[Dialysis and ultrafiltration therapy in patients with cardio-renal syndrome: recommendations of the working group "heart-kidney" of the German Cardiac Society and the German Society of Nephrology]

Renal failure is common in patients with severe heart failure. This complex pathophysiological interaction has been classified as cardio-renal syndrome. In these patients hydropic decompensation is the main cause of hospitalization. In patients with refractory heart failure, characterized by diuretic resistance and congestion due to volume overload, ultrafiltration has to be considered. In acute decompensated heart failure with worsening of renal function, extracorporeal ultrafiltration is the preferred treatment modality. On the other hand, patients suffering from chronic decompensated heart failure, particularly patients with ascites, will profit from the treatment specific advantages of peritoneal ultrafiltration. Prerequisite for an optimized care of patients with cardio-renal syndrome is the close collaboration among intensive care doctors, cardiologists and nephrologists.

[Expert consensus statement on interventional renal sympathetic denervation for hypertension treatment]

This commentary summarizes the expert consensus and recommendations of the working group 'Herz und Niere' of the German Society of Cardiology (DGK), the German Society of Nephrology (DGfN) and the German Hypertension League (DHL) on renal denervation for antihypertensive treatment. Renal denervation is a new, interventional approach to selectively denervate renal afferent and efferent sympathetic fibers. Renal denervation has been demonstrated to reduce office systolic and diastolic blood pressure in patients with resistant hypertension, defined as systolic office blood pressure ≥ 160 mm Hg and ≥ 150 mm Hg in patients with diabetes type 2, which should currently be used as blood pressure thresholds for undergoing the procedure. Exclusion of secondary hypertension causes and optimized antihypertensive drug treatment is mandatory in every patient with resistant hypertension. In order to exclude pseudoresistance, 24-hour blood pressure measurements should be performed. Preserved renal function was an inclusion criterion in the Symplicity studies, therefore, renal denervation should be only considered in patients with a glomerular filtration rate > 45 ml/min. Adequate centre qualification in both, treatment of hypertension and interventional expertise are essential to ensure correct patient selection and procedural safety. Long-term follow-up after renal denervation and participation in the German Renal Denervation (GREAT) Registry are recommended to assess safety and efficacy after renal denervation over time.

Marrow fibrosis and its relevance during imatinib treatment of chronic myeloid leukemia

In chronic myeloid leukemia (CML), imatinib may reverse bone marrow fibrosis (MF). Whether the unfavorable prognosis of MF is also reversed and whether imatinib guarantees against evolution of MF are unclear as yet. Fifty-nine patients with Ph+ CML treated with > or = 400 mg imatinib/day were examined for MF in 6- to 12-month intervals. Imatinib effectively reversed initial MF (P<0.0005). However, during a follow-up period of up to 4.8 years, small foci with abnormal fiber increase (FFI) emerged in 8 of 30 pretreated and 6 of 29 non-pretreated patients. Patients with FFI showed a significantly lower probability of achieving a complete cytogenetic or major molecular response (36 versus 81%; P<0.007). During the further follow up, 57% of patients with FFI but none of the other patients suffered from full-blown MF (P=0.00005). None of the patients with FFI or MF showed a Janus kinase-2 mutation (V617F). Evolutions of FFI and MF were independent significant predictors of imatinib failure (P=0.0031), accelerated phase and death of patients (P=0.0001; multivariate analyses). Imatinib effectively reverses initial MF in CML, but neither eliminates its unfavorable prognosis nor guarantees completely against new evolution of MF.

Reduction of circulating microemboli in the subclavian vein of patients undergoing haemodialysis using pre-filled instead of dry dialysers

BACKGROUND

Chronic microembolization that can be demonstrated by pulsed Doppler ultrasound may give rise to pulmonary side-effects during haemodialysis by direct vessel obstruction, increased complement activation or platelet aggregation. The objective of the present investigation was to study whether the use of pre-filled instead of dry dialysers would help to minimize the number of microemboli.

METHODS

The study cohort consisted of 23 patients undergoing maintenance haemodialysis. Using a 2 MHz pulsed ultrasound device, the subclavian vein downstream to the dialysis fistula was investigated for 10 min during the dialysis session. The ultrasound examination was performed twice during two successive dialysis sessions, using a pre-filled or a dry dialyser in randomized order.

RESULTS

In all patients investigated, numerous microembolic signals (MES) could be observed in the subclavian vein. Treatment with pre-filled dialysers was associated with significantly less MES (82 +/- 94) as compared with dry dialysers (268 +/- 296; P = 0.002).

CONCLUSIONS

In comparison to dry dialysers, the use of pre-filled dialysers leads to a significant reduction in microembolization, which may prevent repeated damage to the pulmonary vasculature and, thus, cause less pulmonary damage.

A Spectroscopic Redshift for the Cl 0024+16 Multiple Arc System: Implications for the Central Mass Distribution

We present a spectroscopic redshift of z=1.675 for the well-known multiply lensed system of arcs seen in the z=0.39 cluster Cl 0024+16. In contrast to earlier work, we find that the lensed images are accurately reproduced by a projected mass distribution which traces the locations of the brightest cluster elliptical galaxies, suggesting that the most significant minima of the cluster potential are not dynamically erased. The averaged mass profile is shallow and consistent with predictions of recent numerical simulations. The source redshift enables us to determine an enclosed cluster mass of M(<100 kpc h-1&parr0;=1.11+/-0.03x1014 h-1 M middle dot in circle (Omega=1) and a mass-to-light ratio of M&solm0;LB(<100 kpc h-1&parr0;=320+/-30 h &parl0;M&solm0;LB&parr0; middle dot in circle (virtually independent of curvature), after correction for passive stellar evolution. The arc spectrum contains many ionized absorption lines and closely resembles that of the local Wolf-Rayet galaxy NGC 4217. Our lens model predicts a high magnification ( approximately 20) for each image and identifies a new pair of multiple images of a galaxy at a predicted redshift of z=1.3.

Use of the Watson-Glaser Critical Thinking Appraisal with BSN students

The complexity and changing nature of nursing today requires proficiency in thinking skills to ensure knowledgeable, confident, creative, and sensitive decisions regarding client care. Nurse educators are faced with the task of promoting educational strategies to develop the abilities of nursing students to think critically in all health care settings (1). However, a lack of consensus on what characterizes critical thinking leads to difficulty in the development of instruments for adequate measurement. It is important to decide on a definition of critical thinking that faculty support and are willing to use in practice. The term is diversely defined in the literature. For example, Alfaro-LeFevre states that critical thinking in nursing "entails purposeful, goal directed thinking; aims to make judgments based on evidence (fact) rather than conjecture (guesswork); is based on principles of science and scientific method; requires strategies that maximize human potential and compensate for problems caused by human nature" (2). The authors of this study use a definition by Paul: "thinking about your thinking while you are thinking in order to make your thinking better, more clear, more accurate, more defensible" (3). The authors believe that the development and/or enhancement of critical thinking ability must be the result of conscious, deliberate activity throughout the nursing program. As the student matures, the ability to think critically will be manifested in decision making that reflects accurate assessment and resolution of problems. The nursing faculty selected an instrument to evaluate the critical thinking abilities of baccalaureate nursing students that had strong reliability and validity documented in the nursing literature: the total and subtest scores of the Watson-Glaser Critical Thinking Appraisal (WGCTA), Form A (4). The instrument was deemed to be congruent with the definition of critical thinking supported by the faculty.

Na+/H+ exchange during an oral glucose challenge in patients with essential hypertension

To determine the effects of an oral glucose challenge on cellular Na+/H+ exchange in vivo we measured plasma glucose concentrations, plasma insulin concentrations, plasma C-peptide concentrations, arterial blood pressure, cytosolic pH (pHi) and cellular Na+/H+ exchange in 24 patients with essential hypertension (HT) and 41 age-matched healthy normotensive control subjects (NT) during a standardized oral glucose tolerance test. Under resting conditions, the plasma glucose concentrations, plasma insulin concentrations, plasma C-peptide concentrations and Na+/H+ exchange activity were significantly higher in HT compared with NT (P < 0.05 in each case). A significant increase in lymphocytic Na+/H+ exchange activity was only seen in NT (resting 0 h: (4.23 +/- 0.2) x 10(-3) pHi/s; mean +/- S.E.M.; 1 h after glucose administration: (6.00 +/- 0.56) x 10(-3) pHi/s; 2 h after glucose administration: (6.65 +/- 0.64) x 10(-3) pHi/s; P = 0.0003 by Friedman's two-way ANOVA), but not in HT (resting 0 h: (6.07 +/- 0.36) x 10(-3) pHi/s; 1 h after glucose administration: (6.72 +/- 1.02) x 10(-3) pHi/s; 2 h after glucose administration: (6.71 +/- 0.62) x 10(-3) pHi/s; P = 0.7470). During an oral glucose challenge the systolic (P < 0.0001) and diastolic (P < 0.0001) blood pressure significantly decreased in HT but not in NT. Essential hypertension shows abnormal in vivo regulation of Na+/H+ exchange and blood pressure following oral glucose intake.

Time to detection of cytomegalovirus (CMV) DNA in blood leukocytes is a predictor for the development of CMV disease in CMV-seronegative recipients of allografts from CMV-seropositive donors following liver transplantation

In 35 cytomegalovirus (CMV)-seronegative recipients of livers from CMV-seropositive donors, 32 (91%) developed CMV infection and 24 of them (75%) experienced disease. Polymerase chain reaction for CMV DNA in leukocytes had the best positive and negative predictive values for the development of disease within 2 months from transplantation, and shell-vial or tube culture viremia was the best predictor thereafter. In patients who developed CMV disease, CMV DNA was first detected at 46 days (median; range, 13-128) after transplantation, significantly earlier than the 77 days (range, 46-174) for those who did not develop CMV disease (P = .02). By a semiquantitative method, the CMV DNA level in the first positive sample did not predict disease development. However, the maximum CMV DNA level during infection was significantly higher in patients who developed CMV disease. In CMV-seronegative recipients of livers from CMV-seropositive donors, the time to DNA positivity following transplantation may predict disease progression and be useful as a guide for the initiation of preemptive therapy.

Circulating immediate-early mRNA in patients with cytomegalovirus infections after solid organ transplantation

Polymerase chain reaction (PCR)-based amplification of cytomegalovirus (CMV) DNA has been demonstrated to be a sensitive tool for the diagnosis of CMV infection. However, PCR can detect the presence of viral DNA in some specimens from clinically asymptomatic patients. In an attempt to obviate this shortcoming, a reverse transcriptase-PCR-based assay (RT-PCR) was developed to look for CMV immediate-early (IE) mRNA in peripheral blood leukocytes from organ transplant recipients. The results of the PCR- and RT-PCR-based assays for CMV were correlated with clinical symptoms from 21 patients. Absence of circulating IE mRNA was associated with a lack of CMV-associated clinical symptoms in all 14 cases, irrespective of the presence or absence of CMV DNA. In contrast, all 7 RNA-positive samples were associated with CMV disease. Thus, RT-PCR appears to be more predictive than PCR for detection of clinically significant CMV disease in immunosuppressed patients.

Culture, stress and substance use in Cambodian refugee women

Initial data were generated on the use of alcohol and other drugs by Cambodian refugee women and their families (N = 120) in two sites: Massachusetts and California. Information on frequency and situations surrounding use, and culturally specific use, was elicited. In those families where alcohol was perceived as a problem, the majority of problem drinkers were husbands. About 45% of the East Coast women, however, said they used alcohol for nervousness, stress, headaches, insomnia and pain. In addition, about 15% of the East Coast women reported that a family member used street drugs and was having dependency problems. While use of alcohol or street drugs was not perceived as problematic on the West Coast, over 58% reported using prescription drugs for self-treatment of illnesses other than those targeted by the prescription. When prescription drugs were misused by women, it was most frequently to get an altered state, or "street drug effect". Numerous stressors influence Cambodian women during the pressures of acculturation to the U.S. lifestyle. Some may turn to self-medication in the form of alcohol, prescription sleeping pills, or other drugs. A better understanding of how and why these women make coping choices is needed.

Stress in Cambodian refugee families

Southeast Asians are a rapidly growing, culturally varied group needing physical and mental health services. The sources, manifestations, and coping strategies associated with stress experienced by this group are not well documented. Interviews were conducted with 120 Cambodian women in this comparative descriptive study to identify their perceptions of stress-related factors confronting families. Memories of the war, financial concerns, and family problems were frequently cited. Somatic manifestations were the most common symptoms. A general sense of inability to cope with stress suggests the need for health care providers to be sensitive to undeclared problems.

Art and multiple personality disorder: an expressive framework for occupational therapy

Patients with multiple personality and dissociative disorders have learned to create an alternate identity system, originally designed to protect them from experiencing the pain of inescapable, unrelieved trauma and abuse. The resulting amnesia and identity confusion cause significant dysfunction in daily living. Issues of trust and control are paramount, and occupational therapists are challenged with the task of engaging these patients in meaningful activity. Although these patients often avoid structured groups, they have generally been responsive to expressive art opportunities as an initial activity. This paper outlines an expressive framework by which occupational therapists can therapeutically manage the artwork behaviors of the patient with dissociative or multiple personality disorder. The material presented is based on clinical observation of more than a dozen patients with multiple personality disorder in various stages of recovery and of many persons with dissociative trauma who may have multiple personality disorder. These observations took place within an acute care, inpatient occupational therapy setting. Guidelines for the creation of a positive working alliance and therapeutic climate for self-expression are outlined, and a progressive model for the viewing of patients' art products is described.