Kidney Transplantation Anastomotic Time Is Jointly Associated With Resident and Attending Experience

INTRODUCTION

Few studies evaluate the interplay of attending and resident learning curves in surgical education. Anastomotic time is known to be correlated with transplant outcomes in kidney transplantation. We aimed to evaluate the correlation between the combination of resident and attending experience and anastomotic time in kidney transplantation.

METHODS

We conducted a single-center retrospective cohort study of deceased donor kidney transplants from 2006 to 2019. To analyze the effect of attending and resident experience, dyads were classified as six combinations of early versus later practice attending and resident postgraduate year (PGY-2, PGY-3, and PGY-4/5). Attendings with less than 3 y of postfellowship practice were considered early practice. Linear mixed effects models tested the effects of attending experience, resident PGY, recipient body mass index, and technical operative characteristics (number of donor arteries, operative side) on anastomosis time.

RESULTS

The final linear mixed effects model included 1306 transplants. Compared to later practice attendings with PGY-4/5 residents as reference, early practice attendings paired with PGY-2 or PGY-3 residents had longer anastomotic times (P ≤ 0.005) when adjusted for recipient body mass index, number of donor arteries, and transplant side. When PGY-4/5 residents were paired with early practice attendings, no difference in anastomotic time was demonstrated. When paired with later practice attendings, PGY-2 residents had longer anastomotic times (P < 0.001) while PGY-3 anastomotic times did not differ from PGY-4/5.

CONCLUSIONS

This study demonstrates the correlation between trainee and attending experience jointly and anastomotic time, suggesting that pairing residents and attendings by experience may improve surgical training and potentially patient-related outcomes.

A2/A2B to B kidney transplantation outcomes: A single center 7-year experience

INTRODUCTION

Data on long-term outcomes following A2/A2B to B kidney transplants since the 2014 kidney allocation system (KAS) changes are few. The primary aim of this study is to report our 7-year experience with A2/A2B to B kidney transplants and to compare post-transplant outcomes of A2/A2B to a concurrent group of B to B kidney transplants. Additionally, the study evaluates the impact of pre-transplant anti-A1 titers on survival outcomes in A2/A2B transplants.

METHODS

This retrospective, single-center analysis included all adults who received A2/A2B to B deceased donor kidney transplants from December 2014 to June 2021 compared to B to B recipients. The effects of pre-transplant IgM/IgG titers, stratified as ≤1:8 and ≥1:16, on death-censored, rejection-free, and overall graft survival were tested.

RESULTS

Fifty-three A2/A2B and 114 B to B adults were included with a median follow-up time of 32 months. Overall graft survival, patient survival, and rejection-free graft survival did not differ between the two groups. There were no differences between the groups' overall kidney function values (p > .80) or their temporal trajectories (time by group interaction p > .11). Unadjusted death-censored graft survival was lower in A2/A2B to B compared to B recipients (p = .03), but the effect was not significant (p = .195) after adjusting for any readmissions (p = .96), rejection episodes (p < .001) or BK infection (p = .76). We did not detect an effect of pre-transplant titer group on death-censored (p = .59), rejection-free (p = .61), or overall graft survival (p = .26) CONCLUSIONS: A2/A2B to B kidney transplants have comparable overall patient and graft survival, rejection-free graft survival, and longitudinal renal function compared to B to B transplants at our center. Allograft survival outcomes were not significantly different between patients with low and high pre-transplant anti-A1 IgM/IgG titers.

Generating strategies for a national comeback in pancreas transplantation: A Delphi survey and US conference report

In the United States, potential transplant candidates with insulin-dependent diabetes mellitus are inconsistently offered pancreas transplantation (PTx), contributing to a dramatic decline in pancreas allograft utilization over the past 2 decades. The American Society of Transplantation organized a workshop to identify barriers inhibiting PTx and to develop strategies for a national comeback. The 2-day workshop focused on 4 main topics: (1) referral/candidate selection, (2) organ recovery/utilization, (3) program performance/patient outcomes, and (4) enhanced education/research. Topics were explored through expert presentations, patient testimonials, breakout sessions, and strategic planning, including the identification of tasks for immediate focus. Additionally, a modified-Delphi survey was conducted among workshop members to develop and rate the importance of barriers, and the impact and feasibility of workgroup-identified improvement strategies. The panelists identified 16 barriers to progress and 44 strategies for consideration. The steps for a national comeback in PTx involve greater emphasis on efficient referral and candidate selection, better donor pancreas utilization practices, eliminating financial barriers to procurement and transplant, improving collaboration between transplant and diabetes societies and professionals, and increasing focus on PTx training, education, and research. Partnership between national societies, patient advocacy groups, and professionals will be essential to realizing this critical agenda.

Characterizing the multi-dimensional reaction dynamics of dihalomethanes using XUV-induced Coulomb explosion imaging

Site-selective probing of iodine 4d orbitals at 13.1 nm was used to characterize the photolysis of CH2I2 and CH2BrI initiated at 202.5 nm. Time-dependent fragment ion momenta were recorded using Coulomb explosion imaging mass spectrometry and used to determine the structural dynamics of the dissociating molecules. Correlations between these fragment momenta, as well as the onset times of electron transfer reactions between them, indicate that each molecule can undergo neutral three-body photolysis. For CH2I2, the structural evolution of the neutral molecule was simultaneously characterized along the C-I and I-C-I coordinates, demonstrating the sensitivity of these measurements to nuclear motion along multiple degrees of freedom.

Rehybridization dynamics into the pericyclic minimum of an electrocyclic reaction imaged in real-time

Electrocyclic reactions are characterized by the concerted formation and cleavage of both σ and π bonds through a cyclic structure. This structure is known as a pericyclic transition state for thermal reactions and a pericyclic minimum in the excited state for photochemical reactions. However, the structure of the pericyclic geometry has yet to be observed experimentally. We use a combination of ultrafast electron diffraction and excited state wavepacket simulations to image structural dynamics through the pericyclic minimum of a photochemical electrocyclic ring-opening reaction in the molecule α-terpinene. The structural motion into the pericyclic minimum is dominated by rehybridization of two carbon atoms, which is required for the transformation from two to three conjugated π bonds. The σ bond dissociation largely happens after internal conversion from the pericyclic minimum to the electronic ground state. These findings may be transferrable to electrocyclic reactions in general.

Photoionization from the Xe 4d orbitals of XeF2

We present a comparison of the photoionization dynamics of the 4d shell of XeF₂ from threshold to 250 eV to those of the prototypical 4d shell of atomic Xe. The new experimental data include spin-orbit and ligand-field-resolved partial cross sections, photoelectron angular distributions, branching fractions, and lifetime widths for the 4d-hole states. The spin-orbit branching fractions and angular distributions are remarkably similar to the corresponding distributions from atomic Xe across a broad energy interval that includes both the intense shape resonance in the f continuum and a Cooper minimum in the same channel. The angular distributions and branching fractions are also in reasonably good agreement with our first-principles theoretical calculations on XeF₂. Data are also presented on the lifetime widths of the substate-resolved 4d-hole states of XeF₂. While the trends in the widths are similar to those in the earlier experimental and theoretical work, the linewidths are considerably smaller than in the previous measurements, which may require some reinterpretation of the decay mechanism. Finally, we present new data and an analysis of the Auger electron spectra for ionization above the 4d thresholds and resonant Auger spectra for several pre-edge features.

Conformer-specific photochemistry imaged in real space and time

[Figure: see text].

Anger and Sadness as Moral Signals

Three studies examined the relationship between emotions and moral judgment from an interpersonal perspective. In Studies 1 and 2, participants justified their decisions in sacrificial dilemmas to an imagined interlocutor. Linguistic analyses revealed that Don’t Sacrifice justifications contained more anger-related language than sadness-related language, whereas Sacrifice justifications contained roughly equal proportions of anger and sadness language. In Study 3, participants made character inferences about an actor who chose to/refused to sacrifice one person to save multiple people. We manipulated the actor’s ratio of anger to sadness. Participants rated the Don’t Sacrifice actor more negatively when they displayed high anger relative to sadness but rated the Sacrifice actor negatively whenever they exhibited high anger (independent of sadness). These data highlight novel ways in which actors and observers use emotions to complement the substance of a moral argument.

Survey of Clinician Opinions on Kidney Transplantation from Hepatitis C Virus Positive Donors: Identifying and Overcoming Barriers

Background

Transplant practices related to use of organs from Hepatitis C virus infected donors (DHCV+) is evolving rapidly.

Methods

We surveyed U.S. kidney transplant programs by email and professional society listserv postings between 7/19-1/20 to assess attitudes, management strategies, and barriers related to use of viremic (nucleic acid testing (NAT)+) donor organs in HCV uninfected recipients.

Results

Staff at 112 unique programs responded, representing 54% of U.S. adult kidney transplant programs and 69% of adult deceased donor kidney transplant volume in 2019. Most survey respondents were transplant nephrologists (46%) or surgeons (43%). Among responding programs, 67% currently transplant DHCV antibody+/NAT- organs under a clinical protocol or as standard of care. By comparison, only 58% offer DHCV NAT+ kidney transplant to HCV- recipients, including 35% under clinical protocols, 14% as standard of care, and 9% under research protocols. Following transplant of DHCV NAT+ organs to uninfected recipients, 53% start direct acting antiviral agent (DAA) therapy after discharge and documented viremia. Viral monitoring protocols after DHCV NAT+ to HCV uninfected recipient kidney transplantation varied substantially. 56% of programs performing these transplants report having an institutional plan to provide DAA treatment if declined by the recipient's insurance. Respondents felt a mean decrease in waiting time of ≥18 months (range 0-60) justifies the practice. Program concerns related to use of DHCV NAT+ kidneys include insurance coverage concerns (72%), cost (60%), and perceived risk of transmitting resistant infection (44%).

Conclusions

Addressing knowledge about safety and logistical/financial barriers related to use of DHCV NAT+ kidney transplantation for HCV uninfected recipients may help reduced discards and expand the organ supply.

Exploring patient willingness to accept hepatitis C-infected kidneys for transplantation

BACKGROUND

As organs infected with Hepatitis C virus (HCV) provide an opportunity to expand the donor pool, the primary aim of this study is to explore patient willingness to accept a kidney from HCV-infected donors compared to other high-risk donors.

METHODS

An anonymous, electronic survey was sent to all active kidney transplant waitlist patients at a single large volume transplant center. Patients were asked to respond to three hypothetical organ offers from the following: 1) HCV-infected donor 2) Donor with active intravenous drug use and 3) Donor with longstanding diabetes and hypertension.

RESULTS

The survey was sent to 435 patients of which 125 responded (29% response rate). While 86 out of 125 patients (69%) were willing to accept an HCV-infected kidney, only a minority of respondents were willing to accept a kidney from other high-risk donors. In contrast to other studies, by multivariable logistic regression, age and race were not associated with willingness to accept an HCV-infected kidney.

CONCLUSIONS

In this exploratory study, utilization of kidneys from HCV-infected donors to expand the donor pool appears to be an acceptable option to patients.

Non-invasive venous waveform analysis (NIVA) for volume assessment in patients undergoing hemodialysis: an observational study

BACKGROUND

Accurate assessment of volume status to direct dialysis remains a clinical challenge. Despite current attempts at volume-directed dialysis, inadequate dialysis and intradialytic hypotension (IDH) are common occurrences. Peripheral venous waveform analysis has recently been developed as a method to accurately determine intravascular volume status through algorithmic quantification of changes in the waveform that occur at different volume states. A noninvasive method to capture peripheral venous signals is described (Non-Invasive Venous waveform Analysis, NIVA). The objective of this proof-of-concept study was to characterize changes in NIVA signal with dialysis. We hypothesized that there would be a change in signal after dialysis and that the rate of intradialytic change in signal would be predictive of IDH.

METHODS

Fifty subjects undergoing inpatient hemodialysis were enrolled. A 10-mm piezoelectric sensor was secured to the middle volar aspect of the wrist on the extremity opposite to the access site. Signals were obtained fifteen minutes before, throughout, and up to fifteen minutes after hemodialysis. Waveforms were analyzed after a fast Fourier transformation and identification of the frequencies corresponding to the cardiac rate, with a NIVA value generated based on the weighted powers of these frequencies.

RESULTS

Adequate quality (signal to noise ratio > 20) signals pre- and post- dialysis were obtained in 38 patients (76%). NIVA values were significantly lower at the end of dialysis compared to pre-dialysis levels (1.203 vs 0.868, p < 0.05, n = 38). Only 16 patients had adequate signals for analysis throughout dialysis, but in this small cohort the rate of change in NIVA value was predictive of IDH with a sensitivity of 80% and specificity of 100%.

CONCLUSIONS

This observational, proof-of-concept study using a NIVA prototype device suggests that NIVA represents a novel and non-invasive technique that with further development and improvements in signal quality may provide static and continuous measures of volume status to assist with volume directed dialysis and prevent intradialytic hypotension.

An experimental and theoretical study of the C 1s ionization satellites in CH3I

The C 1s ionization spectrum of CH₃I has been studied both experimentally and theoretically. Synchrotron radiation has been employed to record polarization dependent photoelectron spectra at a photon energy of 614 eV. These spectra encompass the main-line due to the C 1s single-hole state and the peaks associated with the shake-up satellites. Vertical ionization energies and relative photoelectron intensities have been computed using the fourth-order algebraic-diagrammatic construction approximation scheme for the one-particle Green's function and the 6-311++G^** basis set. The theoretical spectrum derived from these calculations agrees qualitatively with the experimental results, thereby allowing the principal spectral features to be assigned. According to our calculations, two ²A₁ shake-up states of the C 1s^-1 σ_CI → σ_CI ^* type with singlet and triplet intermediate coupling of the electron spins (S' = 0, 1) play an important role in the spectrum and contribute significantly to the overall intensity. Both of these states are expected to have dissociative diabatic potential energy surfaces with respect to the C-I separation. Whereas the upper of these states perturbs the manifold of Rydberg states, the lower state forms a band which is characterized by a strongly increased width. Our results indicate that the lowest shake-up peak with significant spectral intensity is due to the pair (S' = 0, 1) of ²E (C 1s^-1 I 5p → σ_CI ^*) states. We predict that these ²E states acquire photoelectron intensity due to spin-orbit interaction. Such interactions play an important role here due to the involvement of the I 5p orbitals.

Introduction to CAUSES: Description of Weather and Climate Models and Their Near-Surface Temperature Errors in 5 day Hindcasts Near the Southern Great Plains

We introduce the Clouds Above the United States and Errors at the Surface (CAUSES) project with its aim of better understanding the physical processes leading to warm screen temperature biases over the American Midwest in many numerical models. In this first of four companion papers, 11 different models, from nine institutes, perform a series of 5 day hindcasts, each initialized from reanalyses. After describing the common experimental protocol and detailing each model configuration, a gridded temperature data set is derived from observations and used to show that all the models have a warm bias over parts of the Midwest. Additionally, a strong diurnal cycle in the screen temperature bias is found in most models. In some models the bias is largest around midday, while in others it is largest during the night. At the Department of Energy Atmospheric Radiation Measurement Southern Great Plains (SGP) site, the model biases are shown to extend several kilometers into the atmosphere. Finally, to provide context for the companion papers, in which observations from the SGP site are used to evaluate the different processes contributing to errors there, it is shown that there are numerous locations across the Midwest where the diurnal cycle of the error is highly correlated with the diurnal cycle of the error at SGP. This suggests that conclusions drawn from detailed evaluation of models using instruments located at SGP will be representative of errors that are prevalent over a larger spatial scale.

Training physiotherapy students to educate patients: A randomised controlled trial

OBJECTIVE

To determine the effect of a training intervention on physiotherapy students' self-efficacy and skills in the area of patient education.

METHODS

Final year physiotherapy students were randomised to an intervention group or a wait-list control group. The intervention group participated in a 3.5h training intervention about patient education that included video observation, simulated patient practice and structured feedback. The control group did not receive any training. Self-efficacy was assessed at baseline (T1) and after the intervention (or no intervention for the control group) (T2). Patient education performance was assessed by a blinded rater from a video-recorded standardised clinical examination.

RESULTS

83 students were randomised to the intervention group and 81 students to the control group. There were no differences in demographic variables or self-efficacy between groups at baseline. There was significant improvement in self-efficacy for the intervention group, but no change for the control group. The intervention group performed significantly better than the control group for nine of the eleven performance items, with significantly higher scores overall.

CONCLUSION

A training intervention enhances physiotherapy student self-efficacy and performance in patient education.

PRACTICE IMPLICATION

Use of patient education training is recommended to enhance student self-efficacy and performance.

The Impact of a Normoglycemic Management Protocol on Clinical Outcomes in the Trauma Intensive Care Unit

BACKGROUND

The purpose of this study was to determine if protocol-driven normoglycemic management in trauma patients affected glucose control, ventilator-associated pneumonia, surgical-site infection, and inpatient mortality.

METHODS

A prospective, consecutive-series, historically controlled study design evaluated protocol-driven normoglycemic management among trauma patients at Vanderbilt University Medical Center. Those mechanically ventilated > or =24 hours and > or =15 years of age were included. A glycemic-control protocol required insulin infusion therapy for glucose >110 mg/dL. Control patients included those who met criteria, were admitted the year preceding protocol implementation, and had hyperglycemia treated at the physician's discretion.

RESULTS

Eight hundred eighteen patients met study criteria; 383 were managed without protocol; 435 underwent protocol. The protocol group had lower glucose levels 7 of 14 days measured. After admission, both groups had mean daily glucose levels <150 mg/dL. No difference in pneumonia (31.6% vs 34.5%; p = .413), surgical infection (5.0% vs 5.7%; p = .645) or mortality (12.3% vs 13.1%; p = .722) occurred between groups. If one episode of blood glucose level was > or =150 mg/dL (n = 638; 78.0%), outcomes were worse: higher daily glucose levels for 14 days after admission (p < .001), pneumonia rates (35.9% vs 23.3%; p = .002), and mortality (14.6% vs 6.1%; p = .002). One or more days of glucose > or =150 mg/dL had a 2- to 3-fold increase in the odds of death. Protocol use in these patients was not associated with outcome improvement.

CONCLUSIONS

Protocol-driven management decreased glucose levels 7 of 14 days after admission without outcome change. One or more glucose levels > or =150 mg/dL were associated with worse outcome.

Continuous versus bolus tube feeds: Does the modality affect glycemic variability, tube feeding volume, caloric intake, or insulin utilization?

Introduction:

Enteral nutrition (EN) is very important to optimizing outcomes in critical illness. Debate exists regarding the best strategy for enteral tube feeding (TF), with concerns that bolus TF (BTF) may increase glycemic variability (GV) but result in fewer nutritional interruptions than continuous TF (CTF). This study examines if there is a difference in GV, insulin usage, TF volume, and caloric delivery among intensive care patients receiving BTF versus CTF. We hypothesize that there are no significant differences between CTF and BTF when comparing the above parameters.

Materials and Methods:

Prospective, randomized pilot study of critically ill adult patients undergoing percutaneous endoscopic gastrostomy (PEG) placement for EN was performed between March 1, 2012 and May 15, 2014. Patients were randomized to BTF or CTF. Glucose values, insulin use, TF volume, and calories administered were recorded. Data were organized into 12-h epochs for statistical analyses and GV determination. In addition, time to ≥80% nutritional delivery goal, demographics, Acute Physiology and Chronic Health Evaluation II scores, and TF interruptions were examined. When performing BTF versus CTF assessments, continuous parameters were compared using Mann–Whitney U-test or repeated measures t-test, as appropriate. Categorical data were analyzed using Fisher's exact test.

Results:

No significant demographic or physiologic differences between the CTF (n = 24) and BTF (n = 26) groups were seen. The immediate post-PEG 12-h epoch showed significantly lower GV and median TF volume for patients in the CTF group. All subsequent epochs (up to 18 days post-PEG) showed no differences in GV, insulin use, TF volume, or caloric intake. Insulin use for both groups increased when comparing the first 24 h post-PEG values to measurements from day 8. There were no differences in TF interruptions, time to ≥80% nutritional delivery goal, or hypoglycemic episodes.

Conclusions:

This study demonstrated no clinically relevant differences in GV, insulin use, TF volume or caloric intake between BTF and CTF groups. Despite some shortcomings, our data suggest that providers should not feel limited to BTF or CTF because of concerns for GV, time to goal nutrition, insulin use, or caloric intake, and should consider other factors such as resource utilization, ease of administration, and/or institutional/patient characteristics.

Age-related kidney transplant outcomes: health disparities amplified in adolescence

IMPORTANCE

The transition from pediatric to adult health care is a vulnerable time for patients with chronic conditions. We need to better understand the factors affecting the health of kidney transplant recipients during this transition.

OBJECTIVE

To determine the age at which renal transplant recipients are at greatest risk for graft loss.

DESIGN, SETTING, AND PARTICIPANTS

We performed a retrospective analysis of 168,809 first kidney-only transplant events from October 1987 through October 2010, in recipients up to age 55 years as reported by the Organ Procurement Transplantation Network Standard Transplant Analysis and Research Database. Recipient age at transplant was the primary predictor studied. Confounder and effect modifier covariates were identified and studied using Cox proportional hazard models.

EXPOSURE

Kidney-only transplant.

MAIN OUTCOMES AND MEASURES

Patient and renal graft survival, along with death-censored and non–death-censored information.

RESULTS

A total of 168,809 renal transplant events met the inclusion criteria. Recipients who received their first kidney transplant at age 14 to 16 years were at the highest risk of graft loss, with inferior outcomes starting at 1 and amplifying at 3, 5, and 10 years after transplant. Black adolescents were at disproportionately high risk of graft failure. The variables that had significant interaction with recipient age were donor type (deceased vs living) and insurance type (government vs private). Among 14-year-old recipients, the risk of death was 175% greater in the deceased donor–government insurance group vs the living donor–private insurance group (hazard ratio, 0.92 [95% CI, 0.90-0.94] vs 0.34 [95% CI, 0.33-0.36]), whereas patient survival rates in the living donor–government insurance and deceased donor–private insurance groups were nearly identical (hazard ratio, 0.61 [95% CI, 0.58-0.63] vs 0.54 [95% CI, 0.51-0.56]).

CONCLUSIONS AND RELEVANCE

Recipients aged 14 to 16 years have the greatest risk of kidney allograft failure. Black adolescents and those with government insurance are at even higher risk. Private insurance reduces risk of death across all ages. Comprehensive programs are needed for adolescents, especially for those at greater risk, to reduce graft loss during the transition from adolescence to adulthood.

Killer-cell immunoglobulin-like receptors and malaria caused by Plasmodium falciparum in The Gambia

The relevance of innate immune responses to Plasmodium falciparum infection, in particular the central role of natural killer (NK) cell-derived interferon gamma (IFN-γ), is becoming increasingly recognised. Recently, it has been shown that IFN-γ production in response to P. falciparum antigens is in part regulated by killer-cell immunoglobulin-like receptor (KIR) genes, and a study from malaria-exposed Melanesians suggested an association between KIR genotypes and susceptibility to infection. This prompted us to determine and compare the frequencies of 15 KIR genes in Gambian children presenting with either severe malaria (n = 133) or uncomplicated malaria (n = 188) and in cord-blood population control samples (n = 314) collected from the same area. While no significant differences were observed between severe and uncomplicated cases, proportions of individuals with KIR2DS2+C1 and KIR2DL2+C1 were significantly higher among malaria cases overall than in population control samples. In an exploratory analysis, activating KIR genes KIR2DS2, KIR3DS1 and KIR2DS5 were slightly higher in children in disease subgroups associated with the highest mortality. In addition, our data suggest that homozygosity for KIR genotype A might be associated with different malaria outcomes including protection from infection and higher blood parasitaemia levels in those that do get infected. These findings are consistent with a probable role of KIR genes in determining susceptibility to malaria, and further studies are warranted in different populations.

5/6 nephrectomy as a validated rat model mimicking human warfarin-related nephropathy

BACKGROUND/AIMS

We previously reported that patients with chronic kidney disease (CKD) receiving warfarin therapy and whose international normalized ratio increases to >3.0 may develop acute kidney injury (AKI) as a result of glomerular hemorrhage and formation of obstructive red blood cell (RBC) casts. We named this condition warfarin-related nephropathy (WRN). We also previously reported that acute excessive anticoagulation with brodifacoum (superwarfarin) induces AKI in 5/6 nephrectomy (5/6NE) rats. Limitations of the brodifacoum model precluded a careful assessment of dose-response relationships.

METHODS

Warfarin treatment was used in 5/6NE.

RESULTS

Herein we report that warfarin treatment of 5/6NE rats resulted in a dose-dependent increase in serum creatinine (SC). The increase in SC following warfarin treatment was greater at 3 and 19 weeks after the ablative surgery, than that observed 8 weeks after the ablative surgery. The SC increase was correlated with the prothrombin time increase. Morphologically, 5/6NE, but not control rats, had acute tubular injury with RBC and RBC casts in the tubules. Treatment with vitamin K prevented SC increase and morphologic changes in the kidney associated with warfarin treatment. A single episode of WRN did not affect the progression of CKD in 5/6NE.

CONCLUSION

(1) The 5/6NE model of CKD is an appropriate animal model to study the pathogenesis of WRN. (2) The pharmacokinetics of warfarin is better suited to the study of WRN than that of brodifacoum. (3) The more advanced stages of 5/6NE are more susceptible to WRN than the earlier stages. (4) Vitamin K treatment prevents WRN.

The effects of acrolein on the thioredoxin system: implications for redox-sensitive signaling

The reactive aldehyde acrolein is a ubiquitous environmental pollutant and is also generated endogenously. It is a strong electrophile and reacts rapidly with nucleophiles including thiolates. This review focuses on the effects of acrolein on thioredoxin reductase (TrxR) and thioredoxin (Trx), which are major regulators of intracellular protein thiol redox balance. Acrolein causes irreversible effects on TrxR and Trx, which are consistent with the formation of covalent adducts to selenocysteine and cysteine residues that are key to their activity. TrxR and Trx are more sensitive than some other redox-sensitive proteins, and their prolonged inhibition could disrupt a number of redox-sensitive functions in cells. Among these effects are the oxidation of peroxiredoxins and the activation of apoptosis signal regulating kinase (ASK1). ASK1 promotes MAP kinase activation, and p38 activation contributes to apoptosis and a number of other acrolein-induced stress responses. Overall, the disruption of the TrxR/Trx system by acrolein could be significant early and prolonged events that affect many aspects of redox-sensitive signaling and oxidant stress.

P01-226-Line item analysis in paediatric patients with bipolar I disorder treated with aripiprazole

Introduction

Aripiprazole has demonstrated efficacy for the treatment of paediatric patients (10–17 years) with a manic or mixed episode associated with bipolar I disorder in a clinical trial that utilised the Young Mania Rating Scale (YMRS) Total score as the primary outcome measure.

Objectives/aim

This analysis evaluated the profile of discrete symptom response using the YMRS and other measures.

Methods

Post-hoc analysis of individual items of the YMRS and the parent or subject version of the General Behaviour Inventory (GBI) Mania and Depression scales using data from a 4-week, double-blind, randomised trial that compared aripiprazole (10 or 30 mg/day, n = 197) with placebo (n = 99).

Results

In total, 296 patients were randomised; 80% completed the study. Significant decreases at Week 4 (p < 0.05) were seen in eight YMRS items: elevated mood, increased motor activity/energy, need for sleep, irritability, speech (rate and amount), language/thought disorder, abnormal thought content and disruptive/aggressive behaviour. For the GBI, effect sizes for parent-reported mania items were medium to large (for example, 0.41 for ‘depressed but high energy’ to 0.78 for ‘rage combined with unusually happy’) but were consistently small on subject self-reported items of mania and depression and, for the overall scale, had the poorest agreement with clinician ratings.

Conclusions

Aripiprazole demonstrated improvements in some of the more troublesome symptoms of paediatric patients with bipolar I disorder experiencing an acute manic or mixed episode. Of note, irritability and aggression showed large treatment effects on both clinician and parent-reported measures, but less so for subject-reported measures.

Effect of aripiprazole adjunctive to antidepressants on sexual functioning: A subgroup analysis of a 52-week open-label safety study (CN138–164)

Introduction

This presentation addresses impacts of adjunctive aripiprazole (AA) in major depressive disorder (MDD).

Objective

Assess impacts of long-term (≤52 weeks) open-label AA to ADT on efficacy, sexual function and weight change in MDD.

Methods

Data were analyzed post-hoc from de novo patients enrolled in an open-label safety study of AA after inadequate response to one or more ADT. Three ADT classes were included: SSRIs, SNRIs, and a noradrenaline-dopamine reuptake inhibitor, bupropion.

Global well-being with AA was assessed (mean change in CGI-S score from baseline by ADT). Sexual functioning was assessed by Sexual Function Inventory (SFI) items: interest in sex, sexual arousal, achievement of orgasm, erection maintenance and sexual satisfaction. Item 6 captured change in the overall improvement score. Weight change at Week 52 (last observation carried forward) was assessed.

Results

Overall mean change in CGI-S (n = 285) by Week 52 was -1.5. Mean changes in CGI-S from baseline scores (4.2-4.4) were: escitalopram (n=64) -1.5, venlafaxine XL (n = 48) -1.4, sertraline (n = 39) -1.7, fluoxetine (n = 41) -1.3, paroxetine or CR (n = 37) -1.5 and bupropion XL or SR (n = 46) -1.4. Improvements on SFI items (n = 155) ranged from -0.2 (sexual satisfaction) to -0.6 (interest in sex and orgasm). Mean overall improvement score (3.8) indicated mild-to-moderate sexual dysfunction. All AA groups experienced a mean weight increase (range +1.8 kg [sertraline] to +3.3 kg [fluoxetine]).

Conclusions

AA moderately improved CGI-S scores (to a similar degree) when added to three different classes of ADTs. Sexual functioning in patients on ADT modestly improved after adding aripiprazole to ADT.

Validation studies from the Western Australian Congenital Malformations Registry

A series of studies was undertaken in 1989 to validate the data held by the Western Australian Congenital Malformations Registry. Comparison with hospital discharge data identified 1585 children six years of age or younger with malformations discharged from hospitals in Western Australia in 1986, 226 of whom were not already recorded on the Congenital Malformations Register. When the records of a special register for cleft lip and palate were examined, all cases of facial cleft known to the special register were also recorded on the Malformations Register. Comparison of the Western Australian data for major groups of malformations with data from the South Australian Birth Defects Register raised the possibility of under ascertainment in Western Australia of cases of congenital heart disease. Multiple sources of ascertainment and evaluation of the ways in which such sources are tapped are important factors in striving for complete and accurate information on congenital malformations for research and public health purposes.

Follow up and evaluation of the Victorian first-trimester combined screening programme for Down syndrome and trisomy 18

OBJECTIVE

The objective of this study was to follow up and evaluate the statewide first-trimester combined screening programme for Down syndrome and trisomy 18 at Genetic Health Services Victoria, Australia.

DESIGN

Retrospective population cohort.

SETTING

Maternal Serum Screening Laboratory records.

SAMPLE

All women screened between February 2000 and June 2002 (16,153 pregnancies).

METHODS

Screening results were matched to Victorian perinatal and birth defect data via record linkage, with an ascertainment of 96.8% of pregnancy outcomes. Manual follow up with health professionals increased ascertainment to more than 99%.

MAIN OUTCOME MEASURES

Fetal Down syndrome or trisomy 18, and combined screen results, to calculate test characteristics.

RESULTS

Using a risk threshold of 1 in 300 at time of ultrasound, the sensitivities for standard first-trimester combined screening and augmented 13-week combined screening for Down syndrome were 87.3 and 90.5% and the false-positive rates (FPR) were 4.1 and 3.9%, respectively. The sensitivity for trisomy 18 was 66.7% (10/15, 95% CI 42.8-90.5%) with a 0.4% FPR and 15.2% positive predictive value (1 in 250 risk threshold).

CONCLUSIONS

The combined use of record linkage and manual follow-up techniques was effective in ascertaining more than 99% of pregnancy outcomes for calculations of accurate test characteristics of the combined screen. The sensitivity for Down syndrome at Genetic Health is comparable to similar populations. However, the sensitivity for trisomy 18 is lower than that elsewhere, which may reflect the overall low birth prevalence of trisomy 18 and associated small numbers in this particular cohort.

Development of computational models for the purpose of conducting individual livestock and premises traceback investigations utilizing National Animal Identification System-compliant data

Many of the efforts surrounding the development of the National Animal Identification System have encompassed the identification of livestock production and handling premises as well as individuals or herds of animals, whereas little effort has been directed toward the ultimate goal of animal traceback within 48 h. A mock data set representative of the Colorado cattle population was created for modeling of cattle traceability. Using this data set, algorithms were developed to complete rapid and accurate traceback and traceforward of animals or premises or both. On July 19, 2005, the Colorado Department of Public Health and Environment, in conjunction with the Colorado Department of Agriculture, conducted a test exercise pertaining to homeland security. The exercise team randomly identified animal number 926,583 (of the 2 million total animals) as a potentially infected animal of interest and requested a traceback of this animal. Traceback was accomplished in 215 s, and 540 primary coresident animals were identified. However, due to animal movements, the number of coresidents (animals exposed, directly or indirectly, to the animal of interest) expanded with coresidency level (level 1 = direct contact; level 2 = direct contact with an animal that had direct contact with the animal of interest; level 3 = direct contact with an animal that had contact with an animal that had direct contact with the animal of interest, etc.) to more than 1.2 million coresidents at level 4, and more than 90% of all animals identified as a coresident at some level. In addition to the coresidency results, the premises containing the coresidents were identified and sorted by the number of coresidents. Because of animal movement, all 19,391 premises included in the data set had coresidents at some level. This exercise demonstrated the capability of the developed algorithms to complete rapid traceback and the complexity of the resulting animal traceback output.

Decompression illness presenting as breast pain

We present two cases of decompression illness in women in whom the initial symptom causing distress after completion of the dives was breast pain. Both women were also subsequently found to have a patent foramen ovale. We postulate that breast pain may be an unusual under-recognized manifestation of decompression illness.

Diving accidents in sports divers in Orkney waters

Scapa Flow in Orkney is one of the major world centres for wreck diving. Because of the geography of Orkney and the nature of the diving, it is possible to make relatively accurate estimates of the number of dives taking place. The denominator of dive activity allows the unusual opportunity of precise calculation of accident rates. In 1999, one in every 178 sports divers visiting Orkney was involved in a significant accident, in 2000 the figure was one in 102. Some of these accidents appear to have been predictable and could be avoided by better education and preparation of visiting divers.

Nursing the patient with severe communication impairment

BACKGROUND

Effective communication with patients is critical to effective nursing practice. Surprisingly, there is little information on nurses' experiences in caring for patients who are unable to speak.

PURPOSE AND METHOD

This study provides descriptive information from interviews with 20 nurses who cared for patients with severe communication impairment. The interview protocol explored positive and negative experiences of nursing patients with severe communication impairment. Frequency counts and descriptive analyses were conducted to identify the major themes emerging from the interviews.

RESULTS

The results suggest that nurse-patient communication is difficult when the patient has severe communication impairment, although some nurses discovered effective strategies to facilitate communication with such patients. Many of the difficulties could be viewed as a breakdown in understanding arising from the lack of a readily interpretable communication system that could be used by nurse and patient.

CONCLUSIONS

The results suggest a need for training nurses in the use of alternative modes of communication. Nurses also need access to a variety of simple augmentative communication devices for use with patients who are unable to speak. Finally, nurses should collaborate with speech pathologists on the development of preadmission information and bedside training for people who are admitted to hospital with severe communication impairment.

The effect of anti-alpha4 integrin antibody on brain lesion activity in MS. The UK Antegren Study Group

OBJECTIVE

To determine the effect of humanized monoclonal antibody against alpha4 integrin (reactive with alpha4beta1 integrin or very-late antigen-4) on MRI lesion activity in MS.

METHODS

A randomized, double-blind, placebo-controlled trial in 72 patients with active relapsing-remitting and secondary progressive MS was performed. Each patient received two IV infusions of anti-alpha4 integrin antibody (natalizumab; Antegren) or placebo 4 weeks apart and was followed up for 24 weeks with serial MRI and clinical assessment.

RESULTS

The treated group exhibited significantly fewer new active lesions (mean 1.8 versus 3.6 per patient) and new enhancing lesions (mean 1.6 versus 3.3 per patient) than the placebo group over the first 12 weeks. There was no significant difference in the number of new active or new enhancing lesions in the second 12 weeks of the study. The number of baseline-enhancing lesions (i.e., lesions that enhanced on the baseline scan) that continued to enhance 4 weeks following the first treatment was not significantly different between the two groups. The number of patients with acute MS exacerbations was not significantly different in the two groups during the first 12 weeks (9 in the treated group versus 10 in placebo) but was higher in the treatment group in the second 12 weeks (14 versus 3; p = 0.005). The study was not, however, designed to look definitively at the effect of treatment on relapse rate. Treatment was well tolerated.

CONCLUSIONS

Short-term treatment with monoclonal antibody against alpha4 integrin results in a significant reduction in the number of new active lesions on MRI. Further studies will be required to determine the longer term effect of this treatment on MRI and clinical outcomes.

Melatonin secretion and puberty in female lambs exposed to environmental electric and magnetic fields

This study determined whether chronic exposure of female lambs to the electric and magnetic fields (EMF) of a high voltage transmission line can alter pineal secretion of melatonin and the normal occurrence of puberty. Twenty female Suffolk lambs were assigned randomly in equal numbers to a control and a treatment group. Treatment from 2 to 10 mo of age consisted of continuous exposure within the electrical environment of a 500-kV transmission line (mean electric field 6 kV/m, mean magnetic field 40 mG). Treated lambs were penned directly beneath the transmission line; control lambs were maintained in a pen of similar construction 229 m from the line where EMF were at ambient levels (mean electric field < 10 V/m, mean magnetic field < 0.3 mG). Melatonin was analyzed by RIA in serum of blood samples collected at 0.5-3-h intervals over eight 48-h periods. To assess attainment of puberty, serum concentrations of progesterone were determined by RIA from blood samples collected twice weekly beginning at 19 wk of age. Concentrations of circulating melatonin in control and treated lambs were low during daylight hours and increased during nighttime hours. The characteristic pattern of melatonin secretion during nighttime (amplitude, phase, and duration) did not differ between control and treatment groups. Age at puberty and number of subsequent estrous cycles also did not differ between groups. These data suggest that chronic exposure of developing female sheep to 60-Hz environmental EMF does not affect the mechanisms underlying the generation of the circadian pattern of melatonin secretion or the mechanisms involved in the onset of reproductive activity.

Congenital malformations in aborigines and non-aborigines in Western Australia, 1980-1987

A comparison of congenital malformations in Aboriginal and non-Aboriginal children in Western Australia has been made by means of data from the WA Congenital Malformations Registry, for births from 1980 to 1987 inclusive. Although the birth prevalence of all malformations was 3.5% for both Aboriginal and non-Aboriginal infants, significant differences were found in the birth prevalence of some individual malformations. Nervous-system and cardiovascular defects, and cleft lip and palate were significantly more prevalent in Aborigines, and pyloric stenosis and urogenital defects were significantly less prevalent. While some of the observed differences may have been a result of biases in ascertainment, others are likely to represent true differences. A discussion of Aboriginal beliefs concerning conception and birth is included, in order that the quantitative findings from the study might be considered in an appropriate cultural setting.

Job sharing. Part 1

This article is the first of a three part series discussing the impact of nurses job sharing at University Hospital, London, Ontario. This first article explores the advantages and disadvantages of job sharing for staff nurses and their supervising nurse manager, as discussed in the literature. The results of a survey conducted on a unit with a large number of job sharing positions, concur with literature findings. The second article will present the evaluation of a pilot project in which two nurses job share a first line managerial position in the Operating Room. The third article will relate the effects of job sharing on women's perceived general well being. Job sharing in all areas, is regarded as a positive experience by both nurse and administrators.

Nitrous oxide: cardiovascular effects in infants and small children during halothane and isoflurane anesthesia

Two-dimensional and pulsed Doppler echocardiography were used to measure cardiovascular function in 31 unmedicated infants and small children. In 15 patients, the cardiovascular effects of equipotent levels of halothane were compared with and without N2O. In 16 patients, the cardiovascular effects of isoflurane with and without N2O were compared. Prior to anesthesia induction, cardiovascular measurements of heart rate (HR), mean blood pressure (MBP), and two-dimensional and pulsed Doppler echocardiography were recorded. The echocardiographic measurements were used to determine cardiac output (CO), stroke volume (SV), ejection fraction (EF), and left ventricular end-diastolic and end-systolic volume (LVEDV and LVESV). Twenty minutes after mask inhalation induction with halothane or isoflurane with N2O and O2 (3:2 liters/min), cardiovascular measurements were repeated with end-expired halothane or isoflurane maintained at 0.9 MAC. A third set of cardiovascular data was collected 10 minutes after the discontinuation of N2O, with inspired isoflurane or halothane levels in O2 (5 liters/min) increased to maintain 1.5 MAC end-expired levels. Ventilation was controlled throughout the study period and the study was completed before intubation and the start of elective surgery. Heart rate and MBP decreased to similar degrees below awake levels in both patient groups during N2O with halothane or isoflurane. When N2O was discontinued and end-expired levels of halothane or isoflurane increased, MBP remained at levels observed during N2O-O2 with halothane or isoflurane. Heart rate increased during isoflurane in O2. Cardiac output decreased significantly and similarly below awake levels during both halothane of isoflurane with and without N2O.