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Veinot TC, Gillespie B, Argentina M, Bragg-Gresham J, Chatoth D, Collins Damron K, Heung M, Krein S, Wingard R, Zheng K, Saran R. Enhancing the Cardiovascular Safety of Hemodialysis Care Using Multimodal Provider Education and Patient Activation Interventions: Protocol for a Cluster Randomized Controlled Trial. JMIR Res Protoc 2023; 12:e46187. [PMID: 37079365 PMCID: PMC10160944 DOI: 10.2196/46187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 02/19/2023] [Indexed: 02/21/2023] Open
Abstract
BACKGROUND End-stage kidney disease (ESKD) is treated with dialysis or kidney transplantation, with most patients with ESKD receiving in-center hemodialysis treatment. This life-saving treatment can result in cardiovascular and hemodynamic instability, with the most common form being low blood pressure during the dialysis treatment (intradialytic hypotension [IDH]). IDH is a complication of hemodialysis that can involve symptoms such as fatigue, nausea, cramping, and loss of consciousness. IDH increases risks of cardiovascular disease and ultimately hospitalizations and mortality. Provider-level and patient-level decisions influence the occurrence of IDH; thus, IDH may be preventable in routine hemodialysis care. OBJECTIVE This study aims to evaluate the independent and comparative effectiveness of 2 interventions-one directed at hemodialysis providers and another for patients-in reducing the rate of IDH at hemodialysis facilities. In addition, the study will assess the effects of interventions on secondary patient-centered clinical outcomes and examine factors associated with a successful implementation of the interventions. METHODS This study is a pragmatic, cluster randomized trial to be conducted in 20 hemodialysis facilities in the United States. Hemodialysis facilities will be randomized using a 2 × 2 factorial design, such that 5 sites will receive a multimodal provider education intervention, 5 sites will receive a patient activation intervention, 5 sites will receive both interventions, and 5 sites will receive none of the 2 interventions. The multimodal provider education intervention involved theory-informed team training and the use of a digital, tablet-based checklist to heighten attention to patient clinical factors associated with increased IDH risk. The patient activation intervention involves tablet-based, theory-informed patient education and peer mentoring. Patient outcomes will be monitored during a 12-week baseline period, followed by a 24-week intervention period and a 12-week postintervention follow-up period. The primary outcome of the study is the proportion of treatments with IDH, which will be aggregated at the facility level. Secondary outcomes include patient symptoms, fluid adherence, hemodialysis adherence, quality of life, hospitalizations, and mortality. RESULTS This study is funded by the Patient-Centered Outcomes Research Institute and approved by the University of Michigan Medical School's institutional review board. The study began enrolling patients in January 2023. Initial feasibility data will be available in May 2023. Data collection will conclude in November 2024. CONCLUSIONS The effects of provider and patient education on reducing the proportion of sessions with IDH and improving other patient-centered clinical outcomes will be evaluated, and the findings will be used to inform further improvements in patient care. Improving the stability of hemodialysis sessions is a critical concern for clinicians and patients with ESKD; the interventions targeted to providers and patients are predicted to lead to improvements in patient health and quality of life. TRIAL REGISTRATION ClinicalTrials.gov NCT03171545; https://clinicaltrials.gov/ct2/show/NCT03171545. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) PRR1-10.2196/46187.
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Affiliation(s)
- Tiffany Christine Veinot
- School of Information, University of Michigan, Ann Arbor, MI, United States
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, MI, United States
- Department of Learning Health Sciences, School of Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Brenda Gillespie
- Department of Biostatistics, Consulting for Statistics, Computing and Analytics Research, University of Michigan, Ann Arbor, MI, United States
| | | | - Jennifer Bragg-Gresham
- Division of Nephrology, School of Medicine, Ann Arbor, MI, United States
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI, United States
| | | | | | - Michael Heung
- Division of Nephrology, School of Medicine, Ann Arbor, MI, United States
| | - Sarah Krein
- Department of Internal Medicine, School of Medicine, University of Michigan, Ann Arbor, MI, United States
- Veterans Affairs Center for Clinical Management Research, US Department of Veterans Affairs, Ann Arbor, MI, United States
| | | | - Kai Zheng
- School of Information and Computer Sciences, University of California Irvine, Irvine, CA, United States
| | - Rajiv Saran
- Division of Nephrology, School of Medicine, Ann Arbor, MI, United States
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI, United States
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2
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Butcher E, Walker R, Wyeth E, Samaranayaka A, Schollum J, Derrett S. Health-Related Quality of Life and Disability Among Older New Zealanders With Kidney Failure: A Prospective Study. Can J Kidney Health Dis 2022; 9:20543581221094712. [PMID: 35493402 PMCID: PMC9052826 DOI: 10.1177/20543581221094712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 03/14/2022] [Indexed: 12/01/2022] Open
Abstract
Background: Disability is prevalent in individuals with kidney failure and can contribute
to significantly reduced quality of life and survival. In older individuals
with kidney failure, disability can be caused by a combination of factors,
including issues directly related to their kidney disease and/or treatment,
including weakness, low energy, and low activity. Few studies have
investigated health-related quality of life (HRQoL) as a possible predictor
of disability among older individuals experiencing kidney failure. Objective: This study aimed to determine if patient-reported HRQoL, and/or other factors
at baseline, predicts disability in people with kidney failure, aged ≥65
years, after 12 months of follow-up. Design: The DOS65+ study was an accelerated longitudinal cohort design comprising of
both cross-sectional and longitudinal components. Participants were eligible
if they were aged ≥65 years, had chronic kidney disease stage 5G (CKD 5G)
(estimated glomerular filtration rate (eGFR) <15 ml/min/1.73
m2), and had: commenced kidney replacement education, or were
on an active conservative pathway, or were newly incident dialysis patients
commencing dialysis therapy or prevalent on dialysis. Setting: Three New Zealand District Health Board (DHB) nephrology units (Counties
Manukau, Hawke’s Bay, and Southern DHB) were involved in the study. Participants: Participants were eligible if they were aged ≥65 years, had CKD 5G (eGFR
<15 ml/min/1.73 m2), and had: commenced kidney replacement
education, or were on an active conservative pathway, or were newly incident
dialysis patients commencing dialysis therapy or prevalent on dialysis. Measurements: Disability and HRQoL were measured by EQ-5D-3L, a WHO Disability Assessment
Schedule (WHODAS) 2.0. Methods: Baseline and 12-month data from our longitudinal dialysis outcomes in older
New Zealanders’ study were analyzed to determine if HRQoL at baseline
predicted disability outcomes 12 months later. Results: Of the 223 participants at baseline, 157 participants completed a follow-up
interview 12 months later. Individuals with “considerable disability” at
baseline had a significantly (86%) higher risk of experiencing “considerable
disability” at 12 months compared with those with “lesser/no disability” at
baseline. Two thirds of those with ≥3 comorbidities were experiencing
“considerable disability.” In addition, those with problems with EQ-5D-3L
self-care, EQ-5D-3L usual activities, and EQ-5D-3L anxiety/depression
reported higher rates of disability. Limitations: Selection bias is likely to have been an issue in this study as participants
were excluded from the follow-up interview if they had an intercurrent
illness requiring hospitalization within 2 weeks of the survey interview or
if the treating nephrologist judged that the individual’s ability to take
part was significantly impaired. Sample size meant there were a limited
number of explanatory/confounding variables that could be investigated in
the multivariable model. Conclusions: EQ-5D-3L mobility and self-care may be useful in predicting subsequent
disability for individuals with CKD 5G. Although individuals with kidney
failure often experience disability, previous studies have not clearly
identified HRQoL or disability as predictors of later disability for
individuals with kidney failure. Therefore, we would recommend the
assessment of mobility and self-care, in conjunction with existing
disabilities in the clinical review and pre-dialysis education of
individuals with kidney failure as they approach the need for kidney
replacement therapy. Trial registration: the Australian and New Zealand clinical trials registry:
ACTRN12611000024943.
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Affiliation(s)
- Elizabeth Butcher
- Department of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Robert Walker
- Department of Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Emma Wyeth
- Ngāi Tahu Māori Health Research Unit, Department of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Ari Samaranayaka
- Biostatistics Centre, Division of Health Sciences, University of Otago, Dunedin, New Zealand
| | - John Schollum
- Department of Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Sarah Derrett
- Department of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
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Shao Q, Sun C, Zhang Q, Liu J, Xia Y, Jin B, Qian X. Macrophages regulates the transition of pericyte to peritoneal fibrosis through the GSDMD/IL-1β axis. Int Immunopharmacol 2021; 101:108323. [PMID: 34749292 DOI: 10.1016/j.intimp.2021.108323] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 10/21/2021] [Accepted: 10/26/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND End stage renal disease (ESRD) has caused public health problem with high prevalence worldwide. Peritoneum from peritoneal dialysis patients with ESRD can induce pathological changes of the peritoneum, including fibrosis. The trans-differentiation of pericytes has been found to be closely associated with inflammatory diseases, such as organ fibrosis. However, the function of macrophages in regulating the transition of pericyte to peritoneal fibrosis is unclear. METHODS Histological examination was conducted using Hematoxylin and eosin (HE) staining and Masson's trichrome staining. The protein levels were determined via western blot. Enzyme-linked immunosorbent assay (ELISA) was used to examine IL-1β concentrations. Gasdermin D (GSDMD) was knocked out in mice by Clustered Regularly Interspaced Short Palindromic Repeats-CRISPR-Associated 9 (CRISPR-Cas9). RESULTS Mice receiving dextrose peritoneal dialysate displayed mesothelial cell monolayer loss and thickness of submesothelial compact zone increase. Moreover, dextrose peritoneal dialysate treatment up-regulated GSDMD expression. GSDMD knockdown inhibited IL-1β production in macrophages. Further, pericytes were treated with cultural supernatant from macrophages. We found that GSDMD knockdown suppressed fibrosis and vascular endothelial growth factor (VEGF)/phosphoinositide 3-kinase (PI3K) pathway in pericytes. In addition, GSDMD were knocked out in mice using CRISPR/Cas9. The histological examinations revealed that GSDMD-/- alleviated the damage of peritoneal tissue and thickness of submesothelial compact zone. GSDMD-/- attenuated interleukin-1beta (IL-1β) level and peritoneal fibrosis induced by dextrose peritoneal dialysate treatment in pericytes in vivo. CONCLUSION These results demonstrated that macrophages can regulate the transition of pericyte to peritoneal fibrosis via the GSDMD/IL-1β axis, which provides a new therapeutic target.
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Affiliation(s)
- Qiuyuan Shao
- Department of Nephrology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu Province 210008, China
| | - Cheng Sun
- Department of Nephrology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu Province 210008, China
| | - Qingyan Zhang
- Department of Nephrology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu Province 210008, China
| | - Jin Liu
- Department of Nephrology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu Province 210008, China
| | - Yangyang Xia
- Department of Nephrology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu Province 210008, China
| | - Bo Jin
- Department of Nephrology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu Province 210008, China
| | - Xiaoping Qian
- The Comprehensive Cancer Centre, Drum Tower Hospital, Medical School of Nanjing University, Clinical Cancer Institute of Nanjing University, Nanjing, Jiangsu Province 210008, China.
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4
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Schick-Makaroff K, Levay A, Thompson S, Flynn R, Sawatzky R, Thummapol O, Klarenbach S, Karimi-Dehkordi M, Greenhalgh J. An Evidence-Based Theory About PRO Use in Kidney Care: A Realist Synthesis. PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2021; 15:21-38. [PMID: 34109571 DOI: 10.1007/s40271-021-00530-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/18/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND There is international interest on the use of patient-reported outcomes (PROs) in nephrology. OBJECTIVES Our objectives were to develop a kidney-specific program theory about use of PROs in nephrology that may enhance person-centered care, both at individual and aggregated levels of care, and to test and refine this theory through a systematic review of the empirical literature. Together, these objectives articulate what works or does not work, for whom, and why. METHODS Realist synthesis methodology guided the electronic database and gray literature searches (in January 2017 and October 2018), screening, and extraction conducted independently by three reviewers. Sources included all nephrology patients and/or practitioners. Through a process of extraction and synthesis, each included source was examined to assess how contexts may trigger mechanisms to influence specific outcomes. RESULTS After screening 19,961 references, 84 theoretical and 34 empirical sources were used. PROs are proposed to be useful for providing nephrology care through three types of use. The first type is use of individual-level PRO data at point of care, receiving the majority of theoretical and empirical explorations. Clinician use to support person-centered care, and patient use to support patient engagement, are purported to improve satisfaction, health, and quality of life. Contextual factors specific to the kidney care setting that may influence the use of PRO data include the complexity of kidney disease symptom burden, symptoms that may be stigmatized, comorbidities, and time or administrative constraints in dialysis settings. Electronic collection of PROs may facilitate PRO use given these contexts. The second type is use of aggregated PRO data at point of care, including public reporting of PROs to inform decisions at point of care and improve quality of care, and use of PROs for treatment decisions. The third type is use of aggregated PRO data by organizations, including publicly available PRO data to compare centers. In single-payer systems, regular collection of PROs by dialysis centers can be achieved through economic incentives. Both the second and third types of PRO use include pressures that may trigger quality improvement processes. CONCLUSION The current state of the evidence is primarily theoretical. There is pressing need for empirical research to improve the evidence-base of PRO use at individual and aggregated levels of nephrology care.
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Affiliation(s)
- Kara Schick-Makaroff
- Faculty of Nursing, University of Alberta, Third Floor, Edmonton Clinica Health Academy, Edmonton, AB, Canada.
| | - Adrienne Levay
- Faculty of Nursing, University of Alberta, Third Floor, Edmonton Clinica Health Academy, Edmonton, AB, Canada
| | - Stephanie Thompson
- Division of Nephrology, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Rachel Flynn
- Faculty of Nursing, University of Alberta, Third Floor, Edmonton Clinica Health Academy, Edmonton, AB, Canada
| | - Richard Sawatzky
- School of Nursing, Trinity Western University, Langley, BC, Canada.,Centre for Health Evaluation & Outcome Sciences, St. Paul's Hospital, Vancouver, Canada.,Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Onouma Thummapol
- Faculty of Nursing Science, Assumption University of Thailand, Bangkok, Thailand
| | - Scott Klarenbach
- Division of Nephrology, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Mehri Karimi-Dehkordi
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, AB, Canada
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5
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Vieira CF, Costa HS, Lima MMO, Alves FL, Rodrigues VGB, Maciel EHB, Prates MCSM, Lima VP, Mendonça VA, Lacerda ACR, Figueiredo PHS. Maximal inspiratory pressure is associated with health-related quality of life and is a reliable method for evaluation of patients on hemodialysis. Physiother Theory Pract 2020; 38:1050-1058. [PMID: 32914666 DOI: 10.1080/09593985.2020.1818338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To evaluate the association between Maximal Inspiratory Pressure (MIP) and health-related quality of life (HRQoL) and to verify the reliability of the MIP in patients on hemodialysis. METHODS In a repeated-measures design, patients on hemodialysis performed MIP and specific HRQoL questionnaire (trial 1). The MIP was repeated after 6 to 8 weeks (trial 2) and reliability was assessed using Intra-class Correlation Coefficient. Standard Error of Measurement and Minimal Detectable Change scores were calculated. RESULTS Sixty-one individuals (68.9% men) were evaluated in trial 1. MIP was associated with specific domains "Symptoms" (r = 0.45; R2 adjusted = 0.192) and the kidney disease component summary (r = 0.38; R2 adjusted = 0.138). Regarding generic domains, the MIP was associated with "Physical Functioning" (r = 0.57; R2 adjusted = 0.375) and Physical component summary (r = 0.47; R2 adjusted = 0.258). Thirty-three patients were randomly selected to perform a second MIP test (trial 2). The Intra-class Correlation Coefficient was 0.94 (95%CI 0.88-0.97). By Bland-Altman analysis, the bias was 3.2 cmH2O, which represents a difference of 3.7%. The Standard Error of Measurement and Minimal Detectable Change for MIP were 5.9 cmH2O and 13.8 cmH2O, respectively. CONCLUSION The MIP is a reliable test, associated with physical domains of HRQoL in patients on hemodialysis. Thus, it is a useful method for respiratory evaluation in this population.
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Affiliation(s)
- Carlos Filipe Vieira
- Programa de Pós-Graduação em Reabilitação e Desempenho Funcional, Universidade Federal dos Vales do Jequitinhonha e Mucuri, Diamantina, Brazil
| | - Henrique S Costa
- Departamento de Fisioterapia, Universidade Federal dos Vales do Jequitinhonha e Mucuri, Minas Gerais, Brazil
| | - Márcia M O Lima
- Departamento de Fisioterapia, Universidade Federal dos Vales do Jequitinhonha e Mucuri, Minas Gerais, Brazil
| | - Frederico L Alves
- Hemodialysis Unit, Santa Casa de Caridade de Diamantina Hospital, Diamantina, Brazil.,Medical School, Universidade Federal dos Vales do Jequitinhonha e Mucuri, Diamantina, Brazil
| | - Vanessa G B Rodrigues
- Programa de Pós-Graduação em Reabilitação e Desempenho Funcional, Universidade Federal dos Vales do Jequitinhonha e Mucuri, Diamantina, Brazil.,Hemodialysis Unit, Santa Casa de Caridade de Diamantina Hospital, Diamantina, Brazil.,Medical School, Universidade Federal dos Vales do Jequitinhonha e Mucuri, Diamantina, Brazil
| | - Emílio Henrique B Maciel
- Hemodialysis Unit, Santa Casa de Caridade de Diamantina Hospital, Diamantina, Brazil.,Medical School, Universidade Federal dos Vales do Jequitinhonha e Mucuri, Diamantina, Brazil
| | - Maria Cecília S M Prates
- Hemodialysis Unit, Santa Casa de Caridade de Diamantina Hospital, Diamantina, Brazil.,Medical School, Universidade Federal dos Vales do Jequitinhonha e Mucuri, Diamantina, Brazil
| | - Vanessa P Lima
- Programa de Pós-Graduação em Reabilitação e Desempenho Funcional, Universidade Federal dos Vales do Jequitinhonha e Mucuri, Diamantina, Brazil.,Departamento de Fisioterapia, Universidade Federal dos Vales do Jequitinhonha e Mucuri, Minas Gerais, Brazil
| | - Vanessa A Mendonça
- Programa de Pós-Graduação em Reabilitação e Desempenho Funcional, Universidade Federal dos Vales do Jequitinhonha e Mucuri, Diamantina, Brazil.,Departamento de Fisioterapia, Universidade Federal dos Vales do Jequitinhonha e Mucuri, Minas Gerais, Brazil
| | - Ana Cristina R Lacerda
- Programa de Pós-Graduação em Reabilitação e Desempenho Funcional, Universidade Federal dos Vales do Jequitinhonha e Mucuri, Diamantina, Brazil.,Departamento de Fisioterapia, Universidade Federal dos Vales do Jequitinhonha e Mucuri, Minas Gerais, Brazil
| | - Pedro Henrique S Figueiredo
- Programa de Pós-Graduação em Reabilitação e Desempenho Funcional, Universidade Federal dos Vales do Jequitinhonha e Mucuri, Diamantina, Brazil.,Departamento de Fisioterapia, Universidade Federal dos Vales do Jequitinhonha e Mucuri, Minas Gerais, Brazil
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6
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Ware JE, Richardson MM, Meyer KB, Gandek B. Improving CKD-Specific Patient-Reported Measures of Health-Related Quality of Life. J Am Soc Nephrol 2019; 30:664-677. [PMID: 30898870 DOI: 10.1681/asn.2018080814] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Accepted: 01/30/2019] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Patient-reported outcome measures that are more practical and clinically useful are needed for patients with CKD. We compared a new CKD-specific quality-of-life impact scale (CKD-QOL) with currently used measures. METHODS Patients (n=485) in different treatment groups (nondialysis stages 3-5, on dialysis, or post-transplant) completed the kidney-specific CKD-QOL and Kidney Disease Quality of Life-36 (KDQOL-36) forms and the generic SF-12 Health Survey at baseline and 3 months. New items summarizing quality of life (QOL) impact attributed to CKD across six QOL domains yielded single impact scores from a six-item static (fixed-length) form and from computerized adaptive tests (CATs) with three to six items. Validity tests compared the CKD-QOL, KDQOL-36 (Burden, Effects, and Symptoms/Problems subscales), and generic SF-12 measures across groups in four tests of clinical status and clinician assessment of change (CKD-specific tests), and number of comorbidities. ANOVA was used to test for group mean differences, variances in each measure explained by groups, and relative validity (RV) in comparison with the referent KDQOL-36 Burden subscale. RESULTS KDQOL-36 and CKD-QOL measures generally discriminated better than generic SF-12v2 measures. The pattern of variances across CKD-specific tests comparing validity favored CKD-QOL two-fold over KDQOL-36. Two RV test results confirmed CKD-QOL improvements over the referent KDQOL scale. Results for static and CAT CKD-QOL forms were similar. SF-12 Physical and KDQOL-36 Symptoms scores worsened with increasing comorbid condition counts. CONCLUSIONS Overall, compared with the KDQOL-36, the new approach to summarizing CKD-specific QOL impact performed better across multiple tests of validity. CAT surveys were more efficient than static surveys.
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Affiliation(s)
- John E Ware
- John Ware Research Group, Outcomes Measurement Department, Watertown, Massachusetts; .,Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Michelle M Richardson
- William B. Schwartz Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, Massachusetts; and.,Dialysis Clinic, Inc., Outcomes Monitoring Program, Boston, Massachusetts
| | - Klemens B Meyer
- William B. Schwartz Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, Massachusetts; and.,Dialysis Clinic, Inc., Outcomes Monitoring Program, Boston, Massachusetts
| | - Barbara Gandek
- John Ware Research Group, Outcomes Measurement Department, Watertown, Massachusetts.,Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
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7
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Chong K, Unruh M. Why does quality of life remain an under-investigated issue in chronic kidney disease and why is it rarely set as an outcome measure in trials in this population? Nephrol Dial Transplant 2017; 32:ii47-ii52. [PMID: 28206614 DOI: 10.1093/ndt/gfw399] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Accepted: 10/10/2016] [Indexed: 12/14/2022] Open
Abstract
The growing importance of quality of life (QoL) measures in health care is reflected by the increased volume and rigor of published research on this topic. The ability to measure and assess patients' experience of symptoms and functions has transformed the development of disease treatments and interventions. However, QoL remains an under-investigated issue in chronic kidney disease (CKD) and is seldom set as an outcome measure in trials in this population. In this article, we present various challenges in using patient-reported outcome (PRO) end points in CKD trials. We outline the need for additional research to examine more closely patient experiences with specific kidney disease symptoms and conditions, as well as caregiver perspectives of patients' symptom burden and end-of-life experiences. These efforts will better guide the development or enhancement of PRO instruments that can be used in clinical trials to more effectively assess treatment benefit, and improve therapy and care. Better understanding of health-related QoL issues would enable providers to deliver more patient-centered care and improve the overall well-being of patients. Even small improvements in QoL could have a large impact on the population's overall health and disease burden.
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Affiliation(s)
- Kelly Chong
- Renal Division, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Mark Unruh
- Renal Division, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM, USA.,Renal Section, New Mexico VA Health System, Albuquerque, NM, USA
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8
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Rhee CM, Chen Y, You AS, Brunelli SM, Kovesdy CP, Budoff MJ, Brent GA, Kalantar-Zadeh K, Nguyen DV. Thyroid Status, Quality of Life, and Mental Health in Patients on Hemodialysis. Clin J Am Soc Nephrol 2017; 12:1274-1283. [PMID: 28705886 PMCID: PMC5544520 DOI: 10.2215/cjn.13211216] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Accepted: 04/17/2017] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND OBJECTIVES In the general population, there is increasing recognition of the effect of thyroid function on patient-centered outcomes, including health-related quality of life and depression. Although hypothyroidism is highly prevalent in hemodialysis patients, it is unknown whether thyroid status is a risk factor for impaired health-related quality of life or mental health in this population. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We examined the association of thyroid status, defined by serum thyrotropin, with health-related quality of life and depressive symptoms over time in a prospective cohort of 450 patients on hemodialysis from 17 outpatient dialysis facilities from May of 2013 to May of 2015 who underwent protocolized thyrotropin testing, Short-Form 36 surveys, and Beck Depression Inventory-II questionnaires every 6 months. We examined the association of baseline and time-dependent thyrotropin categorized as tertiles and continuous variables with eight Short-Form 36 domains and Beck Depression Inventory-II scores using expanded case mix plus laboratory adjusted linear mixed effects models. RESULTS In categorical analyses, the highest baseline thyrotropin tertile was associated with a five-point lower Short-Form 36 domain score for energy/fatigue (P=0.04); the highest time-dependent tertile was associated with a five-point lower physical function score (P=0.03; reference: lowest tertile). In continuous analyses, higher baseline serum thyrotropin levels (+Δ1 mIU/L) were associated with lower role limitations due to physical health (β=-1.3; P=0.04), energy/fatigue (β=-0.8; P=0.03), and pain scores (β=-1.4; P=0.002), equivalent to five-, three-, and five-point lower scores, respectively, for every 1-SD higher thyrotropin. Higher time-dependent thyrotropin levels were associated with lower role limitations due to physical health scores (β=-1.0; P=0.03), equivalent to a three-point decline for every 1-SD higher thyrotropin. Baseline and time-dependent thyrotropin were not associated with Beck Depression Inventory-II scores. CONCLUSIONS In patients on hemodialysis, higher serum thyrotropin levels are associated with impaired health-related quality of life across energy/fatigue, physical function, and pain domains. Studies are needed to determine if thyroid-modulating therapy improves the health-related quality of life of hemodialysis patients with thyroid dysfunction.
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Affiliation(s)
| | - Yanjun Chen
- Institute for Clinical and Translational Science, University of California, Irvine, California
| | - Amy S. You
- Division of Nephrology and Hypertension and
| | | | - Csaba P. Kovesdy
- Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, Tennessee
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee
| | | | - Gregory A. Brent
- Department of Medicine, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California; and
- Departments of Medicine and
- Physiology, David Geffen School of Medicine at the University of California, Los Angeles, California
| | | | - Danh V. Nguyen
- Department of Medicine, University of California Irvine, Orange, California
- Institute for Clinical and Translational Science, University of California, Irvine, California
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Rhee CM, Brunelli SM, Subramanian L, Tentori F. Measuring patient experience in dialysis: a new paradigm of quality assessment. J Nephrol 2017; 31:231-240. [DOI: 10.1007/s40620-017-0401-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 04/10/2017] [Indexed: 11/24/2022]
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10
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Tong A, Winkelmayer WC, Wheeler DC, van Biesen W, Tugwell P, Manns B, Hemmelgarn B, Harris T, Crowe S, Ju A, O’Lone E, Evangelidis N, Craig JC. Nephrologists' Perspectives on Defining and Applying Patient-Centered Outcomes in Hemodialysis. Clin J Am Soc Nephrol 2017; 12:454-466. [PMID: 28223290 PMCID: PMC5338715 DOI: 10.2215/cjn.08370816] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Accepted: 11/02/2016] [Indexed: 01/15/2023]
Abstract
BACKGROUND AND OBJECTIVES Patient centeredness is widely advocated as a cornerstone of health care, but it is yet to be fully realized, including in nephrology. Our study aims to describe nephrologists' perspectives on defining and implementing patient-centered outcomes in hemodialysis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Face-to-face, semistructured interviews were conducted with 58 nephrologists from 27 dialysis units across nine countries, including the United States, the United Kingdom, Australia, Austria, Belgium, Canada, Germany, Singapore, and New Zealand. Transcripts were thematically analyzed. RESULTS We identified five themes on defining and implementing patient-centered outcomes in hemodialysis: explicitly prioritized by patients (articulated preferences and goals, ascertaining treatment burden, defining hemodialysis success, distinguishing a physician-patient dichotomy, and supporting shared decision making), optimizing wellbeing (respecting patient choice, focusing on symptomology, perceptible and tangible, and judging relevance and consequence), comprehending extensive heterogeneity of clinical and quality of life outcomes (distilling diverse priorities, highly individualized, attempting to specify outcomes, and broadening context), clinically hamstrung (professional deficiency, uncertainty and complexity in measurement, beyond medical purview, specificity of care, mechanistic mindset [focused on biochemical targets and comorbidities], avoiding alarm, and paradoxical dilemma), and undermined by system pressures (adhering to overarching policies, misalignment with mandates, and resource constraints). CONCLUSIONS Improving patient-centered outcomes is regarded by nephrologists to encompass strategies that address patient goals and improve wellbeing and treatment burden in patients on hemodialysis. However, efforts are hampered by ambiguities about how to prioritize, measure, and manage the plethora of critical comorbidities and broader quality of life outcomes in a care setting that is technically demanding and driven by biochemical targets. Identifying critical patient-important outcomes and mechanisms for integrating them into practice may help to deliver patient-centered care in hemodialysis and other chronic disease settings.
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Affiliation(s)
- Allison Tong
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Kidney Research, The Children’s Hospital at Westmead, Sydney, New South Wales, Australia
| | - Wolfgang C. Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Baylor College of Medicine, Houston, Texas
| | - David C. Wheeler
- Centre for Nephrology, University College London, London, United Kingdom
| | - Wim van Biesen
- Renal Division, Ghent University Hospital, Ghent, Belgium
| | - Peter Tugwell
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Braden Manns
- Departments of Medicine and
- Community Health Sciences, Libin Cardiovascular Institute and O’Brien Institute of Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Brenda Hemmelgarn
- Departments of Medicine and
- Community Health Sciences, Libin Cardiovascular Institute and O’Brien Institute of Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Tess Harris
- Polycystic Kidney Disease International, London, United Kingdom; and
| | - Sally Crowe
- Crowe Associates Ltd, Oxford, United Kingdom
| | - Angela Ju
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Kidney Research, The Children’s Hospital at Westmead, Sydney, New South Wales, Australia
| | - Emma O’Lone
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Kidney Research, The Children’s Hospital at Westmead, Sydney, New South Wales, Australia
| | - Nicole Evangelidis
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Kidney Research, The Children’s Hospital at Westmead, Sydney, New South Wales, Australia
| | - Jonathan C. Craig
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Kidney Research, The Children’s Hospital at Westmead, Sydney, New South Wales, Australia
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11
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Psychosocial Factors in End-Stage Kidney Disease Patients at a Tertiary Hospital in Australia. Int J Nephrol 2016; 2016:2051586. [PMID: 27807482 PMCID: PMC5078664 DOI: 10.1155/2016/2051586] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 09/02/2016] [Accepted: 09/14/2016] [Indexed: 11/17/2022] Open
Abstract
Aim. This study seeks to review the psychosocial factors affecting patients with end-stage kidney disease (ESKD) from a tertiary hospital in Australia. Methods. We audited patients with ESKD, referred to social work services from January 2012 to December 2014. All patients underwent psychosocial assessments by one, full-time renal social worker. Patient demographics, cumulative social issues, and subsequent interventions were recorded directly into a database. Results. Of the 244 patients referred, the majority were >60 years (58.6%), male (60.7%), born in Australia (62.3%), on haemodialysis (51.6%), and reliant on government financial assistance (88%). Adjustment issues (41%), financial concerns (38.5%), domestic assistance (35.2%), and treatment nonadherence (21.3%) were the predominant reasons for social work consultation. Younger age, referral prior to start of dialysis, and unemployment were significant independent predictors of increased risk of adjustment issues (p = 0.004, <0.001, and =0.018, resp.). Independent risk factors for treatment nonadherence included age and financial and employment status (p = 0.041, 0.052, and 0.008, resp.). Conclusion. Psychosocial and demographic factors were associated with treatment nonadherence and adjustment difficulties. Additional social work support and counselling, in addition to financial assistance from government and nongovernment agencies, may help to improve adjustment to the diagnosis and treatment plans as patients approach ESKD.
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Ibrahim MK, Elshahid AR, El Baz TZ, Elazab RM, Elhoseiny SA, Elsaie ML. Impact of Uraemic Pruritus on Quality of Life among End Stage Renal Disease Patients on Dialysis. J Clin Diagn Res 2016; 10:WC01-5. [PMID: 27134981 DOI: 10.7860/jcdr/2016/16273.7488] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Accepted: 11/25/2015] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Uraemic pruritus is significant complication in (ESRD) patients and substantially impairs their quality of life (QOL). ESRD is a bothersome problem with attempts being made to increase the survival of patients on dialysis. AIM An attempt was made to compare the QOL of haemodialysis patients and suffering from uraemic pruritus with the QOL of those on haemodialysis but with no presenting uraemic pruritus. MATERIALS AND METHODS A cross-sectional study was conducted to evaluate the QOL of haemodialysis patients suffering from uraemic pruritus. The WHOQOL-BREF questionnaire was used to assess the QOL. Haemodialysis patients with pruritus who had completed three months of maintenance haemodialysis (n=100) were enrolled into the study and 100 controls (n=100) on haemodialysis but with no pruritus were further enrolled. RESULTS The QOL of haemodialysis patients with pruritus was found to be significantly impaired (p < 0.05) in comparison to those on haemodialysis with no prutitis, particularly with respect to all the four WHOQOL-BREF domains. CONCLUSION Quality of life of ESRD patients on dialsysis was siginificantly affected by pruritis.
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Affiliation(s)
- Mohamed K Ibrahim
- Professor, Department of Dermatology, Al azhar University , Cairo Egypt
| | - Ahmed R Elshahid
- Assistant Professor, Department of Dermatology, Al azhar University , Cairo Egypt
| | - Tarek Z El Baz
- Consultant, Department of Dermatology, Al azhar University , Cairo Egypt
| | - Raed M Elazab
- Consultant, Department of Dermatology, Al azhar University , Cairo Egypt
| | - Sara A Elhoseiny
- Specialist, Department of Dermatology, Al azhar University , Cairo Egypt
| | - Mohamed L Elsaie
- Lecturer, Department of Dermatology, National Research Centre , Egypt
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13
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Chen SS, Unruh M, Williams M. In Quality We Trust; but Quality of Life or Quality of Care? Semin Dial 2016; 29:103-10. [PMID: 26860436 DOI: 10.1111/sdi.12470] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The ESRD program provides medical care to a diverse and medically complex patient population. The care for the ESRD patient population has become increasingly benchmarked with process of care measures. These measures include dialysis adequacy, anemia, nutrition, and vascular access outcomes. These process-related dialysis measures may not improve the care of the individual patient as care relates to the individual's goals and values. There is also evidence that these process measures may not be causally related to quality of life, hospitalization, and survival. The adoption of patient-reported outcomes may shift the balance toward more patient-centered care. However, the extent to which mandated measures of health-related quality of life and patient satisfaction result in improved outcomes remains unclear.
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Affiliation(s)
- Shan Shan Chen
- Nephrology Division, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Mark Unruh
- Nephrology Division, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico.,Renal Section, Medicine Service, Department of Medicine, Raymond G. Murphy VA Medical Center, School of Medicine, University of New Mexico, Albuquerque, New Mexico
| | - Mark Williams
- Nephrology Division, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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14
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Cowan D, Smith L, Chow J. CARE OF A PATIENT'S VASCULAR ACCESS FOR HAEMODIALYSIS: A NARRATIVE LITERATURE REVIEW. J Ren Care 2015; 42:93-100. [PMID: 26420385 DOI: 10.1111/jorc.12139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Patients requiring haemodialysis have diverse clinical needs impacting on the longevity of their vascular access and their quality of life. A clinical practice scenario is presented that raises the potential of unsafe cannulation of a patient's vascular access as a result of minimal patient empowerment. Vascular access care is the responsibility of everyone, including the patient and carer. AIM The aim of this narrative literature review (1997-2014) is to explore the current understanding of what factors influence the care of vascular access for haemodialysis. METHOD A narrative literature review allows the synthesis of the known literature pertinent to the research question into a succinct model or unique order to enable new understandings to emerge. The bio-ecological model was used to guide the thematic analysis of the literature. RESULTS The narrative literature review revealed five themes related to care of vascular access: patient experience; relationships-empowerment and shared decision making; environment of healthcare; time; and quality of life as the outcome of care. CONCLUSION The management of vascular access is complicated. Current available literature predominantly concentrates on bio-medical aspects of vascular access care. Contextualised vascular access care in the complex ecology of the patient and carer's lives has the potential to enhance nursing practice and patient outcomes.
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Affiliation(s)
- Debi Cowan
- University of Tasmania, Launceston, Tasmania, Australia.,Central Coast Local Health District, Gosford, New South Wales, Australia
| | - Lindsay Smith
- University of Tasmania, Launceston, Tasmania, Australia
| | - Josephine Chow
- University of Tasmania, Launceston, Tasmania, Australia.,South Western Sydney Local Health District, Sydney, New South Wales, Australia.,University of Sydney, Sydney, New South Wales, Australia
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Abstract
This is the first paper in a two-part Continuing Education (CE) series focusing on psychosocial care of patients with end-stage kidney disease (ESKD), which addresses a variety of psychological responses experienced by patients when adapting to the challenges posed by living with this long-term condition. The second paper will examine further the issues of coping and adjustment to ESKD and the need for renal supportive care to ensure person-centred holistic care is provided to patients.
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Affiliation(s)
- Ciara White
- Transplant, Urology Nephrology Directorate, Beaumont Hospital, Dublin, Ireland
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Hinami K, Smith J, Deamant CD, Kee R, Garcia D, Trick WE. Health perceptions and symptom burden in primary care: measuring health using audio computer-assisted self-interviews. Qual Life Res 2014; 24:1575-83. [DOI: 10.1007/s11136-014-0884-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/01/2014] [Indexed: 11/24/2022]
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17
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Turkistani I, Nuqali A, Badawi M, Taibah O, Alserihy O, Morad M, Kalantan E. The prevalence of anxiety and depression among end-stage renal disease patients on hemodialysis in Saudi Arabia. Ren Fail 2014; 36:1510-5. [DOI: 10.3109/0886022x.2014.949761] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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18
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Simone B, Atchison C, Ruiz B, Greenop P, Dave J, Ready D, Maguire H, Walsh B, Anderson S. Investigating an outbreak of Clostridium perfringens gastroenteritis in a school using smartphone technology, London, March 2013. Euro Surveill 2014; 19. [DOI: 10.2807/1560-7917.es2014.19.19.20799] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Binary file ES_Abstracts_Final_ECDC.txt matches
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Affiliation(s)
- B Simone
- Field Epidemiology Services (Victoria), Public Health England, London, United Kingdom
- These authors contributed equally
- European Programme for Intervention Epidemiology (EPIET), European Centre for Disease Control (ECDC), Stockholm, Sweden
| | - C Atchison
- South West London Health Protection Team, Public Health England, London, United Kingdom
- These authors contributed equally
| | - B Ruiz
- Commercial Environmental Health, London Borough of Richmond Upon Thames, London, United Kingdom
| | - P Greenop
- Commercial Environmental Health, London Borough of Richmond Upon Thames, London, United Kingdom
| | - J Dave
- PHE Public Health Laboratory London, The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - D Ready
- PHE Public Health Laboratory London, The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - H Maguire
- European Programme for Intervention Epidemiology (EPIET), European Centre for Disease Control (ECDC), Stockholm, Sweden
- Field Epidemiology Services (Victoria), Public Health England, London, United Kingdom
| | - B Walsh
- South West London Health Protection Team, Public Health England, London, United Kingdom
| | - S Anderson
- Field Epidemiology Services (Victoria), Public Health England, London, United Kingdom
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Gurland B, Teresi JA, Eimicke JP, Maurer MS, Reid MC. Quality of life impacts on 16-year survival of an older ethnically diverse cohort. Int J Geriatr Psychiatry 2014; 29:533-45. [PMID: 24167085 PMCID: PMC4372056 DOI: 10.1002/gps.4038] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Accepted: 09/23/2013] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The objective of this study is to examine the prediction of mortality, over 16 years, by the domains and domain elements underlying generic measures of quality of life (QoL). METHODS The method used was an analysis of mortality in an older (65 + years) representative sample (N = 2130) of a multicultural community in North Manhattan. Five conventional QoL domains were measured by in-home, rater-administered, and computer-assisted questionnaire: depressed mood, pain, self-perceived health, and function and social relationships. RESULTS Some domain scales that qualitatively express distress, such as depressed mood and widespread pain, significantly predicted lower mortality (were protective) and felt isolation trended in that direction, whereas domains indicating quantitative limitations such as impairment of functioning in daily tasks, stair climbing, as well as social disengagements and lack of support network significantly predicted higher mortality. Domain elements also mattered; contrary to their domain predictions, increased mortality was predicted by the domain elements of somatic symptoms of depression. Self-perceived poor health reflected the predictive (higher mortality) direction of the limitations cluster. CONCLUSIONS The internal complexity of QoL is underscored by differential impacts of domains and elements on mortality. Clinical implications include setting distress domains as important clinical goals, whereas strengthening limiting domains could result in lengthening life and secondarily relieving distress. The relative weighting of these goals could be derived from patient preferences and clinical efficacy. Fundamental implications lie in the interaction between the person's qualitative evaluations of choices and the quantitative building of desired choices for a better QoL.
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Affiliation(s)
- Barry Gurland
- Stroud Centre, Columbia University, New York, NY USA
| | | | | | - Mathew S. Maurer
- Department of Medicine, Division of Cardiology, Columbia University, New York, NY USA
| | - M. Carrington Reid
- Geriatrics and Gerontology, Weill Cornell Medical College, New York, NY USA
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Dharia SM, Brown LK, Unruh ML. Recognition and treatment of obstructive sleep apnea. Semin Dial 2013; 26:273-7. [PMID: 23458074 DOI: 10.1111/sdi.12067] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Sushma M Dharia
- Division of Pulmonary, Critical Care, and Sleep Medicine, Albuquerque, New Mexico, USA
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