DEVELOPMENT OF INDICATORS TO MEASURE

This paper describes a study to capture the key roles and activities of nephrology nurses across different countries in Europe. The concept of the study and the need to clarify the activities of the nephrology nurse arose as part of a larger study to develop the European Practice Database (EPD) (1). The Research Board (EDTNA/ERCA) needed to identify key questions that would detect significant differences in the role and responsibilities of nephrology nurses in different countries and monitor the evolution over time of nephrology nursing practice in Europe. It was therefore appropriate to devise a separate small study to generate evidence based questions for the EPD and confirm the reliability and usefulness of the information captured.

INFECTION CONTROL PRACTICE ACROSS EUROPE: RESULTS OF THE EPD

The European Practice Database (EPD) project, developed by the EDTNA/ERCA Research Board, collects data on renal practice at centre level in different European countries. Results presented in this paper focus on infection control practice in haemodialysis centres from 8 different European countries or regions following data collection from 2002 up to 2004. The prevalence of hepatitis B (HBV), hepatitis C (HCV), human immune deficiency (HIV) and methicillin-resistant staphylococcus Aureus (MRSA) was studied as well as the use of screening and preventive actions. These results will enable international comparison in practice and will stimulate further research and the development of new practice recommendations.

TRANSPLANT PRACTICE IN EUROPE: SELECTION OF PATIENTS

This paper reports the findings from the European Practice Database project (1) providing an overview of transplant practice in Europe and patient selection. From the 276 centres surveyed 25 recorded performing patient transplants across eight different countries. The overall figures indicate that the waiting list for transplants is made up of 38% women and 9% of patients above the age of 65 years. All countries offered pre-transplant counselling and screening and post-transplant follow-up, but the extent to which these activities occurred varied. The waiting/transplant ratio ranged from one in Norway to eight in Slovakia. Differences still exist as a result of country specific policies and legislation regarding transplantation.

COMPARISON OF RENAL CARE PRACTICE IN EUROPE: CENTRE AND PATIENT CHARACTERISTICS

The European Practice Database (EPD) contains data from 8 countries including 276 centres and 21,861 dialysis patients. Comparing patients and centre characteristics, remarkable similarities and pronounced differences in renal practice between different European countries and between centres within each country were found.

SERO-CONVERSION OF HCV NEGATIVE PATIENTS: A EUROPEAN STUDY ON SERO-CONVERSION OF HCV NEGATIVE PATIENTS: A EUROPEAN STUDY ON

This paper reports part of the findings from a larger study reported earlier, the European study on epidemiology and the management of HCV in the haemodialysis population (1). Centres recruited to the larger study were monitored for a further one year observation period to measure and generate a deeper understanding of HCV sero-conversion. From 4724 patients who were studied at the baseline, in 68 centres, only 13 patients were found to have sero-converted. These sero-conversions occurred in 7 hospitals within 5 different countries. Possible routes of transmission and risk factors are described with respect to the individual centres and good practice recommendations based on current evidence presented.

Randomized, placebo-controlled trial of propranolol added to topiramate in chronic migraine

OBJECTIVE

To assess the efficacy and safety of adding propranolol to topiramate in chronic migraine subjects inadequately controlled with topiramate alone.

METHODS

This was a double-blind, placebo-controlled, randomized clinical trial conducted through the National Institute of Neurological Disorders and Stroke Clinical Research Collaboration, expected to randomize 250 chronic migraine subjects inadequately controlled (≥10 headaches/month) with topiramate (50-100 mg/day) to either propranolol LA (long acting) (240 mg/day) or placebo. Primary outcome was 28-day moderate to severe headache rate reduction at 6 months (weeks 16 to 24) compared with baseline (weeks -4 to 0).

RESULTS

A planned interim analysis was performed after 48 sites randomized 171 subjects. The data and safety monitoring board recommended ending the trial after determining that it would be highly unlikely for the combination to result in a significant reduction in 28-day headache rate compared with topiramate alone if all 250 subjects were randomized. No safety concerns were identified. At study closure, 191 subjects were randomized. The 6-month reduction in moderate to severe 28-day headache rate and total 28-day headache rate for combination therapy vs topiramate alone was not significantly different: 4.0 vs 4.5 days (moderate to severe 28-day headache rate; p = 0.57) and 6.2 vs 6.1 days (total 28-day headache rate; p = 0.91).

CONCLUSIONS

This study does not provide evidence that the addition of propranolol LA to topiramate adds benefit when chronic migraine is inadequately controlled with topiramate alone.

CLASSIFICATION OF EVIDENCE

This study provides Class II evidence that propranolol LA, added to topiramate, is ineffective in chronic migraine patients who fail topiramate monotherapy.

The experiences of cancer patients

OBJECTIVES

To assess the needs of cancer patients for information about their condition and to understand the psychological impact of their illness.

BACKGROUND

The discussion of prognosis and treatment options in the palliative setting is an important and difficult part of oncology practice. To evaluate this, we examined the experiences of cancer patients of the physical and psychological impact of their disease on their life, and their opinions on the communication of end-of-life decisions and treatment options.

METHODS

A patient questionnaire was designed that encompassed communication regarding treatment and prognosis, quality-of-life attitudes subsequent to cancer diagnosis, end-of-life care and cancer drug funding. One hundred and twenty-five patients with a diagnosis of cancer were asked to participate and 96 questionnaires were completed and available for analysis. The questionnaire consisted of 63 questions and was completed in both an inpatient and outpatient setting.

RESULTS

This survey brought to light a number of controversial issues in cancer service provision, highlighting the emotional and psychological changes brought about by a cancer diagnosis. Major concerns of our patients include fear of death and pain, changes in interpersonal relationships and financial constraints. Only 66% of the patients wanted to be given a prognosis by their clinicians and just 70% of the patients recalled being given a detailed prognosis. 11% of the patients were not prepared to undergo palliative treatment. In all, 7% were not prepared to accept treatment for 1 year and 2% for 5 years of life in exchange for the potential side effects of cytotoxic chemotherapy. 12% of the patients would not want to be in possession of the information that they were in the terminal phase of the illness with a short time to live and 16% would not want this discussed with their next of kin.

CONCLUSION

This study informs medical professionals about the importance of tailoring information to the needs of the individual patient, and we feel it provides insights into the successes and failures of our communication with cancer patients. It is important that difficult discussions are personalized to the individual patients' wishes. These can vary dramatically both in the area of disclosure of bad news in prognosis and in end-of-life decision making. This study provides compelling evidence for good advanced care planning at an early stage in the management of patients with terminal cancers.

Validation and use of a parametric model for projecting cystic fibrosis survivorship beyond observed data: a birth cohort analysis

Background

The current lifetable approach to survival estimation is favoured by CF registries. Recognising the limitation of this approach, we examined the utility of a parametric survival model to project birth cohort survival estimates beyond the follow-up period, where short duration of follow-up meant median survival estimates were indeterminable.

Methods

Parametric models were fitted to observed survivorship data from the US CF Foundation (CFF) Patient Registry 1980–1994 birth cohort. Model-predicted median survival was estimated. The best fitting model was applied to a Cystic Fibrosis Registry of Ireland dataset to allow an evaluation of the model's ability to estimate predicted median survival. This involved a comparison of birth cohort lifetable predicted and observed (Kaplan–Meier) median survival estimates.

Results

A Weibull model with main effects of gender and birth cohort was developed using a US CFF dataset (n=13 115) for which median survival was not directly estimable. Birth cohort lifetable predicted median survival for male and female patients born between 1985 and 1994 and surviving their first birthday was 50.9 and 42.4 years respectively. To evaluate the accuracy of a Weibull model in predicting median survival, a model was developed for the 1980–1984 Cystic Fibrosis Registry of Ireland birth cohort (n=243), which had an observed (Kaplan–Meier) median survival of 27.7 years. Model-predicted median survival estimates were calculated using data censored at different follow-up periods. The estimates converged to the true value as length of follow-up increased.

Conclusions

Accurate prognostic information that is clinically critical for care of patients affected by rare, life-limiting disorders can be provided by parametric survival models. Problems associated with short duration of follow-up for recent birth cohorts can be overcome using this approach, providing better opportunities to monitor survival and plan services locally.

Location, location, location: important for jet-lagged circadian loops

It is now believed that frequent jet lag or shifts of daily rhythms caused by rotating shift work can lead to deleterious health outcomes. Indeed, many serious health problems, including breast cancer, stroke, and cardiovascular disease, have been linked to an occupational history of shift work. This has heightened interest in better understanding the biological responses to jet lag and shift work, with the hope that this will pave the way to developing compounds that can help people avoid their negative health consequences. In this context, a report in this issue of the JCI takes us to a new level of understanding of the molecular control of the resetting of the multitude of internal biological clocks disrupted in a mouse model of jet lag.

Delayed cystic fibrosis presentation in children in the absence of newborn screening

Newborn cystic fibrosis (CF) screening facilitates early diagnosis and nutritional intervention, which prevents malnourishment and improves growth in childhood. To provide baseline information on the natural history of CF in the Republic of Ireland, where newborn screening has not yet been introduced and CF incidence is high (1:1353 live births), we examined the effect of presentation mode, symptom type and gender on age at diagnosis. Median age at diagnosis was calculated by gender and for presentation mode/symptom type for 601 CF registry children diagnosed 1986-2007. Modes of presentation were each significantly associated with delayed presentation. An adjusted odds ratio of 4.5 (95% CI: 1.8, 11.1) was determined for presentation with family history, 43.1 for gastrointestinal symptoms presentation (95% CI: 18.3, 101.4), 96.9 for both respiratory and gastrointestinal symptoms (95% CI: 38.6, 243,4), and 115.4 for respiratory symptoms (95% CI: 45.2, 294.7). Children with respiratory symptoms had the greatest likelihood of delayed diagnosis (median age: 20.4 months), followed by those with respiratory and gastrointestinal symptoms (9.2 months). Gender was not significantly associated with a delayed presentation when presentation mode was taken into account.

Nonheme-iron absorption in first-degree relatives is highly correlated: a stable-isotope study in mother-child pairs

BACKGROUND

Iron absorption in humans is highly variable even after iron status and dietary components that influence iron absorption are controlled for. Inherited factors may help explain this variance.

OBJECTIVE

Our objective was to compare nonheme-iron absorption from a noninhibitory, stable-isotope-labeled test meal in preschool-aged children and their mothers.

DESIGN

We provided 72 test meals based on degermed maize flour and milk powder and fortified with [(57)Fe]ferrous fumarate or [(58)Fe]ferrous sulfate to healthy Mexican preschool children [n = 18; mean (+/-SD) age: 3.6 +/- 1.0 y] and their mothers [n = 18; mean (+/-SD) age: 28.0 +/- 5.2 y]. Iron absorption was calculated on the basis of incorporation of isotopes into erythrocytes after 14 d and was adjusted for differences in iron status.

RESULTS

There was a wide variation in iron absorption from the test meals: in the mothers and children, the median fractional absorption of ferrous sulfate was 22.55% (range: 1.65-54.83%) and 5.51% (range: 2.23-17.20%), respectively (P < 0.0001). After adjustment for serum ferritin, the significant difference in absorption between mothers and their children disappeared. Despite this broad range of iron absorption, corrected fractional iron absorption from the ferrous fumarate-fortified (r(2) = 0.582) and the ferrous sulfate-fortified test meals (r(2) = 0.557) was strongly correlated in mothers and their children (P < 0.0001). There was a striking positive correlation between the mean corrected fractional iron absorption from both test meals in mothers and their children (r(2) = 0.782, P < 0.0001). In regression analyses that included age, sex, and hemoglobin, the only significant predictor of corrected fractional iron absorption in children was corrected fractional iron absorption in their mothers (standardized beta = 0.884, P < 0.001).

CONCLUSIONS

Nonheme-iron absorption exhibits a strong familial tendency. After differences in meal matrix and serum ferritin are accounted for, these data suggest that inheritance and/or shared environmental factors explain most of the variance in dietary iron absorption.

How research can help control tuberculosis

Tuberculosis (TB) has played a central role in the history of biomedical science from Koch onwards. Research in the nineteenth and twentieth centuries yielded extremely valuable diagnostic, therapeutic and preventive tools for the control of TB. Following the development of shortcourse chemotherapy in the 1970s and 1980s, research into TB virtually evaporated. Despite the availability of an array of tools, TB control faltered, and the disease remains a major killer. The failure of the fruits of scientific research to control TB is a result of the shortcomings of the tools themselves as well the inadequate application of the tools in populations burdened by TB. A changing epidemiologic situation, with escalating rates of human immunodeficiency virus-related TB and the emergence of multidrug-resistant TB, further threatens global TB control. A robust TB research enterprise will be required to meet the global goals for controlling TB in the twentyfirst century. Basic research is needed to better understand its pathogenesis and immunology, and to identify targets for diagnostics, drugs and vaccines. Research into better biomedical tools to detect, treat and prevent TB is also a major priority, as all of the existing tools have important shortcomings. In addition, research into understanding how to apply both existing and new tools to control TB at the population level is urgently needed. Global funding for TB research, $483 million in 2007, is slowly growing but is far behind need. To meet the ambitious goals of the Global Plan to Stop TB and the Millennium Development Goals, a massive investment in research will be necessary.

How research can help control tuberculosis

Tuberculosis (TB) has played a central role in the history of biomedical science from Koch onwards. Research in the nineteenth and twentieth centuries yielded extremely valuable diagnostic, therapeutic and preventive tools for the control of TB. Following the development of short-course chemotherapy in the 1970s and 1980s, research into TB virtually evaporated. Despite the availability of an array of tools, TB control faltered, and the disease remains a major killer. The failure of the fruits of scientific research to control TB is a result of the shortcomings of the tools themselves as well the inadequate application of the tools in populations burdened by TB. A changing epidemiologic situation, with escalating rates of human immunodeficiency virus-related TB and the emergence of multidrug-resistant TB, further threatens global TB control. A robust TB research enterprise will be required to meet the global goals for controlling TB in the twenty-first century. Basic research is needed to better understand its pathogenesis and immunology, and to identify targets for diagnostics, drugs and vaccines. Research into better biomedical tools to detect, treat and prevent TB is also a major priority, as all of the existing tools have important shortcomings. In addition, research into understanding how to apply both existing and new tools to control TB at the population level is urgently needed. Global funding for TB research, $483 million in 2007, is slowly growing but is far behind need. To meet the ambitious goals of the Global Plan to Stop TB and the Millennium Development Goals, a massive investment in research will be necessary.

Prevention of hospitalization due to respiratory syncytial virus: results from the Palivizumab Outcomes Registry

OBJECTIVE

The Palivizumab Outcomes Registry contains data on infants and young children who received palivizumab for the prevention of respiratory syncytial virus (RSV) that causes serious lower respiratory tract illness.

STUDY DESIGN

Prospective observational registry enrolling those who received >or=1 dose of palivizumab during any RSV season (2000 to 2004) at participating US sites.

RESULT

Of 19 548 subjects enrolled, 40% were born before 32 weeks', 48% between 32 and 35 weeks' and 12% after 35 weeks' gestation. Risk factors included child-care attendance, prematurity, chronic lung disease (CLD) and congenital heart disease (CHD). The RSV hospitalization rate of palivizumab recipients was 1.3%. Gender, gestational age <32 weeks, CLD, CHD, congenital airway abnormality, severe neuromuscular disease, Medicaid insurance and >2 children in household were associated with significantly higher rates. Home-care prophylaxis with palivizumab was associated with reduced hospitalization rates.

CONCLUSION

Data on the use of palivizumab prophylaxis in primarily high-risk infants confirm low RSV hospitalization rates.

What would encourage blood donation in Ireland?

BACKGROUND

Recent changes have resulted in the loss of 4% of the donor panel in the Republic of Ireland and 3% in Northern Ireland. In order to increase the number of donors in these two regions, it is important that transfusion service providers explore and understand the reasons, which prevent individuals from donating. The aim of this study was to explore these issues particularly in non-donors and those who had lapsed.

METHODS

This 7-month all-Ireland study was conducted by computer-assisted telephone interview. Data collected included sociodemographic history, donation status, as well as barriers/deterrents to donation.

RESULTS

There were 4166 completed questionnaires (44% donors; 56% non-donors). Of the donors, 13% had donated blood within the last 2 years. Current donors cited 'awareness of patients needs' (88%), 'trust in the blood transfusion service' (70%), and 'an advertising campaign' (70%) as reasons encouraging them to donate blood. Lapsed donors and non-donors cited 'more frequent mobile clinics/sessions' (30% lapsed donors; 53% non-donors), 'if I was asked' (28% lapsed donors; 53% non-donors), and 'more flexible opening hours' (23% lapsed donors; 44% non-donors) as reasons that would encourage them to donate. The main reasons cited by non-donors for never having donated included 'medical reasons' (41% Republic of Ireland; 43% Northern Ireland), 'lack of information' (20% Republic of Ireland; 22% Northern Ireland), 'fear of needles' (15% Republic of Ireland; 17% Northern Ireland), and 'time constraints' (12% Republic of Ireland; 13% Northern Ireland). Among the non-donor group, 10% (Republic of Ireland) and 6% (Northern Ireland) claimed that they are not permitted to donate.

CONCLUSION

Replacing regular donors is a major challenge for the transfusion service providers. This study shows that by facilitating the general public by introducing more mobile clinics/sessions, more flexible opening hours and having a better level of knowledge in the community about blood donation may encourage lapsed donors and new donors to become regular donors.

Behavioral and neurochemical sources of variability of circadian period and phase: studies of circadian rhythms of npy-/- mice

The cycle length or period of the free-running rhythm is a key characteristic of circadian rhythms. In this study we verify prior reports that locomotor activity patterns and running wheel access can alter the circadian period, and we report that these treatments also increase variability of the circadian period between animals. We demonstrate that the loss of a neurochemical, neuropeptide Y (NPY), abolishes these influences and reduces the interindividual variability in clock period. These behavioral and environmental influences, from daily distribution of peak locomotor activity and from access to a running wheel, both act to push the mean circadian period to a value < 24 h. Magnitude of light-induced resetting is altered as well. When photoperiod was abruptly changed from a 18:6-h light-dark cycle (LD18:6) to LD6:18, mice deficient in NPY were slower to respond to the change in photoperiod by redistribution of their activity within the prolonged dark and eventually adopted a delayed phase angle of entrainment compared with controls. These results support the hypothesis that nonphotic influences on circadian period serve a useful function when animals must respond to abruptly changing photoperiods and point to the NPYergic pathway from the intergeniculate leaflet innervating the suprachiasmatic nucleus as a circuit mediating these effects.

Emerging advantages and drawbacks of telephone surveying in public health research in Ireland and the U.K

BACKGROUND

Telephone surveys have been used widely in public health research internationally and are being increasingly used in Ireland and the U.K.

METHODS

This study compared three telephone surveys conducted on the island of Ireland from 2000 to 2004, examining study methodology, outcome measures and the per unit cost of each completed survey. We critically examined these population-based surveys which all explored health related attitudes and behaviours.

RESULTS

Over the period from 2000 to 2005 the percentage of calls which succeeded in contacting an eligible member of the public fell, from 52.9% to 31.8%. There was a drop in response rates to the surveys (once contact was established) from 58.6% to 17.7%. Costs per completed interview rose from 4.48 euro to 15.65 euro. Respondents were prepared to spend 10-15 minutes being surveyed, but longer surveys yielded poorer completion rates. Respondents were willing to discuss issues of a sensitive nature. Interviews after 9 pm were less successful, with complaints about the lateness of the call. Randomisation from electronic residential telephone directory databases excluded all ex-directory numbers and thus was not as representative of the general population as number generation by the hundred-bank method. However the directory database was more efficient in excluding business and fax numbers.

CONCLUSION

Researchers should take cognisance of under-representativeness of land-line telephone surveys, of the increasing difficulties in contacting the public and of mounting personnel costs. We conclude that telephone surveying now requires additional strategies such as a multimode approach, or incentivisation, to be a useful, cost-effective means of acquiring data on public health matters in Ireland and the U.K.

European study on epidemiology and management of hepatitis C virus (HCV) infection in the haemodialysis population. Part 3: prevalence and incidence

An analysis of the literature showed a high prevalence of HCV in the European dialysis population in the nineties. The prevalence was similar in most countries in northern Europe, but infection was more common in France, Italy, Spain, Portugal and Greece (1) and in Eastern European countries (2). The reported prevalence of anti-HCV-positive patients in the EDTA registry was 21% in 1992 and 18% in 1993 (3) ranging from 1% in Finland to 42% in Egypt (4). The incidence of HCV, in new patients starting renal replacement therapy, ranged from 3% to 7% (5,6) and reported seroconversion rates during dialysis treatment varied between 1% (7) and 16% (8) per year.