Impact of single-needle therapy in new chronic hemodialysis starts for individuals with arteriovenous fistulae

The native arteriovenous fistula (AVF) is the "gold standard" for hemodialysis (HD) vascular access. Unfortunately, AVFs can develop complications including inadequate maturation, cannulation difficulties and needle infiltration. In an effort to increase successful cannulations, decrease complications and subsequent central venous catheter (CVC) use, our centre introduced single-needle (SN) dialysis in April 2006 for new chronic patients receiving their first six HD treatments. The purpose of this study was to evaluate the impact of implementing SN dialysis on the incidence of CVC placements, investigative procedures required (e.g., arteriography), and missed HD treatments within the first three months of commencing dialysis. A secondary objective was to compare these data with double-needle (DN) dialysis treatments from the previous year. Retrospective chart reviews were conducted for all new chronic HD outpatient starts from April 2005 to 2006 for patients using DN dialysis and from April 2006 to November 2007 for those using SN. Information gathered included demographic data, location and vintage of the AVF, laboratory parameters, frequency of CVC placements, arteriography, and missed HD treatments due to cannulation difficulties. In total, data pertaining to 11 DN and 22 SN patients were collected. Of the 11 DN patients, 2 (18.2%) required a CVC placement in the first three months of treatment as compared to 2 (9.1%) using SN dialysis. Similarly, arteriographic investigations of the AVF were required in 4 (36.4%) DN versus 3 (13.6%) SN patients. There were a total of 19 missed treatments (8 DN; 11 SN). Dialysis blood work results were within safe and acceptable levels for those receiving SN dialysis. Use of SN dialysis for the first six HD treatments resulted in fewer mean CVC placements and investigations while main-raining adequate laboratory parameters. These results lend support for further research in this area.

Reporting of Clinical Adverse Events Scale: a measure of doctor and nurse attitudes to adverse event reporting

OBJECTIVE

To develop a validated measure of professionals' attitudes towards clinical adverse event reporting (CAER).

DESIGN

Cross-sectional survey with follow-up.

PARTICIPANTS

201 doctors and nurse/nurse-midwives undergoing postqualification training in Leeds, York and Hull Universities in 2003.

MATERIALS

A questionnaire which comprised 73 items extracted from interviews with professionals; a second, statistically reduced version of this questionnaire.

RESULTS

The analysis supported a 25-item questionnaire comprising five factors: blame as a consequence of reporting (six items); criteria for reporting (six items); colleagues' expectations (six items); perceived benefits of reporting events (five items); and clarity of reporting procedures (two items). The resulting questionnaire, the Reporting of Clinical Adverse Effects Scale (RoCAES), had satisfactory internal consistency (Cronbach's alpha = 0.83) and external reliability (Spearman's correlation = 0.65). The construct validity hypothesis-doctors have less positive attitudes towards CAER than nurses-was supported (t = 5.495; p<0.0001).

CONCLUSION

Initial development of an evidence-based, psychometrically rigorous measure of attitudes towards CAER has been reported. Following additional testing, RoCAES may be used to systematically elicit professionals' views about, and inform interventions to improve, reporting behaviour.

Stochastic simulations of ErbB homo and heterodimerisation: potential impacts of receptor conformational state and spatial segregation

ErbB overexpression is linked to carcinogenesis. It is hypothesised that this is due to increased receptor density and receptor clustering, leading to increased receptor dimerisation and activation. Herein, spatial stochastic simulations have been performed to shed light receptor dimerisation processes. First, ligand-independent homodimerisation, is considered, based upon constitutive oligomerisation estimates (14%) in A431 cells that overexpress epidermal growth factor receptor (EGFR). When autocrine stimulation is blocked, ligand-independent EGFR activation is demonstrated by persistent, low levels of phosphorylation. The possibility that ligand-independent signalling is due to the fluctuation of EGFR conformation is considered. The agent-based model predicts the frequency (expressed as a probability) that uniformly distributed receptors would need to flux to the open conformation to reach 14% EGFR dimers at high receptor density. Simulations suggest that ligand-independent EGFR homodimerisation is highly density dependent, since collisions between 'open', dimerisation-competent receptors are a rare event at low receptor levels. Simulations that incorporate receptor clustering lower the threshold for homodimerisation of unoccupied receptors as well as the estimate of the probability for fluxing to the dimer-competent conformation. The impact of ErbB receptor clustering patterns on hetero and homodimerisation rates is also considered, using immunoelectron microscopy data derived from SKBR3 breast cancer cells that express ErbB2>>EGFR>ErbB3. Partial spatial segregation of ErbB receptors has a profound effect on simulated heterodimerisation rates. Despite the general assumption that ErbB2 is a preferred heterodimerising partner for other ErbBs, it is predicted that most ErbB2 will form homodimers. Overall, it is proposed that both receptor density and membrane spatial organisation contribute to the carcinogenesis process.

Work environment, health outcomes and magnet hospital traits in the Canadian nephrology nursing scene

Nephrology, like others areas of health care, is confronting a nursing shortage. Unless action is taken to address nursing shortages, patient care may be negatively affected (American Nephrology Nurses' Association, 2007). Previous studies have been conducted on magnet hospital traits, quality of nursing worklife, empowerment, job satisfaction, burnout, health outcomes, and their influence on nursing retention in Canada. However, there is little research in this area specific to nephrology nursing. This descriptive study examined whether magnet hospital traits, empowerment, and organizational support contribute to Canadian nephrology nurses' job satisfaction, health outcomes, and perceived quality of patient care. A randomly selected sample of 300 nurse members of the Canadian Association of Nephrology Nurses and Technologists (CANNT) was asked to complete a survey consisting of four instruments: The Nursing Work Index (Lake, 2002), the Conditions of Work Effectiveness Questionnaire II (Laschinger, Finegan, Shamian, & Wilk, 2001), the Pressure Management Indicator (Williams & Cooper, 1998), and the Maslach Burnout Inventory (Maslach, Jackson, & Leiter, 1996). There was a 48.1% response rate. Results demonstrated that some aspects of the Canadian nephrology nursing environment were rated quite favourably (e.g., high standards of care are expected; good working relationships with peers), but areas requiring improvement were evident (e.g., assignments that foster continuity of care). Overall, the nurses felt empowered. The results of the Pressure Management Indicator and Maslach Burnout Inventory indicated that nephrology nurses are generally coping well, but that some of them are struggling. Strategies that improve work environments could promote the recruitment and retention of nephrology nurses. Further research in this area is warranted.

Maintaining equilibrium: a theory of job satisfaction for community mental health nurses

This study aimed to explore what was satisfying in the role of community mental health nurse (CMHN). Previous studies have emphasized sources of dissatisfaction but the emphasis on satisfaction allowed the researchers to explore positive aspects of the role which have been largely neglected in previous studies and to explore how these nurses managed to sustain satisfaction. This study used a grounded theory, and the primary source of data was in-depth interviews collected over a 1-year period with 12 CMHNs. Data were analysed using the constant comparative method and theoretical sampling. The therapeutic relationship (being therapeutic, knowing oneself, knowing how) was identified as the most significant source of satisfaction for the CMHNs, but this was mediated by three properties associated with role performance - working for the organization, belonging to a team and maintaining a personal life. The properties associated with role performance affected the participants' experience of the therapeutic relationship which determined whether the CMHNs found their job satisfying. This process of balance and counter-balance is best explained by the core category maintaining equilibrium which accounts for the dynamic interaction that occurs between the therapeutic relationship properties and the role performance properties. As a core category maintaining equilibrium describes the process in which the participants were impelled towards satisfaction.

Predictors of hemodialysis central venous catheter exit-site infections

Central venous catheter (CVC) exit-site infections contribute to bacteremia and patient morbidity and mortality among patients on hemodialysis. This structured observational study examined predictors of positive CVC exit-site infections. Hemodialysis nurses documented the physical appearance of the CVC exit site for sites they believed to be infected and required a swab culture. Additional information that pertained to the catheter, exit-site care and demographic data were also collected. No patient characteristics were associated with an exit-site infection. However, the type of dressing (p=0.007) and cleansing solution (p=0.007) used were positively associated with an exit-site infection. Negative exit-site culture reports were more likely to have dressings changed weekly (p=0. 03). The size of peri-wound erythema (p=0.008) was also associated with a higher incidence of exit-site infections. Patients with dry crust present at the exit site were more likely to have negative culture results (p=0.03). A large number of negative swab culture results (71%) were obtained suggesting that further nursing education is needed. The results of this study contribute to our understanding of the physical characteristics of an infected CVC exit site. Given the morbidity and mortality associated with CVC infections, more nursing research is needed in this area.

The use of a wearable camera, SenseCam, as a pictorial diary to improve autobiographical memory in a patient with limbic encephalitis: A preliminary report

This case study describes the use of a wearable camera, SenseCam, which automatically captures several hundred images per day, to aid autobiographical memory in a patient, Mrs B, with severe memory impairment following limbic encephalitis. By using SenseCam to record personally experienced events we intended that SenseCam pictures would form a pictorial diary to cue and consolidate autobiographical memories. After wearing SenseCam, Mrs B plugged the camera into a PC which uploaded the recorded images and allowed them to be viewed at speed, like watching a movie. In the control condition, a written diary was used to record and remind her of autobiographical events. After viewing SenseCam images, Mrs B was able to recall approximately 80% of recent, personally experienced events. Retention of events was maintained in the long-term, 11 months afterwards, and without viewing SenseCam images for three months. After using the written diary, Mrs B was able to remember around 49% of an event; after one month with no diary readings she had no recall of the same events. We suggest that factors relating to rehearsal/re-consolidation may have enabled SenseCam images to improve Mrs B's autobiographical recollection.

32. Relearning in military surgery: The contributions of Princess Vera Gedroits

It is a well known truth that knowledge is often forgotten and has to be relearned. In medicine, this unfortunate trend is especially prevalent in the history of military surgery. The story of a Russian Princess, military surgeon, and poet, Dr. Vera Gedroits is one such forgotten story. Dr. Gedroits’ largely unrecognized contribution to military surgery was the adoption of laparotomy for penetrating abdominal wounds (PAWs). In the latter half of the 19th Century, the treatment of PAWs was controversial. However, the results of the Spanish-American (1898) and Boer (1899-1902) Wars and the outspoken opinions of prominent experts unified medical opinion; conservative treatment was clearly established as the treatment paradigm for PAWs at the birth of the 20th Century. Indeed, conservative treatment was officially adopted by the Russians at the outset of the Russo-Japanese War (1904-1905). During this war, the bold surgical practices of Dr. Gedroits would seriously challenge this standard of care. Dr. Gedroits performed operations in a converted railway car in a Red Cross hospital train. Despite these suboptimal conditions, she performed laparotomies on victims of PAWs with unprecedented success. These results, which were largely due to strict surgical indications and technical skill, effectively demonstrated the importance of laparotomy in the treatment of such wounds. As a result, the Russians adopted operative treatment as the new standard of care. Interestingly however, no other countries seemed to take any notice. Dr. Gedroits’ results were barely remarked upon and quickly forgotten. Indeed, contemporary Western observers of the Russian medical outfit, and historians since, have interpreted the surgical results of the war to support conservative management. It was not until WWI, ten years later, that surgeons relearned the utility of laparotomy. The story of Dr. Gedroits, both before and after her innovative treatment in the Russo-Japanese war, deserves remembering. Bennett J. Princess Vera Gedroits: military surgeon, poet, and author. British Medical Journal 1992; 305(6868):1532-1534. Harvard V, Hoff J. Reports of Military Observers Attached to the Armies in Manchuria during the Russo-Japanese War. London: HMSO, 1908. Wallace C. War surgery of the abdomen. Lancet 1917; 189(4885):561-5568.

Heavy metal bioaccumulation by the important food plant, Olea europaea L., in an ancient metalliferous polluted area of Cyprus

Aspects of the bioaccumulation of heavy metals are reviewed and possible evidence of homeostasis is highlighted. Examination and analysis of olive (Olea europaea L.) trees growing in close proximity to a copper dominated spoil tip dating from at least 2000 years BP, on the island of Cyprus, revealed both bioaccumulation and partitioning of copper, lead and zinc in various parts of the tree. A factor to quantify the degree of accumulation is illustrated and a possible seed protective mechanism suggested.

Optimal timing of initiation of chronic hemodialysis?

Despite the availability of clinical guidelines for the timing of dialysis initiation in both the United States and Canada, patients continue to start dialysis at very low levels of predicted glomerular filtration rate (GFR). A cross-sectional study was performed to determine the demographic and clinical characteristics of patients who started hemodialysis, their level of GFR, and mortality at 1 and 2 years following the initiation of dialysis. Retrospective data were collected on all eligible patients who commenced chronic hemodialysis in 1 tertiary care center in Canada from March 2001 to February 2005. Only those patients who had been followed by a nephrologist in the chronic kidney disease clinic before dialysis initiation were included (n=271). Seventeen percent of patients started hemodialysis late (GFR<5 mL/min/1.73 m(2)). Compared with the group of patients who started dialysis earlier, the late start group were significantly younger (p=0.008), had more females (p=0.013), more employed (p=0.051), less cardiac (p<0.001), and peripheral vascular disease (p=0.031), and were taking medication for hypertension (p=0.041). Serum albumin was lower in the late start group (p=0.023). At year 1, there was no difference in mortality rate while at year 2, the earlier the dialysis, the greater the mortality rate (p=0.022). After adjustment for demographic variables and comorbidities, only antihypertensive use had an independent but weak association with the 2 year mortality. Adjustment for all these variables eliminated the significant association noted for the 2 year mortality in the early versus late dialysis start. The survival benefit for late versus early dialysis start appears to be multifactorial and relates to a preponderance of clinical and demographic factors favoring a lengthened survival occurring in the late dialysis group. Our survival benefit findings suggest the premorbid health condition is a more important determinant of 2 year survival than the timing of dialysis initiation.