Weight management strategies for those with chronic kidney disease: A consensus report from the Asia Pacific Society of Nephrology and Australia and New Zealand Society of Nephrology 2016 renal dietitians meeting

AIM

The aim of the present study was to develop a consensus report to guide dietetic management of overweight or obese individuals with chronic kidney disease (CKD).

METHODS

Six statements relating to weight management in CKD guided a comprehensive review of the literature. A summary of the evidence was then presented at the renal nutrition meeting of the 2016 Asia Pacific Society of Nephrology and Australia and New Zealand Society of Nephrology. Majority agreement was defined as group agreement on a statement of between 50-74%, and consensus was considered ≥75% agreement. The recommendations were developed via a mini Delphi process.

RESULTS

Two statements achieved group consensus: the current guidelines used by dietitians to estimate energy requirements for overweight and obese people with CKD are not relevant and weight loss medications may be unsafe or ineffective in isolation for those with CKD. One statement achieved group agreement: Meal replacement formulas are safe and efficacious in those with CKD. No agreement was achieved on the statements of whether there is strong evidence of benefit for weight loss prior to kidney transplantation; whether traditional weight loss strategies can be used in those with CKD and if bariatric surgery in those with end stage kidney disease is feasible and effective.

CONCLUSION

There is a limited evidence base to guide the dietetic management of overweight and obese individuals with CKD. Medical or surgical strategies to facilitate weight loss are not recommended in isolation and require a multidisciplinary approach with the involvement of a skilled renal dietitian.

The effect of rectal washout on local recurrence following rectal cancer surgery

Introduction Local recurrence after surgery for rectal cancer is associated with significant morbidity and debilitating symptoms. Intraoperative rectal washout has been linked to a reduction in local recurrence but there is no conclusive evidence. The aim of this study was to evaluate whether performing rectal washout had any effect on the incidence of local recurrence in patients undergoing anterior resection for rectal cancer in the context of the current surgical management. Methods A total of 395 consecutive patients who underwent anterior resection with or without rectal washout for rectal cancer between January 2003 and July 2009 at a high volume single institution were analysed retrospectively. A standardised process for performing washout was used and all patients had standardised surgery in the form of total mesorectal excision. Neoadjuvant and adjuvant therapy was used on a selected basis. Patients were followed up for five years and local recurrence rates were compared in the two groups. Results Of the 395 patients, 297 had rectal washout and 98 did not. Both groups were well matched with regard to various important clinical, operative and histopathological characteristics. Overall, the local recurrence rate was 5.3%. There was no significant difference in the incidence of local recurrence between the washout group (5.7%) and the no washout group (4.1%). Conclusions Among our cohort of patients, there was no statistical difference in the incidence of local recurrence after anterior resection with or without rectal washout. This suggests that other factors are more significant in the development of local recurrence.

Current ESWL practice and outcomes in the UK: A multicentre snapshot

Objectives:

The objective of this article is to investigate the current clinical practice and outcomes of extracorporeal shock wave lithotripsy (SWL) in the United Kingdom.

Patients and methods:

Patient demographics, stone characteristics and SWL protocols were collected prospectively for 30 consecutive new patient referrals at each of seven contributing UK institutions performing SWL. Final outcomes in terms of stone-free rates (SFRs), and complications were recorded.

Results:

Completed demographic data were available for 204 patients. Treatment protocols varied between centres. Mean patient age was 51 years. Over 70% of stones treated measured between 5 and 10 mm, and one-third were in the ureter, with two-thirds in the kidney, where the majority (31% overall) were in the lower pole. The overall cumulative SFR was 50.3% (range 33–70% between centres). SWL was notably more effective for ureteric stones (SFR 59.3% overall) than for renal calculi (SFR 45.6% overall). Complications were noted in six patients.

Conclusion:

This study provides a valuable snapshot of real-life clinical practice and demonstrates considerable variability in the application of SWL in the UK. The results support existing data which suggest that SWL is a safe and well tolerated treatment modality; however, overall SFRs were low.

Exploring the beliefs of Australian prefabricated house builders

The housing sector accounts for a majority of newly constructed buildings. Prefabrication, defined as the factory construction of houses or significant components, is widely promoted as a means to improve efficiency. This paper focuses on the research questions: RQ1. What are the attitudes of builders towards prefabrication adoption? RQ2. What types of stakeholders do builders believe influence their adoption decisions? RQ3. What types of contextual influences do builders believe impact their adoption decisions? Current prefabrication research has focused on the advantages and disadvantages of prefabrication, without further unpacking the beliefs of stakeholders that underpin them. This paper addresses this gap and increases the understanding of beliefs that can frame interventions to increase the market penetration of prefabrication. Fourteen interviews with Australian prefabricators were undertaken as a Belief Elicitation Study. This qualitative methodology is framed by the Theory of Planned Behaviour (TPB) and the Technology Acceptance Model (TAM). Results show that modern high-quality prefabricated housing has struggled to overcome historical stigma; improved construction speed has not and is not likely to translate to reduced totals costs for a majority of firms; and prefabrication adoption has been hindered by an almost completely unsupportive industry infrastructure. Recommendations are made to frame arguments in improving short-term outcomes for an industry driven by practical considerations. Future discourse must focus on cost impacts, financial security and risk reduction. Establishing networks of prefabricators that can build a strong, unified voice for the industry should be prioritised. 

Radial Forearm Free Flap Donor Site Outcomes Comparison by Closure Methods

OBJECTIVE: To compare the functional and aesthetic outcomes of radial forearm free flap (RFFF) donor sites reconstructed with full-thickness skin graft (FTSG), split thickness skin graft (STSG) alone, and STSG overlying an acellular dermal matrix (AlloDerm).

STUDY DESIGN AND SETTING: A cross-sectional cohort study at a tertiary care hospital.

RESULTS: Twenty-five head and neck cancer patients who underwent reconstruction with RFFF completed the evaluations (STSG = 10, FTSG = 8, STSG with AlloDerm = 7). Subjective evaluations of postoperative function by questionnaires showed no significant differences among the 3 groups ( P = 0.93). In blinded evaluations by surgeons, the STSG group obtained the highest aesthetic outcome score (3.39 of 5.0), followed by FTSG (2.89) and STSG with AlloDerm (2.80). However, the difference was not statistically significant ( P = 0.32). Objective measurements of postoperative function by certified occupational therapists were comparable among the 3 groups with the exception of a mildly decreased range of wrist flexion ( P = 0.036) and ulnar deviation ( P = 0.016) in the FTSG group.

CONCLUSIONS: The 3 methods of reconstruction have comparable postoperative functional and aesthetic outcomes.

SIGNIFICANCE: Each of the 3 methods of reconstruction has low morbidity and satisfactory aesthetic and functional outcomes.

EBM rating: B-2b

Innovation Performance and Its Impact on Profitability Among Different Sectors in the Australian Construction Industry

The BRITE (Building Research Information Technology and Environment) project was established by the Australian Cooperative Research Centre for Construction Innovation to encourage innovation in the construction industry. While innovation is generally perceived to be broadly beneficial, there has been little formal study of its occurrence or impact in Australian construction or of the factors which foster an innovative atmosphere within an enterprise. In order to benchmark innovation performance, the BRITE project conducted a survey in 2004 into the nature, incidence and variety of technological and organisational innovations in various sectors of the industry. With some exceptions, the survey found that clients and consultants engaged in significantly higher levels of innovation than did suppliers, main contractors or trade contractors. Within the industry sectors those organisations classified as high innovators favoured the adoption of advanced management practices and had formal evaluation systems in place to judge their progress. They reported significant positive impacts on their profitability from innovation and can therefore provide instructive examples for the rest of the industry to follow.

Integrated Manufacturing-Services Businesses in the Australian Building and Construction Sector

This paper establishes that the emergence of integrated manufacturing-service businessesis a key trademark of innovative industries and ‘the new economy’. Having establishedthe benefits of such integration, the phenomenon is reviewed in relation to theAustralian building and construction (B&C) sector. It is hypothesised that manufacturerssupplying building and construction work are adding value to their own activity, and that ofthe sector, by enhancing their product offerings via the provision of services. A small surveyis undertaken, with the findings revealing the nature of service provision by manufacturersin the Australian B&C sector. It appears that the ‘bundling’ of products and servicesby these manufacturers is a key competitive strategy yielding significant benefits for themand the sector as a whole.

Hormone Replacement Therapy after Endometrial Cancer

Endometrial cancer is the fourth most common female cancer in the UK and the most common gynaecological cancer. Quality of life and symptom control needs to be considered in women who enter a surgically induced menopause. Hormone replacement in this population has been controversial to date. The current evidence regarding the safety of estrogen only and combined hormone replacement therapy is discussed in this review. The use of topical vaginal therapies, alternate therapies and the current data regarding testosterone use for symptom control is also outlined.

HIV-associated gastric natural killer/T-cell lymphoma

Natural killer (NK)/T-cell lymphoma is a rare form of non-Hodgkin's lymphoma that is seen with increased frequency in HIV infection and in transplant recipients. This case report describes an unusual case of extranodal NK/T-cell lymphoma in a patient with advanced HIV disease in which gastric involvement was a significant feature.

How do mental health professionals deal with uncertainty in suicide risk assessment?

Introduction

Suicide risk-assessment forms a significant part of the workload of mental health professionals (MHPs). There is much research regarding efficacy of different methods/scales of suicide risk-assessment, and effects of formal training on risk-assessment. To date, there is little investigation into how approach to risk-assessment varies amongst professionals on an individual level, or how MHPs react when confronted by lack of information.

Objective

This study evaluated how MHPs respond to uncertainty when assessing suicide risk.

Methods

720 MHPs were given 10 clinical scenarios and asked to assess suicide risk in each case. The scenarios were a mixture of high, medium and low risk cases. In addition, there were scenarios where information provided was incomplete or ambiguous. Subjects graded suicide risk-severity from 1–10 (1 = low, 10 = high).

Results

The simple scenarios produced a predictable consensus of opinion amongst MHPs. The ambiguous scenario produced three distinct response peaks (Fig. 1) at low, medium, and high risk.

Fig. 1

Conclusions

Ambiguous suicide risk separates MHPs into three responder groups:1.

This has implications for suicide risk training. Further research is required to fully understand why individuals respond in different ways to suicide risk scenarios.

Financial Incentives and Advanced Construction Procurement Systems

Construction clients often use financial incentives to encourage stakeholder motivation and commitment to voluntary higher-order project goals. Despite the increased use of financial incentives, there is little literature addressing means of optimizing outcomes. Using a case-study methodology, the examination of a successful Australian construction project demonstrates the features of a positively geared procurement approach that promotes the effectiveness of financial incentives. The research results show that if the incentive system is perceived to be fair and is applied to reward exceptional performance, and not to manipulate, then contractors are more likely to be positively motivated.

Action planning: making change happen in clinical practice

This article describes how the authors helped practitioners to develop their action planning skills in conjunction with a practice development strategy in an acute hospital, using an approach called concept analysis, embellished by a systematic literature review. As a result of this, two tools were developed to help practitioners become more effective in action planning. This article describes the process and the tools that resulted, and illustrates the impact and benefits of using these tools in practice. It concludes that action planning, when undertaken rigorously and effectively, is a key skill for changing the workplace culture from one where the action plan belongs to one person to one where everyone takes responsibility for action.

The human polyomaviruses

The Polyomavirus family includes two members, BK virus (BKV) and JC virus (JCV), that naturally infect humans. These viruses are widely distributed among the population worldwide. Primary infection occurs in early childhood and remains for life clinically unapparent in immunocompetent individuals. In the context of severe immunosuppression and other predisposing factors BKV and JCV may reactivate and cause serious illnesses known as Polyomavirus-induced nephropathy and progressive multifocal leukoencephalopathy, respectively. Here we briefly examine the biological and physical characteristics and the lifecycle, namely receptor(s) interaction, mode of entry, intracellular trafficking, viral transcription and replication, and progeny assembly of these two human Polyomaviruses. We also provide an overview of the clinical manifestation of Polyomavirus-induced disorders in affected individuals and discuss the potential involvement of BKV and JCV in human cancer.

Organisational culture and consultant nurse outcomes: Part 1--Organisational culture

Organisational culture is presented as a complex concept underpinned by specific values, beliefs and assumptions that account for the way things are done. Strong organisational cultures and a number of other attributes are highlighted as having influence on performance. The role of leadership is recognised as key to facilitating cultural change, as is the use of approaches which clarify values and highlight contradictions between espoused culture and culture in practice. A three-year study in which a consultant nurse post in critical care was operationalised demonstrated the achievement of an organisational culture with positive impact on the unit in which it was based, on practitioners and their practice, and also on the trust. Transformational leadership combined with other facilitative processes, expertise in the practice of nursing, and other subroles of the consultant nurse are further highlighted as influential.

Organisational culture and consultant nurse outcomes: Part 2. Nurse outcomes

AIM

The aim of this three-year study was to investigate the development of a consultant nurse post and consider whether it contributed to a new organisational culture.

METHODOLOGY

Action research was used because it focuses on developing practitioners, developing practice and contributing to understanding both the phenomena being studied and the processes being used.

RESULTS

The role of leadership is recognised as key to bringing about cultural change, as is the use of approaches that clarify values and highlight the contradiction between espoused culture and culture in practice.

CONCLUSION

This new culture had a positive impact on the unit in which it was based, on practitioners and their practice, and also on the trust. A number of factors, including transformational leadership, other facilitative processes, expertise in the practice of nursing, and other subroles of the consultant nurse were shown to be influential. Part one, published last week, described the concept of organisational culture. This article discusses the consultant nurse outcomes.

Organisational culture and consultant nurse outcomes: Part 1. Organisational culture

AIMS

The aim of this three-year study was to operationalize the role of a consultant nurse and, in so doing, facilitate the development of nurses and nursing for the purpose of providing better patient services.

METHODOLOGY

Action research was used because it focuses on developing practitioners, developing practice and contributing to understanding both the phenomena being studied and the processes being used.

RESULTS

The role of leadership is recognised as key to bringing about cultural change, as is the use of approaches that clarify values and highlight the contradiction between espoused culture and culture in practice.

CONCLUSION

The resulting culture had a positive impact on the unit in which the consultant nurse was based, on practitioners and their practice, and also on the trust. A number of factors, including transformational leadership, other facilitative processes, expertise in the practice of nursing, and other subroles of the consultant nurse were shown to be influential. This article explores the concept of organisational culture, and a second article to be published next week, discusses the consultant nurse outcomes.

Paying Peter and Paul: reconciling concepts of expertise with competency for a clinical career structure

This paper identifies current UK policy for exploring both competence and expertise. It is argued that the purpose of assessing competence and expertise is relevant in deciding the approaches used. Different perspectives about competence, specifically those that have arisen in the United States and the United Kingdom, are considered in relation to how competencies may be developed and assessed. The different terms used in discussion about competency are also discussed. From the literature, criteria for selecting experts in nursing, the attributes of expertise and enabling factors are presented in relation to how expertise in practice may be judged. The pilot recognition process and development of evidence for the Royal College of Nursing's Expert Practice Project, together with its facilitation through critical companionship, are described. It is concluded that the processes necessary for demonstrating expertise in practice are consistent with the recognition that the attributes of expertise are interdependent, complex and situational. Critical companionship provides a mechanism which is primarily developmental and supportive, but focuses on practice development and practitioners' effectiveness and can result in the development of evidence for a range of different purposes such as demonstrating expertise, as well as practice development, service development and career progression.

Msh2 deficiency prevents in vivo somatic instability of the CAG repeat in Huntington disease transgenic mice

Huntington disease (HD), an autosomal dominant, progressive neurodegenerative disorder, is caused by an expanded CAG repeat sequence leading to an increase in the number of glutamine residues in the encoded protein. The normal CAG repeat range is 5-36, whereas 38 or more repeats are found in the diseased state; the severity of disease is roughly proportional to the number of CAG repeats. HD shows anticipation, in which subsequent generations display earlier disease onsets due to intergenerational repeat expansion. For longer repeat lengths, somatic instability of the repeat size has been observed both in human cases at autopsy and in transgenic mouse models containing either a genomic fragment of human HD exon 1 (ref. 9) or an expanded repeat inserted into the endogenous mouse gene Hdh (ref. 10). With increasing repeat number, the protein changes conformation and becomes increasingly prone to aggregation, suggesting important functional correlations between repeat length and pathology. Because dinucleotide repeat instability is known to increase when the mismatch repair enzyme MSH2 is missing, we examined instability of the HD CAG repeat by crossing transgenic mice carrying exon 1 of human HD (ref. 16) with Msh2-/- mice. Our results show that Msh2 is required for somatic instability of the CAG repeat.

Towards practice development--a vision in reality or a reality without vision?

This paper describes the development of a conceptual framework for practice development. Drawing on the authors' combined experiences of facilitating developments in practice, a conceptual framework is proposed. It is argued that much practice development in health care today lacks a systematic approach and is often undertaken by individual practitioners who are poorly prepared for their roles. A short history of practice development is outlined to contextualize current development activities. The proposed framework is located in a critical social science philosophy and it is suggested that such a philosophy enables individual growth and development, empowerment of practitioners and the generation of cultural change that sustains continuous growth and innovation in practice. An example of the framework in use is described and recommendations proposed to enable organizations to embrace a systematic approach to practice development.

Instability of the CAG repeat in immortalized fibroblast cell cultures from Huntington's disease transgenic mice

Huntington's Disease transgenic mice were used for an exploration into the stability of a trinucleotide repeat. The brain shows heterogeneous somatic instability that increases quantitatively with age. To test somatic CAG-repeat alterations during long-term culture, DNA was extracted from transgenic tissue, primary fibroblasts, and SV40-immortalized fibroblasts at intervals of approximately 100 cell doublings. In fibroblasts derived from an adult mouse, there was an initial short truncation of the repeat, followed by an emerging population of cells showing continuous slow expansion. After 15 months in continuous culture (approximately 600 cell doublings following transformation) the major CAG peak has increased from 155 to approximately 170 triplets. This in vitro system can now be used to assay factors that affect instability.

An early-onset congenic strain of the motor neuron degeneration (mnd) mouse

The mouse mutant motor neuron degeneration (mnd/mnd) has been proposed as a model of neuronal ceroid lipofuscinosis (NCL) on the basis of widespread abnormal accumulating lipopigment and neuronal and retinal degeneration. Clinically, the mutant on a C57Bl/6 genetic background shows a progressive motor abnormality starting by 6 months of age, with death prior to 12 months. When mnd is outcrossed to the AKR/J genetic background, ca. 40% of the mnd/mnd F2 progeny show early onset (onset by 4.5-5 months and death by 7 months). A congenic strain of mnd has now been produced by eight generations of backcross onto the AKR background. Mice on this background show average onset at 4 months, and most are moribund prior to 5.5 months. The early onset appears to correlate with levels of abnormal accumulating material, and should prove useful in elucidating NCL neurodegenerative mechanisms.

Nursing staff's perceptions and experiences of primary nursing practice in intensive care 4 years on

This study explores the perceptions of staff who have been practising primary nursing for more than 4 years in intensive care. It considers what primary nursing is, what its benefits, disadvantages, and role impact are and other issues within an intensive care setting from the staff's perceptions and experiences. Although many of the perceived advantages and disadvantages are similar to experiences from other areas of nursing, there are some differences. The differences seem to relate to the way primary nursing is practised within the research setting-each primary nurse works with the same small team of associates, which is perceived as providing added benefits in terms of personal support and development of junior staff. The changes in role are seen to reflect other models in the literature which focus on becoming more patient centred and on working therapeutically. A number of future issues are addressed.

A conceptual framework for advanced practice: an action research project operationalizing an advanced practitioner/consultant nurse role

A preliminary conceptual framework for an advanced practice/consultant nurse role is presented which links the role to its context and outcomes. The conceptual framework was developed in the process of analysing data from a 3-year action research study involving the operationalization of an advanced practice/consultant nurse role in a Nursing Development Unit. The skills and knowledge base of consultancy, underpinned by a strong nursing foundation, augmented by strong leadership and combined with the educator and researcher functions, are presented as the attributes of the advanced practitioner/consultant nurse. The facilitation of a transformational culture is highlighted as central to the skills and processes used within the role. Implications for the preparation and accreditation of the advanced practitioner/consultant nurse are highlighted.

Seroprevalence of HIV infection in childbearing women in Nova Scotia

OBJECTIVE

To determine the prevalence of HIV-1 infection in childbearing women in Nova Scotia.

DESIGN

An anonymous, unlinked seroprevalence study using "leftover" cord bloods. The study was done in 2 stages: I-Halifax Co. women delivering between February 1, 1992 and December 31, 1993; II-non-Halifax Co. women delivering between November 15, 1993 and December 15, 1994.

RESULTS

Of 9,115 deliveries during stage I and 5,515 during stage II, specimens were tested from 8,864 (97.2%) and 5,219 (95%) respectively. Halifax Co. women were older, more often married and more often reported a STD than the non-Halifax Co. participants with 20% under age 20 reporting a history of STD. There was one EIA and WB positive result among Halifax Co. women (seroprevalence 1/10,000; 95% CI 0.03-6.29) and one EIA positive, WB indeterminant result among non-Halifax Co. women (seroprevalence 0/10,000; 95% CI 0-5.7).

CONCLUSION

There is a low prevalence of HIV infection among Nova Scotia childbearing women. However, a substantial number, especially those < age 20, reported a history of STD.

The development of swimming behavior in the neurological mutant weaver mouse

Weaver (wv/wv) mice have well-specified ontogenetic defects in both the cerebellum and striatum, but have not previously been evaluated systematically for patterns of motor development. In this study, the effects of the weaver mutation were evaluated through an examination of swimming behavior over the first 3 postnatal weeks. Detailed movement analyses of individual limb movements as well as interlimb coordination were used to evaluate the effects of the weaver mutation. Weaver mutant mice displayed a developmental lag in terms of swimming style relative to controls. They also displayed a generalized slowness in limb movements during the swim, which correlated with the developmental onset of use of a particular limb during the swim. However, basic motor patterns in weaver swimming continue to exhibit good overall coordination through the 3rd postnatal week, even though locomotor ataxia has become pronounced by this time. Our results indicate that specific and limited alterations in movement can be traced to very early in development (postnatal Day 3) in weaver mutant mice, a time at which the earliest biochemical and neuroanatomical deficits in these animals have been established. Our results also emphasize the need for systematic contextual analyses of movement to understand interlocking processes both in movement ontogeny and its disorders.

Job satisfaction of intensive care nurses practising primary nursing. A comparison with those practising total patient care

This study compares the job satisfaction experienced by intensive care nurses practising primary nursing with those who practised total patient care in an a earlier study using the same tool. Differences in the job aspects of; challenge, initiative, seeing work through, output/goals, knowledge and skills appear to be associated with the organisational approach. Some similarities exist between the two units-nurses gained most sense of achievement from: seeing patients improve, personal achievement, giving care and camaraderie. In both units nurses wanted greater opportunities for inter-professional involvement and decision-making. Primary nursing as an organisational approach may provide opportunities for increasing the amount of challenge, decision-making, opportunities for using initiative, seeing work through and subsequently job satisfaction in intensive care nursing. Further study of the job satisfaction of nurses practising primary nursing in ICU is recommended, but sizes and return rates need to be optimised.

Regulation of pelvic patch water flow in Bufo marinus: role of bladder volume and ANG II

This report examines the importance of bladder volume in regulating cutaneous water uptake (Jv, cm3.cm-2.s-1 x 10(-7)) across the ventral pelvic patch and examines the role of angiotensin II (ANG II) and circulation as the regulatory mechanism. Jv in empty-bladder Bufo marinus (bladder volume 3.89 +/- 1.49%, n = 7) was 1,671 +/- 68 (n = 7). Injection of Ringer solution into the bladder (12.8 +/- 2.2%, n = 7) decreased Jv to 1,025 +/- 202 (n = 7). ANG II injected into toads with filled bladders increased Jv in a dose-dependent manner. At 5 micrograms/100 g toad Jv increased by 136 +/- 63 (n = 6), at 50 micrograms/100 g toad by 432 +/- 82 (n = 7), and at 200 micrograms/100 g toad by 620 +/- 142 (n = 5). Saralasin (200 micrograms/100 g toad) completely inhibited the response to ANG II (50 micrograms/100 g toad) and at 1 mg/100 g toad decreased Jv in empty-bladder toads. These experiments indicate that 1) bladder volume participates in the regulation of Jv in the ventral pelvic patch; 2) ANG II increases the Jv in toads with full bladders; 3) saralasin inhibits the high Jv in empty bladder toads; 4) the high Jv, associated with an empty bladder, requires an intact circulation to be maintained; 5) without an intact circulation, the high water flow associated with an empty bladder causes the Na+ content of the tissue in the ventral patch to be reduced; and 6) ANG II causes only a minimal increases in water permeability in the isolated pelvic patch skin.