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Seven patients underwent primary and contralateral revision total knee arthroplasty (TKA) under one anesthetic in a sequential fashion. The average patient age was 67.6+/-6.9 years. Average blood loss was 764+/-568 cc, average operative time was 269+/-107 minutes, and average length of hospital stay was 9.6+/-3.4 days. One patient with a history of hypertension, diabetes, and coronary heart disease died from pulmonary embolism 7 days after surgery. Deep infection with enterococcus developed in the revised knee of another patient 3 months after surgery. For the six surviving patients, knee pain and function were improved by surgery. However, in this small series of patients, two major complications occurred. These results indicate that if this procedure is considered at all, it should be reserved for only healthy patients with relatively uncomplicated knee reconstructions.
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PMID:Simultaneous primary and contralateral revision total knee arthroplasty. 1032 99

Cardiovascular disease is the leading cause of death in patients receiving dialysis. This is attributed in part to the shared risk factors of cardiovascular disease and end-stage renal disease. The risk factors for coronary artery disease include the classic cardiac risk factors of diabetes mellitus, hypertension, dyslipidemia, and smoking. Also in this population, hyperparathyroidism, hypoalbuminemia, hyperhomocysteinemia, elevated levels of apolipoprotein (a), and the type of dialysis membrane may play a role. Management begins with risk factor modification and medical therapy including aspirin, beta blockers, angiotensin converting enzyme (ACE) inhibitors, and lipid-lowering agents. Revascularization is often important, and coronary artery bypass grafting appears to be preferable to percutaneous transluminal coronary angioplasty. This is especially true for those with multivessel disease, impaired left ventricular function, severe symptoms, or ischemia. Congestive heart failure is another common problem in dialysis patients. The management includes correction of underlying abnormalities, optimal dialysis, and medical therapy. Data obtained from the general population indicate obvious benefits from ACE inhibitors and beta blockers, and these agents would be considered the therapies of choice. Erythropoetin is also an essential component of therapy, but the ideal hemoglobin concentration has yet to be determined. Peritoneal dialysis may be helpful in severe cases of heart failure. Pericarditis is seen in less than 10% of dialysis patients and is best diagnosed by clinical examination and echocardiography. Intensive dialysis is often the best initial therapy. Pericardiocentesis is reserved for the setting of pericardial tamponade, but a pericardial window is more definitive.
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PMID:Cardiac complications of end-stage renal disease. 1092 9

The pathogenic basis and treatment of diabetic polyradiculoneuropathy is a source of recent controversy as there may be two or more distinct forms of diabetic polyradiculoplexopathy. We believe that the following two categories of diabetic polyradiculoneuropathy can be made on the basis of clinically differences: 1) the more common asymmetric, painful polyradiculoneuropathy; and 2) the rare symmetric, painless, polyradiculoneuropathy. The asymmetric, painful form (also known as diabetic amyotrophy) may have an autoimmune basis, but the etiology is not clear. The natural history for diabetic amyotrophy is spontaneous improvement. Nevertheless, various immunotherapies (eg, corticosteroids and intravenous immunoglobulin (IVIg) have been tried with subsequent improvement in symptoms. Treatment is reserved only for patients with severe ongoing pain, given the significant side effects of these medications in those patients with diabetes. Prednisone and IVIg may help alleviate the pain associated with diabetic amyotrophy. Relief of pain can help patients begin physical therapy earlier, however, there are no prospective, blinded, controlled studies that demonstrate that these treatments lead to an earlier and better recovery of muscle strength compared with the natural history of the disorder. The symmetric, painless form of diabetic polyradiculoneuropathy may in fact represent chronic inflammatory demyelinating polyneuropathy (CIDP) occurring in a patient with diabetes mellitus (DM). Patients with idiopathic CIDP may improve various immunomodulating therapies, including corticosteroid treatment, plasma exchange (PE), and IVIg. In this regard, patients with the symmetric, painless, proximal diabetic polyradiculoneuropathy may also respond to corticosteroids, plasma exchange, IVIg, azathioprine, or cyclophosphamide. However, as with diabetic amyotrophy, some patients improve spontaneously without treatment. In still other patients, the neuropathy appears unresponsive to immunotherapy. In such patients, this polyradiculoneuropathy might be caused by metabolic dysfunction associated with DM. Unfortunately, from a clinical, laboratory, and electrophysiologic standpoint, it is impossible to distinguish the patients with a symmetric, painless diabetic polyradiculoneuropathy who might respond to therapy. A trial of PE can be useful in identifying patients who might have a polyradiculoplexopathy that is responsive to immunotherapy. If patients respond to PE, they may continue to receive intermittent exchanges or be switched over to prednisone or IVIg.
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PMID:Diabetic Lumbosacral Polyradiculoneuropathies. 1118 Jul 51

Overweight and obesity represent a rapidly growing threat to the health of populations in an increasing number of countries. Indeed they are now so common that they are replacing more traditional problems such as undernutrition and infectious diseases as the most significant causes of ill-health. Obesity comorbidities include coronary heart disease, hypertension and stroke, certain types of cancer, non-insulin-dependent diabetes mellitus, gallbladder disease, dyslipidaemia, osteoarthritis and gout, and pulmonary diseases, including sleep apnoea. In addition, the obese suffer from social bias, prejudice and discrimination, on the part not only of the general public but also of health professionals, and this may make them reluctant to seek medical assistance. WHO therefore convened a Consultation on obesity to review current epidemiological information, contributing factors and associated consequences, and this report presents its conclusions and recommendations. In particular, the Consultation considered the system for classifying overweight and obesity based on the body mass index, and concluded that a coherent system is now available and should be adopted internationally. The Consultation also concluded that the fundamental causes of the obesity epidemic are sedentary lifestyles and high-fat energy-dense diets, both resulting from the profound changes taking place in society and the behavioural patterns of communities as a consequence of increased urbanization and industrialization and the disappearance of traditional lifestyles. A reduction in fat intake to around 20-25% of energy is necessary to minimize energy imbalance and weight gain in sedentary individuals. While there is strong evidence that certain genes have an influence on body mass and body fat, most do not qualify as necessary genes, i.e. genes that cause obesity whenever two copies of the defective allele are present; it is likely to be many years before the results of genetic research can be applied to the problem. Methods for the treatment of obesity are described, including dietary management, physical activity and exercise, and antiobesity drugs, with gastrointestinal surgery being reserved for extreme cases.
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PMID:Obesity: preventing and managing the global epidemic. Report of a WHO consultation. 1123 59

Genetic background is an important factor for longevity. Life-style and environmental factors, such as nutrition, physical activity, smoking and alcohol, are also important. For example, obesity is negatively associated with health and longevity. It is known that dietary restriction is the most consistent method of extending life span in rats. In human, however, under nutrition as well as over nutrition is a risk factor for a short life. Losing weight is often dangerous in the elderly, in whom reserved physiological functions are limited. Smoking, diabetes mellitus and hypertension accelerate human aging, while physical activity and a moderate amount of alcohol is good to live long. Preventive medicine and health support are also important to promote longevity. Good results of new strategies such as custom-made health support and preventive treatment are anticipated in the near future. Accumulation of basic data in human aging and health are essential to the practice of preventive medicine and health support. A new comprehensive longitudinal study was started at the National Institute of Longevity Sciences (NILS) in 1997 (NILS-Longitudinal Study of Aging, NILS-LSA). The results of this study should be helpful for the practice of preventive medicine and health support.
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PMID:[Physiological requirements for longevity]. 1130 30

Fifteen patients with splenic abscesses were evaluated between 1985 and 1995. The most common predisposing factors were remote infection, diabetes mellitus and heart disease. Common clinical presentations included leucocytosis, fever, left upper quadrant abdominal pain and left pleural effusion. Four patients with splenic abscesses smaller than 4 cm in diameter were treated with antibiotics alone, and 1 in this treatment group died. Among the 10 patients with splenic abscesses larger than 4 cm in diameter receiving percutaneous drainage, 9 (90%) were successfully cured, including 8 with unilocular abscesses and 1 with multilocular abscesses. Two patients underwent splenectomy. In conclusion, percutaneous drainage using ultrasound or computed tomography guidance may be recommended as the treatment of choice for splenic abscess larger than 4 cm in diameter. Antibiotics alone may sometimes be considered for splenic abscesses smaller than 4 cm in diameter. Splenectomy is reserved for those cases where medical treatment has failed.
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PMID:Splenic abscess--a changing trend in treatment. 1139 97

Intermittent claudication (IC), the symptom of exercise-induced muscle ischemia of peripheral arterial disease (PAD), afflicts and limits the activities of a significant number of patients. Incidence and prevalence of IC depends on the population studied and the diagnostic instruments used. In large studies, prevalence has ranged from 3% to 10%, with a sharp increase in those aged > or =70 years. Over the next 20 years, the total number of patients affected is expected to increase significantly due to anticipated demographic changes. Analysis of the natural history of IC demonstrates that the risk of cardiovascular morbidity and mortality far exceeds that of severe limb ischemia or limb loss. In fact, only 2% to 4% of all patients with IC will require a major amputation in their lifetime. However, life expectancy is approximately 10 years less than that of an age-matched cohort. By now, PAD is well recognized as a marker of systemic atherosclerosis. The cornerstone of patient evaluation is a history and physical examination, including a detailed atherosclerotic risk-factor assessment. In the differential diagnosis of IC, clinicians should consider etiologies such as arthritis, spinal stenosis, radiculopathy, venous claudication, or inflammatory processes. In >80% of all patients, it is possible to locate the responsible arterial segment by combining the location and severity of pain with a pulse examination. Noninvasive diagnostic studies help determine the level of disease, may unmask a hemodynamically significant stenosis, and are useful in follow-up. Arteriography is reserved for patients in whom the decision for revascularization has been made. Knowing the anatomic detail of a lesion allows the clinician to determine whether and what type of intervention is feasible. Standard therapy for all patients should be directed at both peripheral and systemic atherosclerosis, beginning with risk-factor modification in the form of smoking cessation, optimal diabetes control, and lipid normalization. The benefits of supervised exercise rehabilitation include significantly increased walking distance and enhanced quality of life. Platelet inhibition has been shown to reduce the risk of ischemic stroke, myocardial infarction, and vascular death and should be prescribed for all but those in whom it is medically contraindicated. Symptom-specific pharmacotherapy with a broad range of medications has yielded disappointing results in the past. However, recent studies have demonstrated that patients receiving the novel agent cilostazol experienced increases in walking distance and improvements in quality of life.
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PMID:Intermittent claudication: magnitude of the problem, patient evaluation, and therapeutic strategies. 1143 94

In September, 2000, the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health called an early halt to the amlodipine arm of the African American Study of Kidney Disease and Hypertension (AASK) trial after careful deliberation by an independent data and safety monitoring board. An interim analysis of the AASK at 3 years revealed a renoprotective effect of the angiotensin-converting enzyme inhibitor ramipril as compared to the dihydropyridine calcium channel blocker (DHP-CCB) amlodipine in patients with mild to moderate renal insufficiency. This differential effect was independent of the blood pressure (BP) levels reached and was evident in proteinuric patients and suggestive in patients with baseline proteinuria < 300 mg/d, but was not conclusive. The AASK trial data suggest that DHP-CCBs should be used cautiously in the presence of mild to moderate renal insufficiency. Judgment should be reserved for the use of other CCBs, such as verapamil or diltiazem, since these are fundamentally different CCBs with the potential for a different impact on hypertensive nephrosclerosis. The blinded observation period for AASK will be completed at the end of September, 2001, at which time additional, clinically useful information is expected to become available. (c)2001 Le Jacq Communications, Inc.
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PMID:The African American Study of Kidney Disease and Hypertension (AASK): new findings. 1149 55

Cardiovascular disease is the leading cause of morbidity and mortality in end-stage renal disease. Causes include those usually found in the general population, those related to the uremic status, and those related to dialytic treatment. Hypertension, hypotension, anemia, hypoalbuminemia, malnutrition, dyslipidemia, reactive C protein, calcium-phosphate product, dialysis modalities, and hyperhomocysteinemia are discussed extensively. Special emphasis is put on hyperparathyroidism as a traditional toxin. The emergent role of sleep apnea has been confirmed in animal models as well as in humans studied using polysomnography. There are difficulties in diagnosing coronary disease, because angiography is not risk-free, is expensive, and should be reserved for patients having symptoms of heart failure and/or patients having diabetes mellitus, and/or patients entering a transplantation list. This allows patients with coronary disease to undergo coronary artery bypass (preferably) or percutaneous transluminal angioplasty. Patients for whom surgery is not appropriate should be treated using more traditional medical procedures.
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PMID:The heart in uremia: role of hypertension, hypotension, and sleep apnea. 1157 20

The authors investigated the effect of a balanced meal on gastric emptying rate and gastrin plasma concentrations in patients with type II diabetes and autonomic neuropathy, in diabetic patients without autonomic neuropathy, and in healthy subjects (controls). Before food the gastrin plasma concentrations were higher in patients with diabetes with autonomic neuropathy. After food, gastric emptying rate was slower in patients with diabetes with autonomic neuropathy, whereas gastrin plasma concentrations increased in 30 minutes in all groups but to a greater extent in patients with diabetes with autonomic neuropathy. Sixty minutes after food, there was a significant decrease in gastrin plasma concentrations in patients with diabetes with autonomic neuropathy, compared with the other two groups. These data suggest that in patients with type II diabetes with autonomic neuropathy, food causes slower gastric emptying and different plasma gastrin level responses from those in patients with type II diabetes without autonomic neuropathy and controls. There are therefore differences in the responses to food ingestion between these groups because of vagal denervation induced by autonomic neuropathy. These tests should be reserved for patients with symptoms suggestive of disturbed gastric emptying, or for patients with autonomic neuropathy without symptoms of gastroparesis.
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PMID:Changes of gastric emptying rate and gastrin levels are early indicators of autonomic neuropathy in type II diabetic patients. 1171 Jul 99


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