Putting patients at the center of kidney care transitions: PREPARE NOW, a cluster randomized controlled trial

Care for patients transitioning from chronic kidney disease to kidney failure often falls short of meeting patients' needs. The PREPARE NOW study is a cluster randomized controlled trial studying the effectiveness of a pragmatic health system intervention, 'Patient Centered Kidney Transition Care,' a multi-component health system intervention designed to improve patients' preparation for kidney failure treatment. Patient-Centered Kidney Transition Care provides a suite of new electronic health information tools (including a disease registry and risk prediction tools) to help providers recognize patients in need of Kidney Transitions Care and focus their attention on patients' values and treatment preferences. Patient-Centered Kidney Transition Care also adds a 'Kidney Transitions Specialist' to the nephrology health care team to facilitate patients' self-management empowerment, shared-decision making, psychosocial support, care navigation, and health care team communication. The PREPARE NOW study is conducted among eight [8] outpatient nephrology clinics at Geisinger, a large integrated health system in rural Pennsylvania. Four randomly selected nephrology clinics employ the Patient Centered Kidney Transitions Care intervention while four clinics employ usual nephrology care. To assess intervention effectiveness, patient reported, biomedical, and health system outcomes are collected annually over a period of 36 months via telephone questionnaires and electronic health records. The PREPARE NOW Study may provide needed evidence on the effectiveness of patient-centered health system interventions to improve nephrology patients' experiences, capabilities, and clinical outcomes, and it will guide the implementation of similar interventions elsewhere.

TRIAL REGISTRATION

NCT02722382.

Do thawing and warming affect the integrity of human milk?

OBJECTIVE

To evaluate the integrity of the human milk (pH, bacterial counts, host defense factors and nutrients) subjected to thawing, warming, refrigeration and maintenance at room temperature.

STUDY DESIGN

Mothers in the neonatal intensive care unit donated freshly expressed milk. A baseline sample was stored at -80 °C and the remainder of the milk was divided and stored for 7 days at -20 °C. The milk was then subjected to two methods of thawing and warming: tepid water and waterless warmer. Thawed milk also was refrigerated for 24 h prior to warming. Lastly, warmed milk was maintained at room temperature for 4 h to simulate a feeding session. Samples were analyzed for pH, bacterial colony counts, total fat and free fatty acids, and the content of protein, secretory IgA and lactoferrin. Data were analyzed by repeated-measures analysis of variance and paired t test.

RESULT

There were no differences between processing methods and no changes in fat, protein, lactoferrin and secretory immunoglobulin A with processing steps. Milk pH and bacterial colony counts declined while free fatty acids rose with processing. Refrigeration of thawed milk resulted in greater declines in pH and bacteria and increases in free fatty acids. Bacterial colony counts and free fatty acids increased with maintenance at room temperature.

CONCLUSION

The integrity of the milk was affected similarly by the two thawing and warming methods. Thawing and warming change the integrity of previously frozen human milk, but not adversely. Concerns about maintaining warmed milk at room temperature need to be explored.

[Interhospital transport of intensive care patients in Lower Saxony : statewide need-based and effective management]

BACKGROUND

Since 2007 interhospital transport of intensive care patients in Lower Saxony appertains to the performance requirements of emergency medical services. Against this background the Working Group for Evaluation of Intensive Care Transport (Arbeitsgemeinschaft Evaluation Intensivverlegung) was established. This group formulated standardized definitions for the requirements of intensive care transport vehicles and a federal statewide monitoring of intensive care transport was implemented to analyze if simultaneously on-call intensive care transport systems (intensive care helicopter and ground based mobile intensive care units) can be deployed need-based and efficiently.

METHODS

A prospective follow-up study and evaluation of intensive care transport in Lower Saxony between April 1(st) 2008 and July 31(st) 2010 was carried out.

RESULTS

A total of 6,779 data records were evaluated in this study of which 4,941 (72.9%) missions were located in Lower Saxony, 2,928 (43.2%) missions were carried out by helicopters and 3,851 (56.8%) by ground based mobile intensive care units. The mean duration of a mission was 3 h 59min±2 h 25 min, 4 h 39 min±2 h 23 min by ground based mobile intensive care units and 2 h 21 in±30 min by helicopter units. All systems proved to be feasible for intensive care transport. The degree of urgency was estimated correctly in 94.8% of the evaluated missions and 58.0% of the transfers could not be deployed. In 76.8% patients were transferred to hospitals with a higher level of medical care, 51.7% of patients were transferred for intensive care therapy and 40.4% for an operation/intervention. Of the patients 38.2% required mechanical ventilation and in 48.3% invasive monitoring was carried out.

CONCLUSION

Interhospital transfer of intensive care patients can be carried out need-based with a limited number of intensive care transport vehicles if the missions are deployed effectively by standardized disposition in accordance with performance requirements.

[Groin abscesses and vascular catastrophes in intravenous drug users--strategy and results]

BACKGROUND

Drug addiction is a global medical and public health-care problem. Infections of the groin and fossa cubitalis are a common clinical problem in these patients. Severe vascular complications are rare but if they occur, therapy is difficult and requires emergency management and surgery because of bleeding problems.

METHODS

In a retrospective case series, we report on patients treated within an emergency setting in our hospital because of groin abscesses with vascular involvement between 2003 and 2006. The therapeutic concepts and results are reported and discussed in the context of a review of the international literature.

RESULTS

We report on 4 patients with a long-standing history of i. v. drug abuse (average age 33, range 29-36 years). All were hepatitis C Ag positive and HIV negative. The general health and nutritional status were not compromised, all patients had one or more DVT in their medical history. In two cases, emergency surgery with revascularisation was necessary (after 2 days in one case and 4 weeks in the other) because of septic bleeding subsequent to abscess incision. Two patients underwent primary revascularisation because of pseudoaneurysms. The grafts were a saphenous vein patch and a superficial femoral artery patch in one and deep vein segments in two cases. In two cases, a sartorius muscle flap and VAC therapy were used to cover the defect. All patients survived, minor amputation became necessary in one case.

CONCLUSION

Abscess excision and debridement have to be as complete as possible and primary revascularisation is the procedure of choice in cases of severe groin infection. In the case of large vessel involvement, abscess incision alone without revision of the vascular structures is dangerous because of subsequent complications like secondary ruptures. For this reason, these patients require intensive care and close monitoring. Successful treatment exclusively based on ligation is described in literature with regard to isolated lesions of the superficial or deep femoral artery. Because of the very common involvement of the femoral bifurcation, revascularisation is, however, necessary in most cases and should be performed with autologous grafts if possible. If complete covering of the defect is not possible, a sartorius muscle flap is a good choice. Primary wound closure can be problematic because of recurrences, therefore vacuum-assisted wound closure is a valuable addition to the overall therapeutic approach in these cases.

Pyroclastic activity at Home Plate in Gusev Crater, Mars

Home Plate is a layered plateau in Gusev crater on Mars. It is composed of clastic rocks of moderately altered alkali basalt composition, enriched in some highly volatile elements. A coarsegrained lower unit lies under a finer-grained upper unit. Textural observations indicate that the lower strata were emplaced in an explosive event, and geochemical considerations favor an explosive volcanic origin over an impact origin. The lower unit likely represents accumulation of pyroclastic materials, whereas the upper unit may represent eolian reworking of the same pyroclastic materials.

Wind-related processes detected by the Spirit Rover at Gusev Crater, Mars

Wind-abraded rocks, ripples, drifts, and other deposits of windblown sediments are seen at the Columbia Memorial Station where the Spirit rover landed. Orientations of these features suggest formative winds from the north-northwest, consistent with predictions from atmospheric models of afternoon winds in Gusev Crater. Cuttings from the rover Rock Abrasion Tool are asymmetrically distributed toward the south-southeast, suggesting active winds from the north-northwest at the time (midday) of the abrasion operations. Characteristics of some rocks, such as a two-toned appearance, suggest that they were possibly buried and exhumed on the order of 5 to 60 centimeters by wind deflation, depending on location.

Surficial Deposits at Gusev Crater Along Spirit Rover Traverses

The Mars Exploration Rover Spirit has traversed a fairly flat, rock-strewn terrain whose surface is shaped primarily by impact events, although some of the landscape has been altered by eolian processes. Impacts ejected basaltic rocks that probably were part of locally formed lava flows from at least 10 meters depth. Some rocks have been textured and/or partially buried by windblown sediments less than 2 millimeters in diameter that concentrate within shallow, partially filled, circular impact depressions referred to as hollows. The terrain traversed during the 90-sol (martian solar day) nominal mission shows no evidence for an ancient lake in Gusev crater.

Two knees or not two knees? Patient costs and outcomes following bilateral and unilateral total knee joint replacement surgery for OA

AIMS

This study aims to address medical and non-medical direct costs and health outcomes of bilateral and unilateral total knee replacement from the patients' perspective during the first year post-surgery.

METHODS

Osteoarthritis patients undergoing primary unilateral total knee or bilateral total knee replacement (TKR) surgery at three Sydney hospitals were eligible. Patients completed questionnaires pre-operatively to record expenses during the previous three months and health status immediately prior to surgery. Patients then maintained detailed prospective cost diaries and completed SF-36 and WOMAC Index each three months for the first post-operative year.

RESULTS

Pre-operatively, no significant differences in health status were found between patients undergoing unilateral TKR and bilateral TKR. Both unilateral and bilateral TKR patients showed improvements in pain, stiffness and function from pre-surgery to 12 months post-surgery. Patients who had bilateral TKR spent an average of 12.3 days in acute hospital and patients who had unilateral TKR 13.6 days. Totally uncemented prostheses were used in 6% of unilateral replacements and 48% of bilateral replacements. In hospital, patients who had bilateral TKR experienced significantly more complications, mainly thromboembolic, than patients who had unilateral TKR. Regression analysis showed that for every one point increase in the pre-operative SF-36 physical score (i.e. improving physical status) out-of-pocket costs decreased by 94%. Out-of-pocket costs for female patients were 3.3 times greater than for males.

CONCLUSION

Patients undergoing bilateral TKR and unilateral TKR had a similar length of stay in hospital and similar out-of-pocket expenditures. Bilateral replacement patients reported better physical function and general health with fewer health care visits one year post procedure. Patients requiring bilateral TKR have some additional information to aid their decision making. While their risk of peri-operative complications is higher, they have an excellent chance of good health outcomes at 12 months and are not going to be doubly "out-of-pocket" for the experience.

Neural substrates of spoken language rehabilitation in an aphasic patient: an fMRI study

Little is known about the neural counterparts of speech therapy in aphasic patients. An fMRI experiment was performed before and after a specific and intensive speech output therapy in RC, a patient with long-lasting speech output deficit following a left-sided ischemic lesion. Overt picture naming and picture/word rhyming were used as activation tasks in RC and 6 control subjects. The naming task concerned the output lexicon deficit to be rehabilitated while rhyming referred to preserved levels of processing and was used to control for repetition effect. The speech therapy program improved naming performance. By comparison to the pattern observed before therapy, the naming task after therapy induced a pattern of activation close to that observed in control subjects, involving left-sided language areas surrounding the lesion. Speech therapy effect was associated with activations in Broca's area and the left supra-marginal gyrus, which might reflect a therapy-induced phonological compensatory strategy for naming.

Mucosal production of antigastric autoantibodies in Helicobacter pylori gastritis

BACKGROUND

Apart form bacterial virulence factors of Helicobacter pylori, certain host factors influence the pathogenesis of H. pylori gastritis. In particular, antigastric autoantibodies that are detectable in the sera of a substantial proportion of H. pylori were shown to correlate with the development of gastric atrophy. The aim of this study was to analyze the possible antigastric autoimmune response in H. pylori gastritis at the site where the action is, i.e. , in the gastric mucosa.

MATERIAL AND METHODS

Gastric biopsy specimens from antrum and corpus mucosa of 24 H. pylori-infected and of 33 noninfected patients were cultured for 3 days, and tissue culture supernatants were analyzed for the amount of locally produced IgA and IgG. Antigastric autoantibodies were screened in the sera and in the supernatants by means of immunohistochemistry.

RESULTS

The infected patients had significantly higher concentrations of locally produced IgA, whereas the IgG concentrations were virtually the same in infected and noninfected patients. IgG or IgA antigastric autoantibodies, or both, were detectable only in the sera (38%) and supernatants (17%) of infected patients. Interestingly, the patient with the strongest local autoimmune response showed body-predominant H. pylori gastritis, with destruction of gastric glands and atrophy of the body mucosa.

CONCLUSIONS

These results demonstrate that antigastric autoimmune reactions are detectable at the site of the disease and might be relevant for the pathogenesis of gastric mucosa atrophy in H. pylori gastritis.

Huckstep intramedullary nailing for non-union of humeral shaft fractures

BACKGROUND

Various techniques of internal fixation for non-union of humeral shaft fractures have been attempted, leading to union rates of between 50 and 90% with persisting non-union causing pain and disability. Some of these techniques have led to shoulder and elbow dysfunction.

METHODS

Eight patients treated with Huckstep nail fixation for humeral shaft non-union were reviewed and the rate of union was determined. Elbow and shoulder function were assessed as well as the presence of pain or disability.

RESULTS

Union was achieved in seven of the eight patients (87.5%). Four patients had occasional mild pain after union. All patients achieved good arm function. Average shoulder abduction was 157 degrees and flexion 151 degrees excluding one patient with antecedent advanced osteoarthrosis of the gleno-humeral joint. No patient experienced any permanent neurological deficit.

CONCLUSIONS

Huckstep nail fixation achieved union rates comparable to or higher than the other techniques of internal fixation for non-union of humeral shaft fractures. Unlike the various methods of closed nailing, Huckstep nail fixation is not associated with shoulder and elbow dysfunction. It should be considered as a therapeutic option in humeral shaft fracture and non-union, especially where the fracture site needs to be opened.

[Benign pleural mesothelioma. Report of 2 cases]

We report two cases of benign pleura mesothelioma. We compare our pre-, intra- and postoperative findings with other reports in the literature. This tumor is rare. The patients have few symptoms. Large tumors may cause hypoglycemia. The treatment of choice is complete resection of the tumor. The prognosis is good.

[What does general practice hypertension mean?]

White coat hypertension means an isolated blood pressure elevation during conventional measurement in the doctor's office, while blood pressure is in the normal range outside the office over 24 hrs. The incidence is about 20-25% of all "hypertensives" identified in the office. Patients with white coat hypertension show no increased blood pressure variability outside the office, and they do not seem to be more anxious regarding psychological testing as compared with hypertensives. The white coat effect is very specific for the situation in the doctors office. The effect is more pronounced in younger and female patients. However, also in isolated systolic hypertension in the elderly the white coat effect is present to a substantial amount. Under dynamic exercise there is no different hemodynamic response in patients with white coat hypertension as compared with normotensives. Differences are however observed with regard to posture and under isometric exercise. So far, white coat hypertension seems to be a benign and harmless condition not related to an increased cardiovascular risk, which must not be treated.

Tophaceous gout of the axial skeleton

A 72-year-old female with a recent episode of podagra, without peripheral tophi, presented with nocturnal back pain and a destructive lesion of the right lamina of L4. A tophus was excised at laminectomy. Evidence of an axial skeletal tophus causing an irritative radiculopathy via mass effect is presented.

The rate and regularity of breathing movements in the normal and growth-retarded fetus

The rate and regularity of fetal breathing movements (FBM) were determined in 14 women with uncomplicated singleton pregnancies, eight of whom were between 30 and 33 weeks gestation and six between 37 and 40 weeks gestation. Similar observations were made in 19 women with pregnancies complicated by severe intrauterine growth retardation, 11 of whom were between 30 and 33 weeks and eight between 37 and 40 weeks. In normal pregnancy recordings of breath-to-breath intervals showed that FBM became more regular with advancing gestational age, and the rate [breaths/min, mean (SEM)] slowed from 57.2 (1.3) at 30-33 weeks to 47.9 (0.8) at 37-40 weeks. FBM in the growth-retarded group were regular at each gestation studied and the rate was even slower than in the normal group at term, being 41.9 (1.2) at 30-33 weeks and 41.1 (1.0) at 37-40 weeks. Hyperoxia and hypercapnia appeared to have no consistent effect on fetal breathing rate. Fasting for greater than 12 h considerably reduced the rate of FBM in the normal fetus but only marginally so in those with growth retardation. It is concluded that the pattern of FBM provides more information about the fetus than the amount of time spent breathing, particularly when growth is retarded.

The evolution of eosinophilic granuloma of bone: a case report

A case of eosinophilic granuloma in the humerus of a three and a half year old boy is described with serial roentgenographic evidence of the lesion developing over a period of two months prior to the commencement of treatment. After open biopsy and local steroid injection the lesion was observed to heal during the next ten months.