A mixed-method study exploring barriers and facilitators to midwives' mental health in Ontario

BACKGROUND

There is a paucity of information regarding the mental health of midwives working in Ontario, Canada. Many studies have investigated midwives' mental health around the world, but little is known about how the model of midwifery care in Ontario contributes to or negatively impacts midwives' mental health. The aim of the study was to gain a deeper understanding of factors that contribute to and negatively impact Ontario midwives' mental health.

METHODS

We employed a mixed-methods, sequential, exploratory design, which utilized focus groups and individual interviews, followed by an online survey. All midwives in Ontario who had actively practiced within the previous 15 months were eligible to participate.

FINDINGS

We conducted 6 focus groups and 3 individual interviews, with 24 midwives, and 275 midwives subsequently completed the online survey. We identified four broad factors that impacted midwives' mental health: (1) the nature of midwifery work, (2) the remuneration model, (3) the culture of the profession, and (4) external factors.

DISCUSSION

Based on our findings and the existing literature, we have five broad recommendations for improving Ontario midwives' mental health: (1) provide a variety of work options for midwives; (2) address the impacts of trauma on midwives; (3) make mental health services tailored for midwives accessible; (4) support healthy midwife-to-midwife relationships; and (5) support improved respect and understanding of midwifery.

CONCLUSION

As one of the first comprehensive investigations into midwives' mental health in Ontario, this study highlights factors that contribute negatively to midwives' mental health and offers recommendations for how midwives' mental health can be improved systemically.

Lyme borreliosis in pregnancy and associations with parent and offspring health outcomes: An international cross-sectional survey

Background

Lyme disease (LD) is a complex tick-borne pathology caused by Borrelia burgdorferi sensu lato bacteria. Currently, there are limited data regarding the health outcomes of people infected during pregnancy, the potential for perinatal transmission to their fetus, and the long-term effects on these children. Therefore, the primary objective of this survey study was to investigate the impact of LD in pregnancy on both the parent and their offspring.

Methods

A seven-section survey was developed and administered in REDCap. Although recruitment was primarily through LD-focused organizations, participation was open to anyone over the age of 18 who had been pregnant. Participant health/symptoms were compared across those with “Diagnosed LD,” “Suspected LD,” or “No LD” at any time in their lives. The timing of LD events in the participants’ histories (tick bite, diagnosis, treatment start, etc.) were then utilized to classify the participants’ pregnancies into one of five groups: “Probable Treated LD,” “Probable Untreated LD,” “Possible Untreated LD,” “No Evidence of LD,” and “Unclear.”

Results

A total of 691 eligible people participated in the survey, of whom 65% had Diagnosed LD, 6% had Suspected LD, and 29% had No LD ever. Both the Diagnosed LD and Suspected LD groups indicated a high symptom burden (p < 0.01). Unfortunately, direct testing of fetal/newborn tissues for Borrelia burgdorferi only occurred following 3% of pregnancies at risk of transmission; positive/equivocal results were obtained in 14% of these cases. Pregnancies with No Evidence of LD experienced the fewest complications (p < 0.01) and were most likely to result in a live birth (p = 0.01) and limited short- and long-term offspring pathologies (p < 0.01). Within the LD-affected pregnancy groups, obtaining treatment did not decrease complications for the parent themselves but did ameliorate neonatal health status, with reduced rates of rashes, hypotonia, and respiratory distress (all p < 0.01). The impact of parent LD treatment on longer-term child outcomes was less clear.

Conclusion

Overall, this pioneering survey represents significant progress toward understanding the effects of LD on pregnancy and child health. A large prospective study of pregnant people with LD, combining consistent diagnostic testing, exhaustive assessment of fetal/newborn samples, and long-term offspring follow-up, is warranted.

Knowledge of US Midwifery Credentials Among Members of the American College of Nurse-Midwives

INTRODUCTION

Three midwifery credentials are granted in the United States: certified nurse-midwife (CNM), certified midwife (CM), and certified professional midwife (CPM). Confusion about US midwifery credentials may restrict growth of the midwifery profession. This survey assessed American College of Nurse-Midwives (ACNM) members' knowledge of US midwifery credentials.

METHODS

ACNM members (N = 7551) were surveyed via email in 2017. The survey asked respondents to report demographic information and to identify correct statements about the education, certification, and scope of practice of CNMs, CMs, and CPMs. Responses to 17 items about all midwives certified in the United States, a 5-item subset specific to CNMs/CMs, and one item related to location of midwifery practice by credential were analyzed.

RESULTS

Nearly a quarter of the membership (22.1%) responded to the survey. Higher scores on the survey indicated greater identification of correct statements about the education, certification, scope, and location of practice of CNMs, CMs, and CPMs. Significant differences in scores were found among ACNM members based on their level of education, degree of professional involvement in midwifery, and prior practice as a nurse. ACNM members with higher scores on the survey held a doctorate, worked in Region I, and had greater professional leadership involvement in midwifery organizations. Participants with less nursing experience prior to their midwifery education also scored significantly higher on the survey.

DISCUSSION

Although two-thirds of respondents correctly answered items on the preparation, credentialing, and scope of practice of CNMs, CMs, and CPMs, a significant minority had gaps in knowledge. Results of this survey suggest the need for outreach about US midwifery credentials. Future research to replicate and expand upon this survey may benefit the profession of midwifery in the United States.

Dlx5 and Dlx6 can antagonize cell division at the G1/S checkpoint

Background

Dlx5 and Dlx6 stimulate differentiation of diverse progenitors during embryonic development. Their actions as pro-differentiation transcription factors includes the up-regulation of differentiation markers but the extent to which differentiation may also be stimulated by regulation of the cell cycle has not been addressed.

Results

We document that expression of Dlx5 and Dlx6 antagonizes cell proliferation in a variety of cell types without inducing apoptosis or promoting cell cycle exit. Rather, a variety of evidence indicates that elevated Dlx5 and Dlx6 expression reduces the proportion of cells in S phase and affects the length of the cell cycle.

Conclusions

Antagonism of S-phase entry by Dlx5 and Dlx6 proteins likely represents a lineage-independent function to effect Dlx-mediated differentiation in multiple progenitor cell types.

Exploring the Potential of Participatory Theatre to Reduce Stigma and Promote Health Equity for Lesbian, Gay, Bisexual, and Transgender (LGBT) People in Swaziland and Lesotho

Stigma and discrimination affecting lesbian, gay, bisexual, and transgender (LGBT) people compromise health and human rights and exacerbate the HIV epidemic. Scant research has explored effective LGBT stigma reduction strategies in low- and middle-income countries. We developed and pilot-tested a participatory theatre intervention (PTI) to reduce LGBT stigma in Swaziland and Lesotho, countries with the world's highest HIV prevalence. We collected preliminary data from in-depth interviews with LGBT people in Lesotho and Swaziland to enhance understanding of LGBT stigma. Local LGBT and theatre groups worked with these data to create a 2-hour PTI composed of three skits on LGBT stigma in health care, family, and community settings in Swaziland (Manzini) and Lesotho (Maseru, Mapoteng). Participants ( n = 106; nursing students, health care providers, educators, community members) completed 12 focus groups following the PTI. We conducted thematic analysis to understand reactions to the PTI. Focus groups revealed the PTI increased understanding of LGBT persons and issues, increased empathy, and fostered self-reflection of personal biases. Increased understanding included enhanced awareness of the negative impacts of LGBT stigma, and of LGBT people's lived experiences and issues. Participants discussed changes in attitude and perspective through self-reflection and learning. The format of the theatre performance was described as conducive to learning and preferred over more conventional educational methods. Findings indicate changed attitudes and awareness toward LGBT persons and issues following a PTI in Swaziland and Lesotho. Stigma reduction interventions may help mitigate barriers to HIV prevention, treatment, and care in these settings with a high burden of HIV.

Greater retention in care among adolescents on antiretroviral treatment accessing "Teen Club" an adolescent-centred differentiated care model compared with standard of care: a nested case-control study at a tertiary referral hospital in Malawi

Introduction

There are numerous barriers to the care and support of adolescents living with HIV (ALHIV) that makes this population particularly vulnerable to attrition from care, poor adherence and virological failure. In 2010, a Teen Club was established in Zomba Central Hospital (ZCH), Malawi, a tertiary referral HIV clinic. Teen Club provides ALHIV on antiretroviral treatment (ART) with dedicated clinic time, sexual and reproductive health education, peer mentorship, ART refill and support for positive living and treatment adherence. The purpose of this study was to evaluate whether attending Teen Club improves retention in ART care.

Methods

We conducted a nested case–control study with stratified selection, using programmatic data from 2004 to 2015. Cases (ALHIV not retained in care) and controls (ALHIV retained in care) were matched by ART initiation age group. Patient records were reviewed retrospectively and subjects were followed starting in March 2010, the month in which Teen Club was opened. Follow‐up ended at the time patients were no longer considered retained in care or on 31 December 2015. Cases and controls were drawn from a study population of 617 ALHIV. Of those, 302 (48.9%) participated in at least two Teen Club sessions. From the study population, 135 (non‐retained) cases and 405 (retained) controls were selected.

Results

In multivariable analyses, Teen Club exposure, age at the time of selection and year of ART initiation were independently associated with attrition. ALHIV with no Teen Club exposure were less likely to be retained than those with Teen Club exposure (adjusted odds ratio (aOR) 0.27; 95% CI 0.16, 0.45) when adjusted for sex, ART initiation age, current age, reason for ART initiation and year of ART initiation. ALHIV in the age group 15 to 19 were more likely to have attrition from care than ALHIV in the age group 10 to 14 years of age (aOR 2.14; 95% CI 1.12, 4.11).

Conclusions

This study contributes to the limited evidence evaluating the effectiveness of service delivery interventions to support ALHIV within healthcare settings. Prospective evaluation of the Teen Club package with higher methodological quality is required for programmes and governments in low‐ and middle‐income settings to prioritize interventions for ALHIV and determine their cost‐effectiveness.

Missed opportunities: Do states require screening of children for health conditions that interfere with learning?

METHODS

Investigators reviewed websites of state departments of health and education, and legislation for all 50 states and DC. For states with mandated screenings and a required form, investigators applied structured analysis to assess HBL inclusion.

RESULTS

No state mandated that schools require screening for all 7 HBLs. Less than half (49%) required comprehensive school health examinations and only 12 states plus DC required a specific form. Of these, 12 of the forms required documentation of vision screening, 11 of hearing screening, and 12 of dental screening. Ten forms asked about asthma and 9 required documentation of lead testing. Seven asked about general well-being, emotional problems, or mental health. None addressed hunger. When including states without comprehensive school health examination requirements, the most commonly required HBL screenings were for vision (80% of states; includes DC), hearing (75% of states; includes DC) and dental (24% of state; includes DC).

CONCLUSION

The lack of state mandated requirements for regular student health screening represents a missed opportunity to identify children with HBLs. Without state mandates, accompanying comprehensive forms, and protocols, children continue to be at risk of untreated health conditions that can undermine their success in school.

Do personality traits assessed on medical school admission predict exit performance? A UK-wide longitudinal cohort study

Traditional methods of assessing personality traits in medical school selection have been heavily criticised. To address this at the point of selection, "non-cognitive" tests were included in the UK Clinical Aptitude Test, the most widely-used aptitude test in UK medical education (UKCAT: http://www.ukcat.ac.uk/ ). We examined the predictive validity of these non-cognitive traits with performance during and on exit from medical school. We sampled all students graduating in 2013 from the 30 UKCAT consortium medical schools. Analysis included: candidate demographics, UKCAT non-cognitive scores, medical school performance data-the Educational Performance Measure (EPM) and national exit situational judgement test (SJT) outcomes. We examined the relationships between these variables and SJT and EPM scores. Multilevel modelling was used to assess the relationships adjusting for confounders. The 3343 students who had taken the UKCAT non-cognitive tests and had both EPM and SJT data were entered into the analysis. There were four types of non-cognitive test: (1) libertariancommunitarian, (2) NACE-narcissism, aloofness, confidence and empathy, (3) MEARS-self-esteem, optimism, control, self-discipline, emotional-nondefensiveness (END) and faking, (4) an abridged version of 1 and 2 combined. Multilevel regression showed that, after correcting for demographic factors, END predicted SJT and EPM decile. Aloofness and empathy in NACE were predictive of SJT score. This is the first large-scale study examining the relationship between performance on non-cognitive selection tests and medical school exit assessments. The predictive validity of these tests was limited, and the relationships revealed do not fit neatly with theoretical expectations. This study does not support their use in selection.

Minority Stress and Safer Sex Practices Among Sexual Minority Women in Toronto, Canada: Results from a Cross-Sectional Internet-Based Survey

PURPOSE

Sexual stigma is a chronic stressor that enhances vulnerability to mental health disparities among lesbian, gay, bisexual, and queer people. Sexual stigma has also been associated with reduced uptake of safer sex practices, such as condom use, among gay and bisexual men. Scant research has examined the relationship between sexual stigma and safer sex practices among sexual minority women (SMW), including lesbian, bisexual, and queer women.

METHODS

We explored associations between sexual stigma and safer sex practices among SMW. We also tested the interaction between sexual stigma, social support, and resilient coping in this relationship. A cross-sectional internet-based survey was administered to SMW in Toronto, Canada.

RESULTS

Among 388 participants with complete measurement data, simple linear regression indicated both perceived and enacted sexual stigma were positively associated with uptake of safer sex practices. In multivariable analyses, significant interactions were found between perceived sexual stigma and resilient coping, and between enacted sexual stigma and social support. At low levels of resilient coping, higher levels of perceived sexual stigma were associated with fewer safer sex practices, while at high levels of resilient coping the relationship was reversed. At low levels of social support, higher levels of enacted sexual stigma were associated with fewer safer sex practices, while at high levels of social support the relationship was reversed.

CONCLUSIONS

These findings document complex relationships between sexual stigma dimensions, coping, social support, and safer sex practices. Understanding the role these variables play in uptake of safer sex practices can inform sexual health interventions tailored for SMW.

Does the UKCAT predict performance on exit from medical school? A national cohort study

OBJECTIVES

Most UK medical programmes use aptitude tests during student selection, but large-scale studies of predictive validity are rare. This study assesses the UK Clinical Aptitude Test (UKCAT: http://www.ukcat.ac.uk), and 4 of its subscales, along with individual and contextual socioeconomic background factors, as predictors of performance during, and on exit from, medical school.

METHODS

This was an observational study of 6294 medical students from 30 UK medical programmes who took the UKCAT from 2006 to 2008, for whom selection data from the UK Foundation Programme (UKFPO), the next stage of UK medical education training, were available in 2013. We included candidate demographics, UKCAT (cognitive domains; total scores), UKFPO Educational Performance Measure (EPM) and national exit situational judgement test (SJT). Multilevel modelling was used to assess relationships between variables, adjusting for confounders.

RESULTS

The UKCAT-as a total score and in terms of the subtest scores-has significant predictive validity for performance on the UKFPO EPM and SJT. UKFPO performance was also affected positively by female gender, maturity, white ethnicity and coming from a higher social class area at the time of application to medical school An inverse pattern was seen for a contextual measure of school, with those attending fee-paying schools performing significantly more weakly on the EPM decile, the EPM total and the total UKFPO score, but not the SJT, than those attending other types of school.

CONCLUSIONS

This large-scale study, the first to link 2 national databases-UKCAT and UKFPO, has shown that UKCAT is a predictor of medical school outcome. The data provide modest supportive evidence for the UKCAT's role in student selection. The conflicting relationships of socioeconomic contextual measures (area and school) with outcome adds to wider debates about the limitations of these measures, and indicates the need for further research.

The effect of long saphenous vein stripping on deep venous reflux

BACKGROUND

The addition of long saphenous vein (LSV) stripping to sapheno-femoral junction (SFJ) disconnection and multiple stab avulsions (MSAs) in the course of varicose vein (VV) surgery is associated with a significant reduction in recurrence, and a significant improvement in quality of life. It is hypothesised that these benefits relate, at least in part, to a favourable effect of stripping on deep venous reflux.

OBJECTIVE

To examine the effect of long saphenous vein (LSV) stripping on deep venous reflux (DVR).

METHODS

This was prospective study of 62 consecutive patients (77 limbs) CEAP class 2-6, undergoing SFJ disconnection and MSAs, with and without successful stripping of the LSV to the knee. A duplex ultrasound examination was performed pre-operatively and at a median (IQR) of 24 (23-25) months post-operatively. Completely stripped limbs were defined as those in whom complete stripping of the LSV to the knee was confirmed on post-operative duplex. Reflux >/=0.5 s. was considered pathological.

RESULTS

Pre-operatively, 32 (42%) limbs had deep venous reflux (DVR). Post-operative duplex at 24 months revealed that the LSV had been completely stripped in 29 (38%) limbs. In patients with pre-operative DVR, complete stripping was associated with a significant reduction in the prevalence of superficial femoral vein (SFV) (p<0.001) and popliteal vein (PV) (p=0.016), McNemar test) on post-operative duplex. By contrast, in patients without pre-operative DVR, incomplete stripping was associated the development of SFV (p=0.031) and PV (p=0.008) reflux.

CONCLUSIONS

Complete LSV stripping abolishes DVR in a significant proportion of limbs, whereas failure to strip is frequently associated with the development of new DVR. These data support for routine stripping and suggest that the benefits of stripping may relate, at least in part, to a favourable impact on deep venous function.

The Effect of Superficial Venous Surgery on Generic Health-related Quality of Life

BACKGROUND

Superficial venous surgery (SVS) is associated with a significant improvement in disease-specific health related quality of life (HR-QoL) but the effect on generic HR-QoL remains uncertain. The aim of this study was to determine the effect of SVS on responses to the Short Form [SF]-36, the most widely used generic HR-QoL instrument.

METHOD

Two hundred and three patients undergoing SVS completed the SF-36 pre-operatively and 24 months post-operatively. Scores for the 8 SF-36 domains [physical (PF) and social functioning (SF), role limitation due to physical (RP) and emotional (RE) problems, mental health (MH), vitality (V), pain (P), and general health perception (HP)] were calculated and normalised using UK standard data.

RESULTS

Pre-operatively, patients scored significantly lower (worse) than the general UK population in PF, RP and P. Surgery was associated with a significant improvement in PF and P (45.3 vs. 42.5 and 48.9 vs. 43.8 postop vs. preop, p<0.001, WSR) at 2 years.

CONCLUSION

SVS leads to a statistically and clinically significant improvement in the physical components of the SF-36. These data will allow the clinical benefits of SVS to be compared with other interventions so helping informing decisions about how venous surgery should be prioritised appropriately within the NHS.

The benefits of a curved suture needle in laparoscopic partial fundoplications in infants

A modified Watson fundoplication technique is described using curved needles introduced through the anterior abdominal wall. This technique has clear advantages over ski needles, allows for a wider choice of sutures and helps curtail costs in laparoscopic fundoplication in the small child.

Carotid endarterectomy in patients aged 75 and over: Early results and late outcome

BACKGROUND

The mean age of patients in the European Carotid Surgery Trial with greater than 70% stenosis was 62 years. With changing demographics older patients are increasingly being referred for carotid endarterectomy (CEA).

OBJECTIVES

To assess the complications and survival (stroke-free and overall) of patients over the age of 75 undergoing CEA.

METHODS

Analysis of a database, clinical records and cause of death of patients undergoing CEA in a single regional unit over a 7 year period (1/4/1993 until 1/4/2000), with follow-up to April 2002. The rates of further neurological events were obtained from the Scottish Morbidity Record 1 (SMR 1) of hospital discharges. Patients referred from outside the region were excluded. Differences between groups were assessed by the Chi-squared test, with Yates correction and log-rank tests.

RESULTS

Of the 235 patients undergoing CEAs, 55 (23%) were 75 years or older. The post-operative neurological complication rate was 1.7% in the under 75's and 5.4% in the older group (p < 0.05). The 30 day mortality was 1.1% (two patients) and 1.8% (one patient) respectively. The Kaplan-Meier estimated survival for the under 75's and older were 93 and 75% at 3 years and 80 and 59% at 5 years respectively (p < 0.001). The Kaplan-Meier estimated neurological event-free 5 year survival for the under 75's and older patients were 96 and 82% respectively (p < 0.001).

CONCLUSION

CEA in patients aged 75 years and over is associated with a significantly increased risk of stroke and death. CEA may not benefit elderly patients with a reduced life expectancy.

A comparison of patients who developed venous leg ulceration before and after their 50th birthday

BACKGROUND

although chronic venous ulceration (CVU) is often viewed primarily as a disease of the elderly, recent epidemiological data suggest that a significant proportion of patients first develop CVU before middle age. Such patients may represent a distinct group in terms of aetiology, natural history, prognosis and therapeutic options.

AIM

to compare patients who developed CVU before (Group 1) and after (Group 2) their 50th birthday.

METHODS

one hundred and eighteen consecutive patients with "pure" CVU underwent history and examination, measurement of ankle-brachial pressure index (ABPI) and duplex ultrasound examination of the affected limb. Pure venous ulcers were defined as those of >4 weeks duration in the presence of venous reflux (>0.5) and in association with an ankle: brachial pressure index of >0.8.

RESULTS

patients in Group 1 (n = 54, 46%) were more likely to be male (32/54 [59%] vs 14/64 [23%], p < 0.001 chi(2)), to have a higher median (interquartile [IQR]) body mass index (32 [27-39] vs 27 [23-34], p = 0.003, Mann-Whitney U [MWU]), to have a history of deep venous thrombosis (23/54 [43%] vs 16/64 [25%], p = 0.04 chi(2)) and of ipsilateral long bone fracture (13/54 [24%] vs 5/64 [8%], p = 0.01, chi(2)), to have previously undergone venous surgery (27/54 [50%] vs 19/64 [30%] a median (IQR) of 11.5 (6.5-19) and 10 (2-20) years earlier respectively, and to have worse disease in terms of the duration of present ulcer (12 (6-36) vs 8.5 [3-18] months, p = 0.035 MWU), the total duration of ulcer disease (216 [72-360] vs 48 [12-120] months, p < 0.001 MWU), and the number of episodes of ulceration (3 [2-7] vs 1 [1-3], p = 0.002 MWU). There was no significant difference between the two groups in the pattern and severity of venous reflux with 46/54 (85%) of Group 1 and 54/64 (84%) of Group 2 patients having surgically correctable superficial venous reflux.

CONCLUSION

patients who develop CVU before their 50th birthday appear to represent a distinct group in terms of aetiology, natural history and prognosis. The importance of thrombo-embolic prophylaxis in the prevention, and the detection and correction of superficial venous reflux in the treatment, of such ulcers is re-emphasised.

Thrombophilia and chronic venous ulceration

It is known that thrombophilia (TP) is a risk factor for deep venous thrombosis (DVT), and that DVT predisposes to chronic venous ulceration (CVU). However, the relationship between TP and CVU has not been well studied. Review of the literature reveals that the prevalence of TP in CVU patients is high--similar to the prevalence found in patients with a history of DVT. This is despite many patients with CVU having no clear history, or duplex evidence of previous DVT. TP may predispose to CVU by leading to macro- or micro-vascular thrombosis. This association raises several issues regarding the investigation, prevention and management of patients with venous disease.

The effect of long saphenous vein stripping on quality of life

PURPOSE

Long saphenous vein (LSV) stripping in the treatment of varicose veins may reduce the recurrence of varices but may also increase morbidity rates. The effect of stripping on health-related quality of life (HRQoL) is unknown. The aim of this study was to examine the effect of LSV surgery, with and without successful stripping, on HRQoL.

METHODS

This prospective study comprises 102 consecutive patients who underwent varicose vein surgery that included attempted stripping of the LSV to the knee. HRQoL was assessed before surgery and at 4 weeks, 6 months, and 2 years after surgery with the Aberdeen varicose vein severity score (AVSS; disease-specific) and the Short-Form 36 (SF-36; generic). Patients defined as stripped were those in whom complete thigh stripping to the knee was confirmed with postoperative duplex scanning at 2 years. Patients defined as incompletely stripped were those in whom any LSV remnant was found in the thigh after surgery. Deep venous reflux (DVR) was defined as reflux of 0.5 seconds or more in at least the popliteal vein.

RESULTS

Sixty-six of 102 patients (65%) provided complete HRQoL data at all four time points. At baseline, there was no significant difference between patients who were stripped (n = 25) and incompletely stripped (n = 41) in terms of AVSS, SF-36, age, gender, DVR, or CEAP grade. Significantly more patients in the incompletely stripped group underwent surgery for recurrent disease (29/41, 71%, versus 8/25, 32%; P =.002, with chi(2) test). Both groups gained significant improvements in AVSS scores for as much as 2 years. After adjustment for recurrent disease, stripping conferred additional benefit in terms of AVSS at 6 months (median [interquartile range]) (9 [4 to 16] versus 15 [9 to 24]; P =.031) and 2 years (7 [2 to 10] versus 9 [5 to 15]; P =.014), which was statistically significant in patients without preoperative DVR but not significant in patients with preoperative DVR. SF-36 scores were not affected by stripping.

CONCLUSION

LSV surgery leads to a significant improvement in disease-specific HRQoL for as much as 2 years. In patients without DVR, stripping to the knee confers additional benefit.

Bicarbonate/lactate- and bicarbonate-buffered peritoneal dialysis fluids improve ex vivo peritoneal macrophage TNFalpha secretion

Peritoneal macrophage (PMO) function was examined ex vivo after their in vivo exposure to either acidic, lactate-buffered solutions (PD4; 40 mM lactate, pH 5.2), bicarbonate/lactate-buffered solution (TBL; 25 mM/15 mM bicarbonate/lactate, pH 7.3), or bicarbonate-buffered solution (TB; 38 mM bicarbonate, pH 7.3), containing either 1.36 or 3.86% glucose. Initial experiments demonstrated that tumor necrosis factor-alpha (TNFalpha) release (assessed by TNF-direct immunoassay [DIA]) from PMO isolated from the peritoneal cavities of patients exposed to conventional fluid (PD4 1.36% glucose) was lowest after 30 min of intraperitoneal dwell (3591+/-1200 versus 28,946+/-9359 for 240-min dwell [pg/ml], n=5, P < 0.05). Five patients were exposed on 3 successive days to PD4, TBL, and TB for 30-min acute dwells containing 1.36% glucose in the first week and 3.86% glucose during the second. PMO TNFalpha release was assessed after ex vitro exposure to lipopolysaccharide (LPS). Exposure of PMO to TBL or TB (1.36% glucose) resulted in a significant increase in the generation of TNFalpha (pg/2 X 10(6) PMO) compared with PD4. TBL: 68,659+/-35,633, TB: 53,682+/-26,536 versus PD4 17,107+/-8996 (LPS 1.0 ng/ml, n=5 patients, P=0.043 versus PD4 for both). PMO that were recovered from PD4 and TB dwells (3.86% glucose) showed no significant difference in TNFalpha secretion (21,661+/-6934 and 23,923+/-9147, respectively). In contrast, exposure to TBL resulted in a significant increase (41,846+/-11,471) compared with PD4 (LPS 1.0 ng/ml, n=5 patients, P=0.043). These data demonstrate enhanced PMO function after in vivo exposure to bicarbonate- and bicarbonate/lactate-buffered solutions. This response was sustained in TBL alone at the highest glucose concentrations. These results suggest that the newer solutions, and particularly bicarbonate/lactate, might improve host defense status in peritoneal dialysis patients.