51096
769.5
934.8

P (mmol)
  127
  111.5
  1.91
  2.34

B2M (mg)
  311
  763.5
 34.2
 30.16

In HF*6, predialysis solute concentration increased and weekly small molecule mass transfer was insufficient. B2M mass transfer was significantly increased and predialytic plasma concentration decreased, showing a higher clearance of middle molecules with convective transfer. The clinical tolerance was excellent during the two phases of treatment. This study allows to determine the optimal conditions for adequate daily HF: higher QB and exchange volume. Further studies with QB of at least 300 mL/min and with exchange volume of 15 L/session seem to be necessary.
Thrombotic Thrombocytopenic Purpura‐Hemolytic Uremic Syndrome in a Hemodialysis Patient Following Hematoma
Authors: Wood N.r. , Haqqie S.s.
Published: December 2004

Thrombotic thrombocytopenic purpura‐hemolytic uremic syndrome (TTP‐HUS) is a rare clinical syndrome defined by the presence of thrombocytopenia and microangiopathic hemolytic anemia. The etiology of TTP‐HUS is diverse, and many cases remain idiopathic. Recognized causes include Shiga toxin‐producing Escherichia coli, quinine toxicity, certain cancers and cancer chemotherapy, antiphospholipid antibodies, pregnancy and OCP's, cyclosporine, tacrolimus, OKT3, antiplatelet agents, AIDS and HIV infection, and pneumococcal infection. After an extensive literature review, we found no cases of TTP‐HUS following traumatic injury. We present the case of a 57‐year‐old white male hemodialysis patient with end‐stage renal disease secondary to type 2 diabetes, severe CAD with multiple MI's, HTN, history of coronary artery bypass grafting ×4, and transmyocardial reperfusion. The patient fell in the bathroom with questionable LOC and was found to have a subarachnoid hemorrhage diagnosed by head CT. 4 days after the fall, he developed TTP‐HUS with severe thrombocytopenia (platelet‐count falling from 181,000 to 6000), hemolytic anemia, mental status changes, and renal function abnormalities. He was treated by plasma exchange with subsequent improvement of symptoms and laboratory abnormalities. Of interest, we present another case of TTP‐HUS following trauma. A 42‐year‐old white male with no applicable medical history fell 6 feet from a ladder, developing a renal hematoma. 4 days after the fall, he developed TTP‐HUS. This patient was also treated with plasma exchange with subsequent improvement of symptoms and laboratory abnormalities. Based on these two case studies, we suggest that hematoma be considered as a potential trigger in the development of TTP‐HUS.
Bayesian analysis of climate change impacts in phenology
Authors: Dose Volker , Menzel Annette
Published: December 2004

The identification of changes in observational data relating to the climate change hypothesis remains a topic of paramount importance. In particular, scientifically sound and rigorous methods for detecting changes are urgently needed. In this paper, we develop a Bayesian approach to nonparametric function estimation. The method is applied to blossom time series ofPrunus aviumL.,Galanthus nivalisL. andTilia platyphyllosSCOP. The functional behavior of these series is represented by three different models: the constant model, the linear model and the one change point model. The one change point model turns out to be the preferred one in all three data sets with considerable discrimination of the other alternatives. In addition to the functional behavior, rates of change in terms of days per year were also calculated. We obtain also uncertainty margins for both function estimates and rates of change. Our results provide a quantitative representation of what was previously inferred from the same data by less involved methods.
Developing a Multilayered Integrated Numerical Model of Surface Physics – Growing Plants Interaction (MINoSGI)
Authors: Watanabe Tsutomu , Yokozawa Masayuki , Emori Seita , Takata Kumiko , Sumida Akihiro , Hara Toshihiko
Published: December 2004

This paper describes a Multilayered Integrated Numerical Model of Surface Physics – Growing Plants Interaction (MINoSGI), which represents interactions between the dynamics of forest ecosystems and microclimate. Aiming at a large‐scale study in the future, we describe forest dynamics by using area‐averaged prognostic equations for thedistributions of plant density and plant weight with respect to plant height classes, instead of individual‐based treatments for small‐scale forest patches. Growth and mortality of plants are modelled based on the carbon balance of each plant height class. The area‐averaged microclimate (e.g., light, wind speed, temperature, humidity, CO2 concentration) within the forest canopy is simulated by a one‐dimensional multilayer canopy model, which includes most of the physical and physiological processes that control the forest microclimate. Owing to its multilayered framework, a direct specification is possible for the difference in the growing environment among plants of different size and species. Given hourly meteorological conditions, the model outputs energy, water, CO2 and momentum fluxes to and from a forest, of which the structure changes through competition among plants. The model's performance was tested by comparing its outputs with observed data on the development of plant size distribution taken over a 5‐year period in an evergreen coniferous (Cryptomeria japonica) forest. The model produced realistic estimates of the total biomass increments during the period. The ratio of net primary production to gross primary production (=0.45) was consistent with previous estimates for temperate forests. The bimodal seasonal pattern in net ecosystem production was similar to the seasonal trend in the CO2 flux measured over a forest of the same species. Although some limitations due to the one‐dimensional representation of microclimate were noticeable, the model adequately simulated distributions of annual growth rate, plant weight and diameter across plant height classes. Since the basic equations can be extended to include the effect of spatial variability with marginal increase of computational costs, the present model framework is feasible for large‐scale studies.
Climate controls on vegetation phenological patterns in northern mid‐ and high latitudes inferred from MODIS data
Authors: Zhang Xiaoyang , Friedl Mark A. , Schaaf Crystal B. , Strahler Alan H.
Published: December 2004

Recent studies using both field measurements and satellite‐derived‐vegetation indices have demonstrated that global warming is influencing vegetation growth and phenology. To accurately predict the future response of vegetation to climate variation, a thorough understanding of vegetation phenological cycles and their relationship to temperature and precipitation is required. In this paper, vegetation phenological transition dates identified using data from the moderate‐resolution imaging spectroradiometer (MODIS) in 2001 are linked with MODIS land surface temperature (LST) data from the northern hemisphere between 35°N and 70°N. The results show well‐defined patterns dependent on latitude, in which vegetation greenup gradually migrates northward starting in March, and dormancy spreads southward from late September. Among natural vegetation land‐cover types, the growing‐season length for forests is strongly correlated with variation in mean annual LST. For urban areas, the onset of greenup is 4–9 days earlier on average, and the onset of dormancy is about 2–16 days later, relative to adjacent natural vegetation. This difference (especially for urban vs. forests) is apparently related to urban heat island effects that result in both the average spring temperature and the mean annual temperature in urban areas being about 1–3°C higher relative to rural areas. The results also indicate that urban heat island effects on vegetation phenology are stronger in North America than in Europe and Asia. Finally, the onset of forest greenup at continental scales can be effectively described using a thermal time‐chilling model, which can be used to infer the delay or advance of greenup onset in relation to climatic warming at global scale.
Emergency Medicine Management of the Geriatric Patient: An Educational Program for Medical Students
Authors: Shah Manish N. , Heppard Brian , Medina‐Walpole Annette , Clark Nancy S. , McCann Robert
Published: December 2004

This article describes the experience of fourth‐year medical students participating in a geriatric education program integrated into a 4‐week emergency medicine student clerkship. Between July 2002 and April 2003, all students in this required clerkship participated in a geriatric educational program consisting of a small group discussion of medical and psychosocial issues of older adult emergency department (ED) patients. Students used learned skills to evaluate older adult ED patients for medical and psychosocial issues and later followed up with these patients by telephoning them at their homes or visiting them in the hospital. Students tracked their evaluations of the medical problems, functional abilities, and social supports of patients in the ED. Students also noted when their assessments resulted in the acquisition of new skills or knowledge and when their evaluation of geriatric syndromes resulted in a change of the patient care plan. Seventy‐seven students evaluated 217 patients in the ED, of whom 167 (77%) received a follow‐up visit or phone call. Students documented learning new skills while caring for 80 (48%) of the older adult patients. Qualitative survey responses from students indicated that students had increased understanding of the importance of assessing functional status and social supports and providing interdisciplinary care. Integrating geriatric education modules into existing emergency medicine clerkships is an effective method to expand the geriatric curriculum in medical schools and to emphasize the importance of geriatric assessment and syndromes in emergency care.
Global Assessment of Relational Functioning Scale (GARF): I. Background and Rationale
Authors:   GROUP FOR THE ADVANCEMENT OF PSYCHIATRY COMMITTEE ON THE FAMILY
Published: December 2004

The Committee on the Family of the Group for the Advancement of Psychiatry has introduced the Global Assessment of Relational Functioning (GARF), a scale that describes and quantifies the relational context within which patients live and problems occur. The GARF is intended to serve as a device that alerts clinicians to pay attention to the evaluation not only of individuals but also of relational functioning. In this article, we describe from a historical perspective the scientific and political context within which this scale was developed. The GARF is analogous to Axis V of the DSM GAF scale (Global Assessment of Functioning) that is used to assess individual functioning. The GARF is a composite derivative of three major dimensionalized constructs, namely, joint problem solving, organization, and emotional climate. We provide five clinical vignettes to illustrate the process of arriving at GARF ratings. Finally, we discuss caveats and limitations for use of the GARF at present, and make recommendations for research projects and training methods that may enhance the value of this instrument in the future.
A View through the Bubble: Some Insights from Teaching Negotiation Online
Authors: Weiss Joshua N.
Published: December 2004

The teaching of negotiation in an online context is not only possible, but surprisingly provides a number of opportunities that the traditional face‐to‐face classroom setting lacks. The author, drawing on his practical experience over the past few years, puts forth suggestions for preparing and teaching negotiation online. After explaining the preparation and structure of the course, the author offers six core insights to consider when teaching negotiation in this context.
Accepting Conflict and Experiencing Creativity: Teaching “Concertation” Using La Francilienne CD‐ROM
Authors: De Carlo Laurence
Published: December 2004

This article discusses the use of the La Francilienne CD‐ROM, which I developed with my colleague Alain Lempereur, law professor at ESSEC Business School, near Paris. As a professor in the ESSEC Department of Environment, I use the CD‐ROM as the basic tool for my course “Concertation, Decision, and Local Democracy.” The CD‐ROM's simulation of a public negotiation process for a highway project allows me not only to teach basic concepts and methods of negotiation and mediation but also to enhance two important concepts in public decision processes in planning and environment: conflicts and creativity. The students are given the opportunity first to experience, and then to discuss, conflict and creativity in a quasi‐real setting. These experiences and discussions encourage an internal change process for the students and help them to integrate the negotiation and mediation concepts and methods taught. This internal change will be conceptualized in this article according to two educational theories: transitional thinking theory and experiential learning theory.
Gingival crevicular fluid monocyte chemoattractant protein‐1 and RANTES levels in patients with generalized aggressive periodontitis
Authors: Emingil Gülnur , Atilla Gül , Hüseyinov Afig
Published: December 2004

Background: Local and systemic inflammatory and immune mechanisms may be implicated in the pathogenesis of the aggressive forms of periodontal disease. Chemokines, monocyte chemoattractant protein‐1 (MCP‐1) and regulated on activation, normal T cells expressed and secreted RANTES (regulated on activation, normal T cells expressed and secreted), are involved in the activation and recruitment of inflammatory and immune cells to the infected sites and thereby mediating a variety of pathophysiological conditions. The aim of the present study was to examine the gingival crevicular fluid (GCF) levels of MCP‐1 and RANTES in patients with generalized agressive periodontitis (G‐AgP).

Methods: MCP‐1 and RANTES levels were investigated in GCF samples of 10 patients with G‐AgP and 10 periodontally healthy subjects. Periodontal status was evaluated by measuring probing depth, clinical attachment loss, presence of bleeding on probing and plaque. In the G‐AgP group, GCF samples were collected from the two approximal sites; from one single‐rooted tooth and from one first molar tooth with 6 mm probing depth. In the healthy group, GCF samples were collected from one of the single‐rooted teeth. GCF MCP‐1 and RANTES levels were quantified by enzyme immunoassay.

Results: The G‐AgP patients had significantly higher GCF MCP‐1 and RANTES levels compared to the healthy group (p<0.05). GCF MCP‐1 and RANTES levels were positively correlated with both probing depth and clinical attachment loss (p<0.05). There was no correlation between GCF MCP‐1 and RANTES levels and the percentage of sites with bleeding (p>0.05).

Conclusions: The results of the present study suggest that MCP‐1 and RANTES could play key roles in both activation and recruitment of inflammatory and immune cells in periodontal environment of G‐AgP patients. In conclusion, these CC chemokines may be considered in the biological mechanism underlying the pathogenesis and progression of G‐AgP.