Improving management of needle distress during the journey to dialysis through psychological education and training-the INJECT study feasibility pilot protocol

BACKGROUND

Needle-related distress is a common yet poorly recognised and managed problem among haemodialysis (HD) patients. The aim of this pilot study is to test the feasibility and acceptability of the INJECT Intervention-an innovative psychology-based intervention to empower patients to self-manage needle distress with the support of dialysis nurses.

METHODS

This investigator-initiated, single-arm, non-randomised feasibility study will take place in a large dialysis service in Adelaide, Australia. Participants will include patients aged ≥ 18 years, commencing or already receiving maintenance HD, recruited through dialysis physicians and nursing staff as individuals believed to be at risk of needle distress. They will be screened for inclusion using the Dialysis Fear of Injection Questionnaire (DFIQ) and enrolled into the study if the score is ≥ 2. The multi-pronged intervention encompasses (i) psychologist review, (ii) patient self-management program and (iii) nursing education program. The primary aim is to evaluate feasibility and acceptability of the intervention from patient and dialysis nurse perspectives, including recruitment, retention, engagement with the intervention and completion. Secondary exploratory outcomes will assess suitability of various tools for measuring needle distress, evaluate acceptability of the nursing education program and measure cannulation-related trauma and vascular access outcomes.

CONCLUSION

The results will inform the protocol for larger trials addressing needle distress in HD patients.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12621000229875, approved 4 April 2021, https://www.anzctr.org.au/ .

Helping the general physician to improve outcomes after PEG insertion: how we changed our practice

During their careers, most general physicians are involved in the decision-making process for patients that potentially require percutaneous endoscopic gastrostomy (PEG) insertion. However, poor patient selection and less than favourable outcomes are frequently observed in this group. With the aim of identifying and addressing the underlying issues, the PEG service at University Hospital Llandough was radically changed over an eight-year period. The development of a nurse-led pre-assessment service and design of a specific referral form was successful in reducing the number of PEG referrals and consequently the 30-day mortality rate. Furthermore, the educational and training needs of general physicians of all grades regarding the issues surrounding PEG placement were identified and addressed at formal teaching sessions. A combination of these factors has positively impacted on our service, with more appropriate patient selection and a reduced 30-day mortality rate.

Retinoic acid promotes rod photoreceptor differentiation in rat retina in vivo

Previous studies have indicated that retinoic acid (RA) promotes rod photoreceptor differentiation in dissociated cultures of rat retina and in zebrafish embryos. To determine whether RA will have the same affect in the mammalian retina in vivo, pregnant rats were given single i.p. injections of RA on the 18th and 20th days of gestation, and the retinas of the pups were analyzed for rods. HPLC showed that i.p. injections of RA substantially increased levels of retinal RA in the embryos. Embryonic exposure to RA caused an increase in the number of cells that differentiated as rod photoreceptors. There was a comparable decrease in the number of cells that differentiated as amacrine cells. These results demonstrate that RA promotes the differentiation of rods in vivo and further support the hypothesis that differentiation of rods is normally controlled partly by the RA concentration in the developing retina or RPE.

Ligands of steroid/thyroid receptors induce cone photoreceptors in vertebrate retina

The mechanisms by which multipotent progenitor cells are directed to alternative cell identities during the histogenesis of the vertebrate central nervous system are likely to involve several different types of signaling systems. Recent evidence indicates that 9-cis retinoic acid, which acts through members of the steroid/thyroid superfamily of receptors, directs progenitor cells to the rod photoreceptor cell fate. We now report that another effector of this family of receptors, thyroid hormone, induces an increase in the number of cone photoreceptors that develop in embryonic rat retinal cultures, and that combinations of 9-cis retinoic acid and triiodothyronine cause isolated progenitor cells to differentiate as either rods or cones, depending on the relative concentrations of the ligands. These results implicate thyroid hormone in CNS cell fate determination, and suggest that different photoreceptor phenotypes may be modulated through the formation of thyroid/retinoid receptor heterodimers.

Regulation of proliferation and photoreceptor differentiation in fetal human retinal cell cultures

PURPOSE

To examine whether fetal human retinal cells can be maintained in vitro over long time periods and to determine whether exogenous growth factors can be used to generate large numbers of photoreceptors within these cultures.

METHODS

Fetal human retinas (6 to 13 weeks after conception) were dissected, dissociated, and plated into culture wells. Specific growth factors and steroid/thyroid hormones, which have been shown to influence retinal progenitor cell proliferation and differentiation in rats, were added to the culture medium to determine whether any of these factors had similar effects on human retinal cells.

RESULTS

Fetal human retinal cells survived and continued to proliferate for up to 300 days in vitro. Under control conditions, 15 million cells were generated from an initial plating of 100,000 cells; however, the addition of either epidermal growth factor or basic fibroblast growth factor stimulated proliferation and resulted in the generation of more than 100 million cells. A percentage of these cells was induced to differentiate as photoreceptors by adding either retinoic acid or triiodo-thyronine to the culture medium.

CONCLUSIONS

Fetal human retinal cells can be maintained and expanded in vitro, indicating that this technique may be useful for generating large numbers of retinal cells. The number and types of cells generated can be influenced by adding exogenous factors to the culture medium. The response of human retinal cells to growth factors and hormones is similar to the response of rodent retinal cells to the same factors, suggesting that the effects of these factors are conserved across species.

Retinoic acid promotes differentiation of photoreceptors in vitro

The results of several recent studies have demonstrated that cell commitment and differentiation in the developing vertebrate retina are influenced by cell-cell interactions within the microenvironment. Retinoic acid has been shown to influence cell fates during development of the nervous system, and retinoic acid has been detected in the embryonic retina. To determine whether retinoic acid mediates the differentiation of specific neuronal phenotypes during retinal histogenesis, we treated dissociated cell cultures of embryonic and neonatal rat retina with varying concentrations of all-trans or 9-cis retinoic acid and analyzed the effects on cell fate using neuron and photoreceptor-specific antibodies. Addition of exogenous retinoic acid caused a dose-dependent, specific increase in the number of cells that developed as photoreceptors in culture throughout the period of retinal neurogenesis. In the same cultures, retinoic acid also caused a dose-dependent decrease in the number of cells that developed as amacrine cells. Also, results of double-labeled immunohistochemical studies using bromodeoxyuridine demonstrated that the primary effect of retinoic acid was to influence progenitor cells to develop as newly generated rod photoreceptors. Since retinoic acid and at least one of the retinoic acid receptors (RAR alpha) have been localized to the developing neural retina, these results suggest that retinoic acid may play a role in the normal development of photoreceptor cells in vivo.

The influence of a change in practice setting on pediatrician activity: a case study

A time-and-motion study was performed of a pediatrician's activities in his fee-for-service solo practice and again after he joined a prepaid group practice. A comparison was made between time spent with fee patients in solo practice and time spent with fee patients continuing to see him in group practice. Total time per patient visit was not changed significantly by the group setting. Activities within the visit were modified in the group setting. History-taking and physical examination were reduced; counseling and charting were increased. Time spent in well-child visits in the group setting was significantly longer with the increased time spent in counseling. For sick visits there was no change in total time per visit nor in activities within the visit.

Lack of effect of an experimental prepaid group practice on utilization of surgical care

The utilization of surgical care in an experimental period group practice for a 3 year period is reported. In contrast to what was expected, prepaid enrollees used the same or more surgical care than did control enrollees. The same proportion of emergency, urgent, and nonurgent admissions, occurred in both groups. Likewise there was no difference in the proportion of various procedures often thought to be overutilized in the traditional medical care system. High quality of surgical care in the area where the study was conducted was considered the most likely explanation for failure to show differences in the prepaid growth practice. Few, if any, unnecessary operations were performed in either group studied. Thus, under the conditions of this study, no significant measurable effect on surgical utilization by a change in the method of medical care organization and payment could be demonstrated.