Late referral for dialysis: improving the management of chronic renal disease

BACKGROUND

Timely nephrological referral of patients with chronic renal failure (CRF) is important, but referral at a late stage of disease is common.

AIM

To investigate whether late referral of patients is avoidable, and where the missed opportunities lie.

DESIGN

Prospective ascertainment of new cases and comprehensive review of pre-end stage history.

METHODS

Patients admitted to Bristol and Portsmouth renal units for chronic RRT between June 1997 and May 1998 were identified from computer databases. Data were collected from case notes and hospital records, and a self-administered patient questionnaire. Late referral, defined as dialysis within 4 months of first referral to a dialysing nephrologist, was categorized by algorithm as unavoidable or avoidable.

RESULTS

Of 250 patients, 96 (38%) were referred late. Forty-three (45%) had definite avoidable reasons: 35 (37%) with raised serum creatinine for a median 3.7 years (IQR 1.5-8.2) before referral, and eight (8%) with risk factors for renal disease but scant assessment of renal function; 12/43 (31%) had a diagnosis of diabetic nephropathy. Late referred patients were less likely to receive standard renal therapies for chronic renal failure, were in a poorer clinical state at start of RRT, and more often required emergency dialysis, compared to patients referred early. Late referrals were as likely from a hospital as a primary care physician.

DISCUSSION

A significant proportion of patients are avoidably referred to a dialysing renal unit at a very late stage. Guidelines on referral should be developed by nephrologists, primary and secondary care physicians, and patient groups, and further research is needed into the cost-effectiveness of early referral strategies.

High-performance liquid chromatographic profiling of fluorescent labelled N-glycans on glycoproteins

Monitoring protein glycosylation is becoming increasingly important as novel recombinant glycoprotein therapeutics, such as glycoprotein hormones, cytokines and clotting factors, are introduced into clinical use. In this report, we describe an HPLC strategy and an improved and simplified pre-column derivatization procedure to profile N-linked glycans obtained from a variety of commercially available glycoproteins as examples. N-Glycans were first released by peptide:N-glycosidase F and labelled with the fluorescent label, 4-aminobenzoic acid by reductive amination. The labelled N-Glycans were then resolved by normal-phase HPLC and the N-glycan profile could be further improved by separating the N-glycans first according to charge by anion-exchange HPLC prior to the normal-phase HPLC. If required, identification of the fractionated derivatized oligosaccharides can be determined by mass spectrometry. The whole profiling process is simple and can be implemented in most laboratories. Because of the high sensitivity, batch glycan-analysis of low-yield recombinant glycoproteins such as samples in ampoules or obtained in the early stage of production development is possible.

Approximate quantum cloning with nuclear magnetic resonance

Here we describe a nuclear magnetic resonance (NMR) experiment that uses a three qubit NMR device to implement the one-to-two approximate quantum cloning network of Buzek et al. [Phys. Rev. A 56, 3446 (1997)]. As expected the experimental results indicate that the network clones all input states with similar fidelities, but as a result of decoherence and incoherent evolution arising from B(1) inhomogeneity the total fidelity achieved does not exceed the measurement bound.

Prospective randomized trial of low- versus high-dose radiation therapy in adults with supratentorial low-grade glioma: initial report of a North Central Cancer Treatment Group/Radiation Therapy Oncology Group/Eastern Cooperative Oncology Group study

PURPOSE

To compare survival and toxicity in adult patients treated with low-dose (50.4 Gy/28 fractions) versus high-dose (64.8 Gy/36 fractions) localized radiation therapy (RT) for supratentorial low-grade astrocytoma, oligodendroglioma, and mixed oligoastrocytoma.

PATIENTS AND METHODS

From 1986 to 1994, 203 eligible/analyzable patients were randomized: 101 to low-dose RT, 102 to high-dose RT. Almost half were younger than 40 years, and 95% had grade 2 tumors. Histologic subtype was astrocytoma (or mixed oligo-astrocytoma with astrocytoma dominant) in 32% of patients and oligodendroglioma (or oligoastrocytoma with oligodendroglioma dominant) in 68%. Tumor diameter was less than 5 cm in 35% of patients, and 41% of tumors showed some degree of contrast enhancement. Extent of resection was gross total in 14% of patients, subtotal in 35%, and biopsy only in 51%.

RESULTS

At the time of the present analysis, 83 patients (41%) are dead, and median follow-up is 6.43 years in the 120 who are still alive. Survival at 2 and 5 years is nonsignificantly better with low-dose RT; survival at 2 and 5 years was 94% and 72%, respectively, with low-dose RT and 85% and 64%, respectively, with high-dose RT (log rank P =.48). Multivariate analysis identified histologic subtype, tumor size, and age as the most significant prognostic factors. Survival is significantly better in patients who are younger than 40 years and in patients who have oligodendroglioma or oligo-dominant histology. Grade 3 to 5 radiation neurotoxicity (necrosis) was observed in seven patients, with one fatality in each treatment arm. The 2-year actuarial incidence of grade 3 to 5 radiation necrosis was 2.5% with low-dose RT and 5% with high-dose RT.

CONCLUSION

This phase III prospective randomized trial of low- versus high-dose radiation therapy for adults with supratentorial low-grade astrocytoma, oligodendroglioma, and oligoastrocytoma found somewhat lower survival and slightly higher incidence of radiation necrosis in the high-dose RT arm. The most important prognostic factors for survival are histologic subtype, tumor size, and age. The study design of the ongoing intergroup trial in this population will be discussed.

Is Change in Electrical Potential or pH a Hatching Signal for Heterodera glycines?

ABSTRACT This study explored the possibilities that changes in the egg shell/lipid layer electrical potential or pH communicate external hatching conditions to the Heterodera glycines second-stage juvenile (J2) within the mature egg and that electrophysiology could measure effects of chemicals on emergence. Potentials were measured following application of the emergence inducers (ZnSO(4) and ZnCl(2)), ions that do not affect emergence, or synthetic emergence inhibitors. Results were compared with pH measurements and emergence bioassays. Healthy appearing eggs had negative resting potentials. Application of ZnSO(4) caused a smooth depolarization. However, eggs containing J2 and immature eggs depolarized to a similar degree when ZnSO(4) was added. In addition, ZnSO(4), synthetic emergence inhibitors, and CaCl(2) caused similar depolarization, and some depolarization was measured in dye-permeable eggs and empty shells. Results suggest that change in cation surface charge contributed to depolarization and that Cl penetrated the egg shell/lipid layer without causing potential changes. In bioassays, zinc consistently stimulated emergence to a greater degree than H(2)O, other cations, or buffers, and counteracted emergence inhibitors. Zinc-caused emergence stimulation was independent of pH. In summary, it is concluded that depolarization and pH are not emergence signals and electrophysiology is unlikely to measure effectiveness of emergence stimulators or inhibitors.

Analysis of bovine trigeminal ganglia following infection with bovine herpesvirus 1

Following primary infection of the eye, oral cavity, and/or nasal cavity, bovine herpesvirus 1 (BHV-1) establishes latency in trigeminal ganglionic (TG) neurons. Virus reactivation and spread to other susceptible animals occur after natural or corticosteroid-induced stress. Infection of calves with BHV-1 leads to infiltration of lymphocytes in TG and expression of IFN-gamma (interferon-gamma), even in latently infected calves. During latency, virus antigen and nucleic acid positive non-neural cells were occasionally detected in TG suggesting there is a low level of spontaneous reactivation. Since we could not detect virus in ocular or nasal swabs, these rare cells do not support high levels of productive infection and virus release or they do not support virus production at all. Dexamethasone (DEX) was used to initiate reactivation in latently infected calves. Foci of mononuclear or satellite cells undergoing apoptosis were detected 6h after DEX treatment, as judged by the appearance of TUNEL+ cells (terminal deoxynucleotidyltransferase-mediated dUTP-biotin nick end labeling). BHV-1 antigen expression was initially detected in lymphocytes and other non-neural cells in latently infected calves following DEX treatment. At 24h after DEX treatment, viral antigen expression and nucleic acid were readily detected in neurons. Our data suggest that persistent lymphocyte infiltration and cytokine expression occur during latency because a low number of cells in TG express BHV-1 proteins. Induction of apoptosis and changes in cytokine expression following DEX treatment correlates with reactivation from latency. We hypothesize that inflammatory infiltration of lymphoid cells in TG plays a role in regulating latency.

Sociodrama: a teaching method for expanding the understanding of clinical issues

Sociodrama is a powerful teaching strategy that combines a case study approach with traditional role-play methodology to illustrate critical issues in end-of-life care. Building on principles of adult learning and communication skills, the sociodrama method enables the skilled facilitator to draw on the learner's past experiences as resources for teaching and reflective practice. This article describes the use of sociodrama in end-of-life education with illustrations from actual sessions including key discussion points, a typical instructional plan and staging tips.

Relationship style between GPs and community mental health teams affects referral rates

BACKGROUND

Community mental health teams (CMHTs) are the established model for supporting patients with serious mental illness in the community. However, up to 25% of those with psychotic disorders are managed solely by primary care teams. Effective management depends upon locally negotiated referral and shared care arrangements between CMHTs and primary care.

AIM

To examine whether the style of working relationship between general practices and CMHTs affects the numbers and types of referrals from general practices to CMHTs, taking into account population and practice factors and provision of other mental health services which may influence referral rates.

DESIGN OF STUDY

Cross-sectional study.

SETTING

All 161 general practices in East London and the City Health Authority.

METHOD

Questionnaire survey to all general practices to identify style of relationship. Collection of routinely available referral data to all statutory mental health services over a two-year period. Main outcome measures were number and types of referrals from general practices to CMHTs.

RESULTS

The average annual referral rate to the eleven CMHTs in east London is 10 per 1000 adult population annually. The teams show a sixfold variation in rates of referral from all sources. Where good working relationships (a consultation-liaison style) exist between CMHTs and general practice, there are greater numbers of referrals requiring both long and short-term work by CMHTs. Two-stage multivariate models explained 47% of the referral variation between practices. Where primary care-based psychologists work with practices there are greater numbers of CMHT referrals, but less use of psychiatric services.

CONCLUSION

Shifting to a consultation-liaison relationship should increase rates of referral of patients with serious mental illness, including those who can most benefit from the skills of CMHTs. Increasing the provision of primary care-based psychology might improve practice use of mental health services, reducing avoidable outpatient psychiatric referrals.

Routine acid decalcification of bone marrow samples can preserve DNA for FISH and CGH studies in metastatic prostate cancer

Production of paraffin-section material from tissue samples that contain bone requires decalcification. Techniques such as acidic decalcification or EDTA chelation are suitable methods. Acid decalcification is generally quicker than EDTA chelation but studies have suggested that it may result in hydrolysis of DNA. Here we show that limited acid decalcification (less than 24 hr) in 5% formic acid can preserve DNA sufficient for fluorescent in situ hybridization (FISH) or comparative genomic hybridization (CGH) and that prolonged 10% formic acid decalcification results in failure of FISH and only limited retrieval of DNA for CGH studies.

Cognitive behaviour therapy for schizophrenia

BACKGROUND

Medication is the mainstay of treatment for schizophrenia. Many people with schizophrenia, however, continue to experience symptoms in spite of medication and may experience side effects that are unwanted and unpleasant. In addition to medication additional forms of treatment include talking therapies such as cognitive behavioural therapy. This approach helps to link the person's feelings and patterns of thinking which underpin distress.

OBJECTIVES

To review the effectiveness of cognitive behavioural therapy for people with schizophrenia, when compared to standard care, specific medication, other therapies and non-intervention.

SEARCH STRATEGY

Electronic searches of Biological Abstracts (1980-1998), CINAHL (1982-1998), The Cochrane Library (Issue 2, 1998), The Cochrane Schizophrenia Groups' Register of Trials, which encompasses up to date searches of all listed databases (January 2001), EMBASE (1980-1998), MEDLINE (1966-1998), PsychLIT (1887-1997), SIGLE (1990-1998), Sociofile (1980-1998) were undertaken. All references of the articles selected were searched for further relevant trials.

SELECTION CRITERIA

This review includes relevant randomised trials of cognitive behaviour therapy for people with a diagnosis of schizophrenia-like illnesses. Outcomes such as death, mental state, relapse, psychological well-being and acceptability of treatment were sought.

DATA COLLECTION AND ANALYSIS

Studies were reliably selected and assessed for methodological quality. Data were extracted by two reviewers working independently. Dichotomous data were analysed on an intention-to-treat basis and continuous data with 65% completion rate are presented. Where possible, for dichotomous outcomes, a relative risk (RR) with the 95% confidence interval (CI) was estimated along with the number needed to treat statistic (NNT).

MAIN RESULTS

Twenty-two relevant papers describing thirteen trials were identified. Cognitive behavioural therapy in addition to standard care did not significantly reduce the rate of relapse and readmission to hospital when compared with standard care alone (medium term 1 RCT, N=61, RR 0.1 CI 0.01 to 1.7; long term 2 RCTs, N=123, RR 1.1 CI 0.8 to 1.5). A significant difference was observed, however, favouring cognitive behavioural therapy over standard care alone, in terms of being able to be discharged from hospital (1 RCT, N=62, RR 0.5 CI 0.3 to 0.9, NNT 3 CI 2 to 12). For 'no important improvement in mental state' data showed a significant difference favouring the cognitive behavioural therapy group over standard care alone when measured at 13 to 26 weeks (2 RCTs, N=123, RR 0.7 CI 0.6 to 0.9, NNT 4 CI 2 to 8). After one year the difference was no longer significant (3 RCTs, N=211, RR 0.95 CI 0.6 to 1.5). On continuous measures (BPRS, CPRS, Psychiatric Assessment Scale) data are not convincing of an effect. A cognitive behavioural therapy approach focusing on compliance may have some effects on insight and attitudes to medication, but the clinical meaning of these data is unclear. When compared with supportive psychotherapy, cognitive behavioural therapy had no effects on relapse rate and clinically meaningful improvements in mental state. Cognitive behavioural therapy combined with other psycho-social/educational interventions may decrease the numbers of people able to tolerate the intervention, at least under study conditions.

REVIEWER'S CONCLUSIONS

Cognitive behavioural therapy is a promising but under evaluated intervention. Currently, trial-based data supporting the wide use of cognitive behavioural therapy for people with schizophrenia or other psychotic illnesses are far from conclusive. More trials are justified, especially in comparison with a lower grade supportive approach. These trials should be designed to be both clinically meaningful and widely applicable.

A comparison of the clinical, histopathologic, and ultrastructural phenotypes in carriers of X-linked and autosomal recessive Alport's syndrome

Previous series that described phenotypes in carriers of Alport's syndrome did not distinguish genetically between carriers of X-linked and autosomal recessive disease. In this study, modes of inheritance in unselected families with Alport's syndrome associated with two city and two provincial hospitals were determined using microsatellite markers, and carriers of disease haplotypes were identified within these families. All 47 carriers (100%) from 18 families with X-linked Alport's syndrome had dysmorphic hematuria on phase-contrast microscopy, but few developed renal failure (3 of 40 carriers; 8%), clinical hearing loss (2 of 45 carriers; 4%), retinopathy (1 of 30 carriers; 3%), or lenticonus (0 of 30 carriers; 0%). Eleven of the 14 carriers (79%) from 2 families with autosomal recessive disease had dysmorphic hematuria, but none had renal failure, clinical hearing loss, retinopathy, or lenticonus. Urinary red blood cell counts in carriers of X-linked Alport's syndrome were greater than those in carriers of autosomal recessive disease (P < 0.0001), but the frequency of proteinuria and hypertension and levels of proteinuria were not different. There was more tubulointerstitial damage in carriers of X-linked disease (P = 0.012); however, carriers of autosomal recessive disease had more widespread and more uniform thinning of the glomerular basement membrane (P < 0.0001) and less lamellation (P < 0.04).

Building capacity for awareness and risk factor identification in the community: the blood pressure assessment program of the Calgary Fire Department

In 1995, the Calgary Fire Department developed a program to assess blood pressure in community fire stations, selected businesses and public venues. The program has gradually expanded. Currently, all 30 fire stations across Calgary, Alberta assess blood pressures for the public seven days per week throughout the year. Since 1995, there have been 10,883 measurements in 3477 people. Most people (2106) assessed had hypertensive readings, and 72 had readings greater than 220 mmHg systolic or greater than 120 mmHg diastolic, and were referred for immediate medical assessment. The program has been recently integrated into a more global vision for the prevention and control of cardiovascular disease in Calgary. Future plans include offering lipid assessments, assisting other communities to adopt the program and using the program to provide physical measures (of blood pressure, glucose, total and high density lipoprotein cholesterol, height and weight) to an ongoing questionnaire that surveys the health of Calgarians. The history of the program, its training methods, quality control, preliminary results and future plans are presented in detail to provide an example of a community-based program that could aid in the detection, monitoring and awareness of hypertension.

The stabilisation and reactivity of indium trihydride complexes

Indium trihydride complexes were unknown prior to 1998. This article focuses on the development of this field over the last 4 years. Emphasis is placed on strategies employed to stabilise such complexes, their structure, properties and use in inorganic and organic synthesis. Throughout, comparisons are drawn with the chemistries of related lighter group 13 metal trihydride complexes. A number of similarities and differences have been observed in these comparisons which have been rationalised in terms of the properties of the group 13 elements involved.

Twenty-two novel LMX1B mutations identified in nail patella syndrome (NPS) patients

We report twenty-two novel mutations in the gene encoding the transcription factor LMX1B, previously shown to be mutated in persons with Nail Patella Syndrome (NPS). The mutations comprised eight missense, one splice-site, three insertion/deletion and ten nonsense or frameshift mutations. A sub-set of five recurrent mutations within the homeodomain represents over one-quarter of the described NPS mutations. The type and distribution of the mutations is consistent with the hypothesis that NPS is the result of haploinsufficiency for LMX1B.

The problem of erectile dysfunction following myocardial infarction

The causes of erection problems after an MI can be physical, psychological, a result of medication or a combination of these factors. This paper examines the causes and considers ways in which nurses can help men experiencing this problem, who may still feel embarrassed to broach this subject even though it is now more publically discussed.

Complementary therapies: what is the evidence for their use?

Complementary therapies are being increasingly used by patients and health-care professionals, but often with little awareness of the evidence for their use. The Internet offers a valuable and easy-to-use resource for assessing a growing amount of published information. Nurses need to be aware of a treatment's effectiveness and warn patients of potential risks or unprofessional claims.

The bovine herpesvirus 1 immediate-early protein (bICP0) associates with histone deacetylase 1 to activate transcription

Infected-cell protein 0 encoded by bovine herpesvirus 1 (BHV-1) (bICP0) is necessary for efficient productive infection, in large part, because it activates all 3 classes of BHV-1 genes (U. V. Wirth, C. Fraefel, B. Vogt, C. Vlcek, V. Paces, and M. Schwyzer, J. Virol. 66:2763-2772, 1992). Although bICP0 is believed to be a functional homologue of herpes simplex virus type 1-encoded ICP0, the only well-conserved domain between the proteins is a zinc ring finger located near the amino terminus of both proteins. Our previous studies demonstrated that bICP0 is toxic to transfected cells but does not appear to directly induce apoptosis (Inman, M., Y. Zhang, V. Geiser, and C. Jones, J. Gen. Virol. 82:483-492, 2001). C-terminal sequences in the last 320 amino acids of bICP0 mediate subcellular localization. Mutagenesis of the zinc ring finger within bICP0 revealed that this domain was important for transcriptional activation. In this study, we demonstrate that bICP0 interacts with histone deacetylase 1 (HDAC1), which results in activation of a simple promoter containing four consensus Myc-Max binding sites. The interaction between bICP0 and HDAC1 correlated with inhibition of Mad-dependent transcriptional repression. In resting CV-1 cells, bICP0 relieved HDAC1-mediated transcriptional repression. The zinc ring finger was required for relieving HDAC1-induced repression but not for interacting with HDAC1. In fetal bovine lung cells but not in a human epithelial cell line, bICP0 expression correlated with reduced steady-state levels of HDAC1 in crude cytoplasmic extracts. We hypothesize that the ability of bICP0 to overcome HDAC1-induced repression plays a role in promoting productive infection in highly differentiated cell types.

Loss of heterozygosity at cylindromatosis gene locus, CYLD, in sporadic skin adnexal tumours

AIM

The gene for familial cylindromatosis (CYLD) has been localised to chromosome 16q, and has recently been cloned. Loss of heterozygosity (LOH) at 16q has also been demonstrated in sporadic cylindromas. The aim of this study was to investigate whether CYLD plays a role in the development of other skin appendage tumours.

METHODS

A total of 55 cases of skin adnexal tumours, comprising 12 different types, and a control group of 14 squamous cell carcinomas (SCCs) and basal cell carcinomas (BCCs) were studied. Three microsatellites (D16S407 (16p), D16S304 (16q), and D16S308 (16q)) were analysed for LOH after microdissection from paraffin wax embedded sections using laser capture microdissection.

RESULTS

In keeping with previous data, a proportion of cylindromas exhibited LOH at markers on 16q, but not at 16p. The skin adnexal tumours showing a similar pattern included apocrine hydrocystomas, eccrine spiradenomas, and sebaceous adenoma. One case of syringoma showed LOH at 16q, and a further case at 16p, but not 16q. One case of eccrine hydrocystoma showed loss at 16p, but not 16q. The remaining tumours were either negative or non-informative. All tumours in the control group were either negative or non-informative, except for a single case of BCC showing LOH at 16q.

CONCLUSION

CYLD may be involved in the development of skin adnexal tumours other than cylindromas.

Smoking cessation through comprehensive critical care

There has been little research on smoking cessation after critical illness. Smokers make up a high percentage of patients admitted to intensive care (ICU) and stopping smoking is one message that should be clearly given to recovering patients. The recovery period provides an important opportunity for patients to quit smoking as the period of sedation and ventilation allows patients to start nicotine withdrawal. Smoking cessation advice was included in a 6-week self-help ICU rehabilitation package comprising information and an exercise programme. Recovering ICU patients were randomised to receive either the routine follow-up of ward visits and ICU clinic appointments or routine follow-up plus the ICU rehabilitation package. Twenty out of thirty-one intervention patients and 16/30 control patients were smokers pre-ICU admission. At the 6-month follow-up, previous smokers given the rehabilitation package had a relative risk reduction for smoking of 89% (CI 98%-36%). Smoking cessation after critical illness is aided by the provision of a rehabilitation programme.