Biomedical subjects

F O Finkelstein

Publications and source records attributed to F O Finkelstein.

At least 37 records · Page 2Linked to original sources

PubMed1997

Psychosocial factors and clinical outcome on CAPD.

Patient dropout from chronic peritoneal dialysis (CPD) and transfer to hemodialysis remains a major problem with patients on CPD. Peritonitis, exit-site infections, and medical complications requiring hospitalization often adversely affect the outcome of CPD. The role of psychosocial factors in determining patient outcome and influencing the rates of these complications is not clear. Our group has employed a variety of instruments, including the Patient Related Anxiety Scale (PRAS), Beck's Depression Inventory (BDI), Kupfer-Detre System II somatic symptom scale (KDS-II), and a patient self-assessed quality of life (PAQOL) questionnaire to assess quality of life and to objectively evaluate the psychosocial status of the patient treated with CPD. The present study extends previous observations by relating the results of these psychosocial instruments to the incidence of various complications in 103 patients maintained on CPD. Patients were divided into low-scoring (lowest symptoms of depression, anxiety, somatic symptoms, and best quality of life evaluation), intermediate, and high-scoring (highest symptoms of depression, anxiety, somatic symptoms, and worst quality of life) categories. The peritonitis rates, exit-site infection rates, and days of hospitalization of the three categories were then compared. The results demonstrate significantly higher complication rates in the high-scoring when compared to the low-scoring patients. Thus screening patients maintained on CPD with objective measures of psychosocial functioning may enable caregivers to more accurately predict which patients are at greater risk for developing medical complications.

Adult↗

PubMed1997

Quality of life assessment in chronic peritoneal dialysis patients.

Previous studies by our group have attempted to examine quality of life (QoL) issues in a cohort of end-stage renal disease (ESRD) patients maintained on chronic peritoneal dialysis (CPD) by assessing a variety of psychological tests and by asking patients to rate their own QoL. The present study was undertaken to extend previous observations by asking patients to spontaneously select those domains of life experience that they think are most important in determining their quality of life. Sixty-eight medically stable CPD patients were asked to spontaneously select those three to five domains felt to be most important to them in defining their QoL. The 307 responses were then grouped into 22 broad categories by three investigators. The most frequently selected domains focused on interpersonal relationships. Domains that enhance the quality of one's day and add meaning to one's life were selected with a midrange frequency. Some domains that might intuitively seem to be important for a patient's QoL were selected with a surprisingly low frequency. These findings suggest that to understand what CPD patients value in assessing their QoL can best be determined by asking them directly and not by using predetermined variables.

Adult↗

PubMed1996

Fungal peritonitis in a large chronic peritoneal dialysis population: a report of 55 episodes.

Fungal peritonitis (FP) is a rare but serious complication of chronic peritoneal dialysis (CPD) therapy and is associated with high morbidity and CPD drop-out. Risk factors and management of FP remain controversial. We reviewed our experience with FP in an attempt to identify risk factors and to examine outcome in relation to treatment strategies. Between March 1984 and August 1994, 704 patients were maintained on CPD therapy in our unit. A total of 1,712 episodes of peritonitis were identified among these patients. Fungal peritonitis accounted for 55 (3.2%) of these episodes. The patients on CPD therapy who developed FP were similar to those who did not develop FP with regard to age, gender, underlying etiology for end-stage renal disease, and comorbid disease. Prior antibiotic use was noted in 87.3% of episodes of FP. The peritonitis rate in the patients who developed FP was one episode every 5.1 months compared with one episode every 9.9 patient-months in the CPD patients who did not develop this infection. Candida sp caused 74.5% of the episodes of FP. All patients were treated with antifungal drugs. In 85.5% of infections the Tenckhoff catheter was removed within 1 week of the diagnosis of FP; 31.9% of the patients who had the Tenckhoff catheter removed did not have the catheter replaced because of death or transfer to hemodialysis. In the patients who developed FP, 68.1% had the Tenckhoff catheter replaced; of these patients, 90.6% and 59.4% were on CPD therapy 1 and 6 months after catheter replacement, respectively. We conclude that risk factors identified in our population include peritonitis rate and prior antibiotic use. Fungal peritonitis is rare in our CPD population, and although it leads to significant CPD drop-out, it can be managed in many patients with antifungal therapy, early catheter removal, and temporary hemodialysis. Of the catheters replaced between 2 and 8 weeks after the diagnosis of FP, 91% functioned successfully, allowing continuation of CPD.

Amphotericin B↗

PubMed1996

Nine episodes of CPD-associated peritonitis with vancomycin resistant enterococci.

Nine episodes of chronic peritoneal dialysis (CPD)-associated peritonitis with vancomycin resistant enterococci (VRE) were described between November 1993 and February 1996 in our dialysis unit. During the time period, 216 patients were treated for 227 episodes of peritonitis. Of the patients developing peritonitis with VRE the mean age +/- SD was 56.3 +/- 9.7 years. There were 5 females, 4 males, 5 Caucasians and 4 African-Americans. Diabetes mellitus, cardiovascular disease and gastrointestinal disease were present in 7, 8 and 7 of the 9 patients with VRE peritonitis, respectively. Patients were maintained on CPD therapy for an average of 29.9 +/- 19.2 patient months before developing VRE peritonitis. The prior rate of CPD associated peritonitis in the patients developing VRE peritonitis was significantly higher than the rate noted in the CPD patients not developing peritonitis with VRE (1 episode in 6.3 patient months vs. 1 episode in 12.5 patient months, P < 0.05). All 9 patients had used vancomycin in the six months prior to the development of VRE peritonitis and 78% had used a cephalosporin. The antimicrobial therapy used to eradicate peritonitis with VRE varied among the 9 patients with chloramphenicol used in 4 patients. The Tenckhoff catheter was removed in 6 of the 9 patients and was successfully reinserted in one patient. The catheter was not removed in 3 patients and 2 of these patients expired. Five of the 9 patients expired while being treated for VRE, 2 transferred to hemodialysis and 2 continued CPD therapy. VRE peritonitis is a major concern for patients maintained on CPD therapy. Future studies are needed with case controls to determine the significance of prior vancomycin and cephalosporin therapy, fecal VRE carriage and certain demographic data on the acquisition of VRE peritonitis. Furthermore, the optimal therapy and outcome may be better clarified through such a review.

Adult↗

PubMed1996

Quality of life in peritoneal dialysis patients.

In 49 patients receiving continuous ambulatory peritoneal dialysis, we assessed the relative influences of adequacy of dialysis (assessed by kinetic transfer/volume urea) and psychological symptoms (depression and anxiety) upon the patients' evaluation of their overall quality of life (QoL). Subjects completed self-rating forms for anxiety, depressive, and somatic symptoms, for discrete areas relevant to QoL, and for overall QoL; clinicians also rated QoL. Depressive symptoms proved a much stronger correlate of overall QoL than did the biochemical measure of dialysis adequacy, and they remained influential even after adjustment for anxiety, kinetic transfer/volume, and somatic symptoms. In contrast, the effects of kinetic transfer/volume, anxiety symptoms, and somatic symptoms dropped sharply when adjusted for the other variables. Because psychological (especially depressive) symptoms may be stronger determinants of patients' overall QoL than is adequacy of dialysis, assessing QoL and psychological status should be part of the care of end-stage renal disease patients.

Adult↗

PubMed1996

Sexual experience of the chronic peritoneal dialysis patient.

The actual and desired frequency of intercourse was studied in 68 randomly selected chronic peritoneal dialysis (CPD) patients. The results were correlated with standard measures of depression (Beck Depression inventory), anxiety (Patient Related Anxiety Scale), physical symptoms (Kupfer-Detre System 2), adequacy of dialysis (KT/Vurea) and nutrition (serum albumin level). In addition, patients assessed their quality of life (PAQOL) using an 1 to 10 analog scale. The mean +/- SD age of all patients studied was 54 +/- 11 yr, the mean dialysis duration was 24 +/- 24 months; 46% of the patients were female, and 34% were diabetic. Sixty-three percent of the patients reported never having intercourse (Group 1), 19% reported having intercourse < or = two times per month (Group II), and 18% reported having intercourse > two times per month (Group III). Dialysis duration, serum albumin level, KT/Vurea, and age were not significantly different among the three groups. Nearly 50% of patients in Group I desired to have intercourse, and 54% of the patients in Group II desired to have intercourse more frequently, Group I patients had significantly higher depression and anxiety scores, more physical symptoms, a poorer overall PAQOL, and less satisfaction with their sexual activity than Group III patients. These results suggest that there is a high prevalence of sexual difficulties in CPD patients. Patients not having intercourse have a poorer quality of life and higher degree of depression and anxiety than patients having intercourse more than two times per month.

Adult↗

PubMed1996

Psychosocial factors and incidence of peritonitis.

It has been suggested that psychosocial (PS) factors may influence morbidity and mortality in chronically ill patients. However, investigators have not examined how PS factors affect specific medical problems in chronic peritoneal dialysis (CPD) patients. Sixty-eight patients maintained on CPD therapy were studied. PS testing included a self-rating form of patient-assessed quality of life (PaQOL), depression [Beck's Depression Inventory (BDI)], anxiety [Patient Rated Anxiety Scale (PRAS)], and assessment of physical symptoms (KDS-II). Peritonitis rates six months prior to PS assessment and six months after assessment were tabulated. The data show that during the study period patients with more than one episode of peritonitis compared to those with no episodes of peritonitis had: (1) significantly higher anxiety and physical symptom scores; (2) significantly lower PaQOL; and (3) higher depression scores, which did not reach statistical significance (p < 0.06). Whether higher peritonitis rates result in worse PS symptoms, or whether poor PS symptoms cause higher peritonitis rates needs to be determined with further investigations.

Adult↗

PubMed1995

Outcome of polymicrobial peritonitis in continuous ambulatory peritoneal dialysis patients.

Polymicrobial peritonitis is a relatively uncommon, but potentially serious complication that develops in continuous ambulatory peritoneal dialysis (CAPD) patients. Its cause and optimal management remain controversial. The authors reviewed the frequency and natural history of polymicrobial peritonitis in 432 CAPD patients. Of 1,405 episodes of peritonitis, 80 were polymicrobial (6%). Patients with polymicrobial peritonitis were similar to all CAPD patients in age, gender, race, and underlying renal disease. Diabetes mellitus, human immunodeficiency virus (HIV) status, and clinically apparent gastrointestinal disease did not predisposes patients to polymicrobial peritonitis. Thirty days after the polymicrobial peritonitis, 64 patients remained on CAPD (80%), and at 180 days 48 patients continued CAPD. Prior exit-site infections were present in 12 patients (14%) with polymicrobial peritonitis. Only 22% of patients required catheter removal to treat the infection. We conclude that polymicrobial peritonitis accounts for 6% of the total episodes of peritonitis; diabetes, HIV infection, and underlying gastrointestinal disease are not more prevalent in patients with multiorganism infections. Most patients continue CAPD therapy at 30 and 180 days after the episode of polymicrobial peritonitis.

AIDS-Associated Nephropathy↗

PubMed1995

Infection rates in end-stage renal disease patients treated with CCPD and CAPD using the UltraBag system.

Previous studies have shown the incidence of peritonitis to be generally lower for patients performing continuous cycling peritoneal dialysis (CCPD) than patients maintained on continuous ambulatory peritoneal dialysis (CAPD). Recent changes in CAPD techniques, particularly the introduction of the UltraBag system, have resulted in a marked decrease in peritonitis rates in CAPD patients. The purpose of the present study was to compare peritoneal dialysis-related infections in 73 patients treated with CCPD and 57 patients treated with CAPD using the UltraBag system for a 12-month period. Demographic data of the two groups were comparable. Peritonitis rates were significantly lower in the patients treated with CAPD on the UltraBag (one infection/23 patient-months) than in patients treated with CCPD (one infection/14.4 patient-months, p < 0.05). Exit-site infections were also significantly lower in patients treated with CAPD (one episode/35 patient-months) compared to patients treated with CCPD (one episode/11.5 patient-months, p < 0.05). The spectrum of organisms causing infection was similar in both groups of patients. The study suggests that peritonitis and exit-site infections are significantly less common in patients treated with CAPD with the UltraBag system than in patients treated with CCPD.

Catheters, Indwelling↗

PubMed1994

Abdominal abscesses complicating peritonitis in continuous ambulatory peritoneal dialysis patients.

Ten patients with end-stage renal disease maintained on continuous ambulatory peritoneal dialysis therapy developed abdominal abscesses between 1982 and 1992. During this period, 537 patients cared for in our continuous ambulatory peritoneal dialysis unit developed 1,345 episodes of peritonitis. All abdominal abscesses were attributed to concomitant or antecedent peritonitis, suggesting that abscesses developed in 0.7% of peritonitis episodes. Abdominal pain, tenderness, fever, and nausea and vomiting were the most common presenting symptoms and signs. Radiographic findings that were helpful in establishing the diagnosis included abnormalities on computed tomography (CT) scanning, ultrasound, and Indium scanning. Seven patients developed intraperitoneal abscesses, two developed abdominal wall abscesses, and one developed both abdominal wall and intraperitoneal abscesses. Drainage of the abscesses was performed in all cases either surgically or percutaneously. Two patients died. The remaining eight patients have been maintained on hemodialysis therapy. The present data suggest that abdominal abscesses are uncommon complications of continuous ambulatory peritoneal dialysis-associated peritonitis. Prompt diagnosis by clinical criteria and radiographic techniques is important to permit appropriate drainage of the abscess cavity.

Abscess↗

PubMed1994

Pulse oral calcitriol to treat hyperparathyroidism in 43 CAPD patients.

To further study the effect of pulse oral calcitriol on the level of intact parathyroid hormone (iPTH), we have studied the response of 43 patients treated with 5.0 mcg calcitriol bi-weekly for one year. Mean iPTH decreased from 603 pg/mL +/- 262 (+/- SD) to 222 pg/mL +/- 185 (p < 0.001). Thirty-six patients responded showing a decrease in iPTH from baseline; 7 patients showed no decrease in iPTH. Transient hypercalcemia (calcium > 10.5 mg/dL) was noted in 6 patients of the responder group which corrected with temporary discontinuation of pulse therapy. Pulse oral calcitriol is an effective therapy to decrease elevated iPTH levels in continuous ambulatory peritoneal dialysis (CAPD) patients with hyperparathyroidism.

Administration, Oral↗

PubMed1994

Selected outcome criteria and adequacy of dialysis in diabetic and elderly patients on CAPD therapy.

There has been a gradual increase in the number of diabetic and elderly patients maintained on continuous ambulatory peritoneal dialysis (CAPD) replacement therapy. Eighty randomly selected patients were studied over two years. Weekly normalized urea clearance (KT/Vurea), weekly creatinine clearance/1.73 m2 body surface area (BSA) (Ccr), and protein catabolic rate (PCR) were measured. Selected clinical outcome criteria were assessed. Weekly KT/Vurea was correlated with weekly Ccr (r = 0.538, p < 0.001), and weekly KT/Vurea was correlated with PCR (r = 0.393, p < 0.001). Patients were then stratified according to presence or absence of diabetes mellitus and age > 60 or < or = 60 years. Diabetic and nondiabetic patients had similar weekly KT/Vurea, weekly Ccr, PCR, serum albumin levels, weekly erythropoietin (EPO) requirements, peritonitis rates, and CAPD-related hospitalization rates. The total hospitalization rates, however, were higher in diabetic patients. Elderly and younger patients had similar weekly KT/Vurea, weekly Ccr, PCR, serum albumin levels, and weekly EPO requirements. Elderly patients, however, had higher peritonitis rates and higher total and CAPD-related hospitalization rates.

Adult↗

PubMed1993

Outcome of HIV infected patients on continuous ambulatory peritoneal dialysis.

A retrospective analysis of 39 HIV infected patients with ESRD cared for in New Haven from 1987 to June 1992 was performed. All patients had evidence for HIV infection at the start of CAPD therapy. Cumulative technique survival at one and two years was 43% and 27%, respectively. Only eight patients transferred to center dialysis. One and two year patient survival on CAPD was 58% and 54%, respectively. Mortality was higher in patients with advanced infection than in those with asymptomatic HIV infection. Hospitalization rates were also higher in patients with advanced infection. HIV infected patients had higher rates of peritonitis (3.9 episodes/outpatient CAPD year) compared to non-HIV infected patients (1.5 episodes/CAPD year), especially for pseudomonal and fungal infections. Active injection drug use and use of the "straight set" system were associated with increased rates of peritonitis. CAPD deserves consideration as a therapy for HIV infected patients with ESRD.

Adult↗

PubMed1993

Hyperparathyroidism in CAPD patients: therapy with pulse oral calcitriol.

Hyperparathyroidism remains a cause of significant morbidity in dialysis patients. We studied pulse oral calcitriol, 5.0 micrograms biweekly to control hyperparathyroidism in 12 continuous ambulatory peritoneal dialysis (CAPD) patients. Parathyroid hormone (PTH) levels fell, while calcium and phosphorus levels remained in good control. Pulse oral calcitriol is an effective therapy for hyperparathyroidism in CAPD patients.

Administration, Oral↗

PubMed1993

Weekly KT/V urea and selected outcome criteria in 56 randomly selected CAPD patients.

The optimal way to objectively measure the adequacy of continuous ambulatory peritoneal dialysis (CAPD) therapy remains controversial. It has been suggested that one-third or more of all CAPD patients are presently receiving "inadequate dialysis" when dialysis prescriptions are not carefully calculated. To better define the therapy being delivered in a large, freestanding CAPD center, weekly KT/V urea and creatinine clearance per 1.73 m2 body surface area were measured in 56 of 180 patients randomly selected from our unit in whom dialysis prescriptions were arbitrarily determined by nurses and physicians. In addition, protein catabolic rates and selected clinical outcome criteria were assessed. Weekly KT/V urea correlated with weekly creatinine clearance (r = 0.50) as well as with the protein catabolic rate (r = 0.45). Patients were arbitrarily divided into three groups based on KT/V urea measurements. Thirty percent of the patients had weekly KT/Vs < or = 1.4, 41% had KT/Vs between 1.5 and 1.8, and 29% had weekly KT/Vs > or = 1.9. Significant differences were not noted in hospitalization rates, erythropoietin doses, or serum albumin concentrations in patients with KT/Vs < or = 1.4 and in patients with KT/Vs > or = 1.9. Peritonitis rates were highest in the patients with KT/V > or = 1.9. Therefore, in patients randomly selected from our large CAPD center, 30% of the patients had weekly KT/V urea measurements < or = 1.4. The clinical significance of this finding remains uncertain.

Adult↗

PubMed1993

CAPD therapy for patients over 80 years of age.

OBJECTIVE: The purpose of the study is to review our experience with patients over 80 years of age with end-stage renal disease (ESRD) treated with continuous ambulatory peritoneal dialysis (CAPD). DESIGN: The records of all patients over 80 years of age treated in our unit with CAPD since 1979 were reviewed. SETTING: Out-patient CAPD facility. PATIENTS: Eighteen patients over 80 years of age were identified and studied. MAIN OUTCOME MEASURES: The duration of CAPD therapy, duration of CAPD training, mortality rate, hospitalization rate, peritonitis rate, and family assessment were reviewed and analyzed. RESULTS: The mean +/- SD duration of therapy was 20 +/- 17 months. Nine patients expired, 3 transferred to hemodialysis, 1 recovered renal function, and 5 remained on CAPD therapy. Peritonitis rates were 1.7 episodes/patient year. Of the organisms causing peritonitis, 56% were gram-positive bacteria. The average hospitalization rate was 13.9 days/patient year. The most frequent causes of hospitalization were peritonitis and cardiovascular disease. CONCLUSION: CAPD therapy is a reasonable therapeutic option for patients with end-stage renal disease over 80 years of age.

Age Factors↗

PubMed1992

Pseudomonas exit site infections in continuous ambulatory peritoneal dialysis patients.

The purpose of this study is to examine the natural history of Pseudomonas aeruginosa exit site infections in continuous ambulatory peritoneal dialysis (CAPD) patients treated with oral ciprofloxacin and local exit site care. A retrospective view was undertaken of 18 episodes of P. aeruginosa exit site infections developing in 17 patients maintained on CAPD during 1989 and 1990. Standardized therapy for the exit site infection consisted of oral ciprofloxacin (500 mg twice daily) and local exit site care with antiseptic agents. Fifteen (83%) of 18 of the pseudomonas exit site infections resolved with therapy. Three episodes (17%) required catheter removal to successfully eradicate the infection. Four of the 15 patients whose exit site infections resolved developed P. aeruginosa peritonitis 2 to 9 months after the clinical resolution of the exit site infection. The majority of pseudomonas exit site infections in CAPD patients can be successfully treated with oral ciprofloxacin and local care. Approximately 17% of the patients in this study required catheter removal to successfully eradicate the infection and an additional 22% of the patients developed pseudomonas peritonitis several months after the resolution of the exit site infection.

Administration, Oral↗

PubMed1991

Initiatives in peritoneal dialysis: where do we go from here?

In 1989, a conference was held to discuss the current status of technique survival for patients treated with continuous ambulatory peritoneal dialysis (CAPD). Major reasons for patient drop-out from CAPD-peritonitis, inadequate dialysis, catheter-related problems and psychosocial factors-were reviewed, as were constructive techniques for dealing with these problems and areas for future investigation.

Catheterization↗