CURRENT PRACTICE IN RENAL ANAEMIA MANAGEMENT: TWO MULTINATIONAL SURVEYS

The European Best Practice Guidelines recommend that 85% of patients with standard causes of chronic renal failure should achieve a target haemoglobin concentration of > or = 11 g/dL. However, patient outcomes need to be improved as many patients respond suboptimally to treatment and fail to reach these targets. Two multinational surveys of nursing practice in the management of renal anaemia in northern (with comparative data from Australia) and southern Europe were conducted. The aim was to assess variations in the role and amount of responsibility delegated to nurses in renal units throughout Europe and Australia. Patient care could be optimised by developing formal training and educational programmes for nephrology nurses and this has already occurred in many units in the UK.

Health-related quality of life in patients with metastatic colorectal cancer treated with panitumumab in first- or second-line treatment

Background:

Panitumumab in combination with chemotherapy was evaluated in two pivotal clinical trials in first- and second-line treatment of metastatic colorectal cancer (mCRC), respectively. This analysis compared the health-related quality of life (HRQoL) of patients with or without panitumumab in the two trials.

Methods:

Patients with mCRC were randomised to FOLFOX (first-line trial) or FOLFIRI (second-line trial)±panitumumab. The EuroQoL 5-Dimensions Health State Index (EQ-5D HSI) and Visual Analogue Scale (EQ-5D VAS) were assessed at baseline and monthly follow-up until disease progression. Patients with wild-type KRAS mCRC with baseline and post-baseline HRQoL scores were included. Difference in change from baseline between treatment groups was evaluated using linear mixed and pattern-mixture models.

Results:

In the first-line trial, 576 patients with wild-type KRAS mCRC (284 panitumumab+FOLFOX4 and 292 FOLFOX4 alone) were included in the HRQoL analyses. In the second-line trial, 530 patients with wild-type KRAS mCRC were included in these analyses (263 panitumumab+FOLFIRI and 267 FOLFIRI alone). There was no significant difference in the change in EQ-5D HSI and VAS scores between treatment groups in either trial.

Conclusion:

The addition of panitumumab to FOLFOX4 or FOLFIRI in first- or second-line treatment of wild-type KRAS mCRC significantly improved progression-free survival without compromising HRQoL.

Establishment of an HIV/sexually transmitted disease programme and prevalence of infection among incarcerated men in Jamaica

The goal of this study is to describe the establishment of an HIV testing and treatment programme in the Jamaican correctional system and to estimate the prevalence of HIV/sexually transmitted disease (STD) among adult incarcerated men in this country. A demonstration project was implemented by the Jamaican Department of Correctional Services and Ministry of Health in the nation's largest correctional centre. All inmates were offered HIV and syphilis testing, and a subset was offered chlamydia, gonorrhoea and trichomoniasis testing. Cross-sectional data from the project were reviewed to determine the prevalence and correlates of HIV/STD. HIV test acceptance was 63% for voluntary testers (n = 1200). The prevalence of HIV was 3.3% (95% confidence interval [CI] 2.33-4.64) (n = 1017) and the prevalence syphilis was 0.7% (95% CI 0.29-1.49) (n = 967). Among the subset tested (n = 396) the prevalence of chlamydia was 2.5% (95% CI 1.22-4.49) and for trichomoniasis it was 1.8% (95% CI 0.01-3.60), but no cases of gonorrhoea were detected (n = 396). The prevalence of HIV was significantly higher at 25% (95% CI 13.64-39.60) for persons located in a separate section where individuals labelled as men who have sex with men (MSM) are separated. HIV/STD testing is important and feasible in Jamaica. A special focus should be placed on providing services to inmates labelled as MSM. Other Caribbean nations may also benefit from similar programmes.

Comparison of codes assessing galactic cosmic radiation exposure of aircraft crew

The assessment of the exposure to cosmic radiation onboard aircraft is one of the preoccupations of bodies responsible for radiation protection. Cosmic particle flux is significantly higher onboard aircraft than at ground level and its intensity depends on the solar activity. The dose is usually estimated using codes validated by the experimental data. In this paper, a comparison of various codes is presented, some of them are used routinely, to assess the dose received by the aircraft crew caused by the galactic cosmic radiation. Results are provided for periods close to solar maximum and minimum and for selected flights covering major commercial routes in the world. The overall agreement between the codes, particularly for those routinely used for aircraft crew dosimetry, was better than +/-20 % from the median in all but two cases. The agreement within the codes is considered to be fully satisfactory for radiation protection purposes.

Renal anaemia: recent developments and future directions for improved management

The global burden of chronic kidney disease (CKD) and associated anaemia is substantial. With the increasing numbers of patients that are likely to be affected in the future, approaches are required to improve anaemia management without increasing the workload of renal units. Advocating early treatment may improve patient outcomes and nurses are in an ideal position to identify and manage anaemia at an early stage in patients with CKD. In addition, adopting a multidisciplinary approach, alongside nephrologists, diabetologists, cardiologists, social workers, nutritionists and pharmacists, may allow nurses to detect and treat anaemia earlier in patients with CKD. Maintaining awareness of factors associated with decreased erythropoiesis-stimulating agents (ESAs) efficacy (e.g. iron deficiency or poor nutritional status) is also important. To reduce the burden on healthcare providers, anaemia management could be simplified by extending the administration interval of ESAs. Recent studies have explored the clinical efficacy of administration of currently available agents at intervals of up to once monthly in highly selected, stable patients. The use of an ESA that can control anaemia while maintaining haemoglobin levels within guideline ranges with extended administration intervals in all patients without the need for additional screening or stepwise dose adjustments with attendant monitoring may help improve patient care while reducing the workload of healthcare providers.

A patient follow-up survey programme for alosetron: assessing compliance to and effectiveness of the risk management programme

BACKGROUND

In November 2002, alosetron HCl (Lotronex, GlaxoSmithKline Research Triangle Park, NC, USA) was re-introduced to the US marketplace for women with severe diarrhoea-predominant irritable bowel syndrome. In support of the re-introduction, a risk management programme was implemented, which included a patient follow-up study in which all users of alosetron could participate.

AIM

We report on the methods used and the effectiveness of key elements of the risk management programme.

METHODS

Patients voluntarily enroled in the study and completed questionnaires at baseline, after 5 and 10 weeks, and quarterly thereafter. Questions focussed on patient eligibility, knowledge of risks and benefits, and adherence to the recommended programme elements for education, prescribing and dispensing.

RESULTS

Between December 2002 and 2004, 4,803 patients enrolled in the study, and <3% were lost to follow-up. The average follow-up time was approximately 6 months, and the response rate for each assessment was >95%. A total of 90% of patients at baseline met the full clinical criteria recommended for the treatment. Patient adherence to the risk management programme was >87%.

CONCLUSIONS

Using the Lotronex risk management programme, patients met clinical criteria, were knowledgeable about treatment risks and benefits, and were adherent to the process elements of the programme. These patients seemed to engage in active dialogue with their physicians about symptoms and use of alosetron.

Twice-weekly administration of peginterferon-alpha-2b improves viral kinetics in patients with chronic hepatitis C genotype 1

The decline in hepatitis C viral load on treatment with peginterferon-alpha-2b is not continuous. The aim of this study was to investigate whether twice weekly dosing of peginterferon-alpha-2b may improve viral kinetics. Ten interferon-naïve patients with chronic hepatitis C (genotype 1a or b) were randomized to receive either 1.0 microg/kg peginterferon-alpha-2b once (group A) or twice weekly (group B) for 4 weeks. Viral load and serum concentrations of peginterferon-alpha-2b were measured. Peginterferon-alpha-2b reached maximal blood concentrations 24 h after the first dose, followed by a linear decline during the subsequent days. On the day before administration of the next dose, peginterferon-alpha-2b was undetectable in nine patients in group A (once weekly dosing). The same pattern was observed during the next 3 weeks of therapy. In group B (twice weekly dosing) peginterferon-alpha-2b was detectable at any given time point and higher than in group A (P between 0.01 and <0.0001). Viral load decreased in all patients within 2 days after the first dose of peginterferon-alpha-2b, but increased again on day 3. In group A, it further increased until day 7. A similar pattern was observed in the second week. In contrast, in group B, viral load decreased again on day 4 and remained lower until the end of the study (P < 0.001). To achieve continuous drug exposure and to improve initial viral clearance, peginterferon-alpha-2b has to be given at least two times weekly.

Insulin-like growth factor-1 inscribes a gene expression profile for angiogenic factors and cancer progression in breast epithelial cells

Activation of the insulin-like growth factor-1 receptor (IGF-1R) by IGF-1 is associated with the risk and progression of many types of cancer, although despite this it remains unclear how activated IGF-1R contributes to cancer progression. In this study, gene expression changes elicited by IGF-1 were profiled in breast epithelial cells. We noted that many genes are functionally linked to cancer progression and angiogenesis. To validate some of the changes observed, the RNA and/or protein was confirmed for c-fos, cytochrome P450 1A1, cytochrome P450 1B1, interleukin-1 beta, fas ligand, vascular endothelial growth factor, and urokinase plasminogen activator. Nuclear proteins were also temporally monitored to address how gene expression changes were regulated. We found that IGF-1 stimulated the nuclear translocation of phosphorylated AKT, hypoxic-inducible factor-1 alpha, and phosphorylated cAMP-responsive element-binding protein, which correlated with temporal changes in gene expression. Next, the promoter regions of IGF-1-regulated genes were searched in silico. The promoters of genes that clustered together had similar regulatory regions. In summary, IGF-1 inscribes a gene expression profile relevant to cancer progression, and this study provides insight into the mechanism(s) whereby some of these changes occur.

Assessing gene significance from cDNA microarray expression data via mixed models

The determination of a list of differentially expressed genes is a basic objective in many cDNA microarray experiments. We present a statistical approach that allows direct control over the percentage of false positives in such a list and, under certain reasonable assumptions, improves on existing methods with respect to the percentage of false negatives. The method accommodates a wide variety of experimental designs and can simultaneously assess significant differences between multiple types of biological samples. Two interconnected mixed linear models are central to the method and provide a flexible means to properly account for variability both across and within genes. The mixed model also provides a convenient framework for evaluating the statistical power of any particular experimental design and thus enables a researcher to a priori select an appropriate number of replicates. We also suggest some basic graphics for visualizing lists of significant genes. Analyses of published experiments studying human cancer and yeast cells illustrate the results.

Patient falls from bed and the role of bedrails in the acute care setting

The use of bedrails in preventing patient falls from bed remains highly controversial and has received only limited research attention throughout the last decade. The present study questioned the relationship between bedrail use and patient falls from bed particularly in terms of age-gender characteristics, mental status and the severity of injuries sustained. A retrospective, cross-sectional analysis was conducted of 419 patient falls occurring in an urban, acute care hospital from 1993-2000. This audit identified 136 falls from bed. It was found that for all age-gender groups the incidence of falls from bed with bedrails elevated was equal to or higher than when bedrails were not elevated. Patients in a 'non rational' state at the time of falling were significantly more likely to have fallen with the bedrails elevated (chi 2 = 19.463, p < 0.001). Whilst there was no statistically significant relationship between the position of bedrails and the severity of injuries sustained (chi 2 = 1.088, p = 0.780) the fact that there was a patient death resulting from a fall from bed over elevated bedrails was considered to be of particular clinical significance. Thus the role of bedrails as protective or safety devices was challenged and an urgent re-evaluation of current practices recommended.

Improving the nurse-patient relationship: a multi-faceted approach

AIM

A Corporate Education Session was held to provide concrete strategies for overcoming several specific barriers in the daily nurse-patient relationship that negatively affect the patient, nurse, or both, and to provide the latest information about best practice as it affects nurses in renal care.

METHODOLOGY

The session was led by a moderator who presented three video case studies to the audience. Communication strategies for recognising and overcoming nurse-patient communication barriers were presented. The audience expressed their views about each case study using voting pads, and a panel of experts addressed the comments of the audience and discussed guidelines for best practice in renal care. The panel comprised three experienced renal nurses, a senior nephrologist, and an expert in social interaction.

CONCLUSIONS

Optimal treatment of patients with renal disease should include early treatment of anaemia, adequate levels of dialysis, and a multidisciplinary approach, responding to both the medical and the social needs of the patient.

MAPS: a microarray project system for gene expression experiment information and data validation

SUMMARY

MAPS is a MicroArray Project System for management and interpretation of microarray gene expression experiment information and data. Microarray project information is organized to track experiments and results that are: (1) validated by performing analysis on stored replicate gene expression data; and (2) queried according to the biological classifications of genes deposited on microarray chips.

Nurse practitioners: an evaluation of the extended role of nurses at the Kirketon Road Centre in Sydney, Australia

The aim of the present study was to formally evaluate the effectiveness, professional appropriateness and acceptability of the extended role of the nurse practitioner at the Kirketon Road Centre (KRC) in Sydney, Australia. Data collection consisted of client and staff surveys and case file review by two assessors (one medical and one nursing). This paper will report on one section of this research, namely the case file review section of the study. Total study subjects were 1046 'at risk' youth, sex workers and injecting drug users attending KRC for their primary health care needs between September 1994 and April 1995. Nurse practitioners (NP) saw 613 of the clients who presented over this period. The majority of these clients were women (77.3%). The majority of NP consults were related to STD (51%), gynaecological (17%) and hepatitis (16%) issues. The results demonstrated that nurse practitioners were professionally appropriate in all aspects of expected 'best practice' in over 95% of consultations.

Pre-training assessment tool (JPAT)--a pilot study

A tool for assessing the suitability of candidates for home dialysis (Jo-Pre-training Assessment Tool--JPAT) was developed. JPAT acts as a screening instrument to identify suitable candidates for the home dialysis programme, and therefore increases a patient's chance of learning to manage the programme. JPAT is in the form of an interview questionnaire consisting of 38 assessment items in six domains: physical stability, nutritional status, communication, ability to maintain self-care, psychological suitability and social support. A pilot study was conducted (n = 20, 1996-1997) using a descriptive study design, with subjects randomly selected from an existing dialysis programme. Pearson correlation and 2-tailed tests were employed to explore the relationship between the assessment outcome (i.e. the initial JPAT scores) and the follow up data (i.e. data collected within the seven days following the initial JPAT assessment). Many of the variables attained statistical significance (p < 0.05). The inter-rater reliability was calculated at an average Kappa value of 0.909. Overall, results suggest that JPAT is sufficiently reliable to be used as a tool for assessing patients who suffer from ESRD.