Evaluation of the diagnostic performance of the creatinine-based Chronic Kidney Disease Epidemiology Collaboration equation in people with diabetes: A systematic review.

AIMS: GFR estimated with the creatinine-based Chronic Kidney Disease Epidemiology Collaboration (CKD-EPICr ) equation is used to screen for diabetic kidney disease and assess its severity. We systematically reviewed the process and outcome of evaluating CKD-EPICr in estimating point GFR or GFR decline over time in adults with type 1 or type 2 diabetes. METHODS: In this systematic review, MEDLINE, Embase and Cochrane Central Register of Controlled Trials were searched up to August 2019. Observational studies comparing CKD-EPICr with measured GFR (mGFR) in adults with diabetes were included. Studies on people with kidney transplant, non-diabetes related kidney disease, pregnancy, potential kidney donors, and those with critical or other systematic illnesses were excluded. Two independent reviewers extracted data from published papers and disagreements were resolved by consensus. Risk-of-bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. (PROSPERO registration number: CRD42018108776). RESULTS: From the 2820 records identified, 29 studies (14 704 participants) were included. All studies were at risk of bias. Bias (eight different forms) ranged from -26 to 35 ml min-1  1.73 m-2 ; precision (five different forms) ranged between 9 and 63 ml min-1  1.73 m-2 ; accuracy (five different forms) ranged between 16% and 96%; the correlation coefficient between CKD-EPICr and mGFR (four different forms) ranged between 0.38 and 0.86; and the reduced major axis regression slope ranged between 0.8 and 1.8. CONCLUSIONS: Qualitative synthesis of data suggested CKD-EPICr was inaccurate in estimating point GFR or GFR decline over time. Furthermore, a lack of consistency in the methods and processes of evaluating the diagnostic performance of CKD-EPICr limits reliable quantitative assessment. The equation needs to be improved in adults with diabetes.

THE IMPACT OF DEPRESSION ON MATERNAL RESPONSES TO INFANT FACES IN PREGNANCY.

Research has suggested that prenatal depression may be associated with disrupted maternal responses to infant stimuli, with depressed pregnant women not showing the bias toward distressed infants as that observed in nondepressed pregnant women. The current study examined the effects of depression on self- reported responses to infant stimuli, in early pregnancy. Women with clinical depression (n = 38), and nondepressed women (n = 67) were recruited from a wider cognitive behavioral therapy trial. They completed Maternal Response Scales in which they were presented with images of distressed, neutral, and happy infant faces, with no time limit. The women rated their responses to these images along three dimensions--wanting to comfort, wanting to turn away, and feelings of anxiety--using Likert scales via a computerized task. There was evidence that women with depression in pregnancy showed different responses than did women without depression. Women with depression were substantially more likely to be in the highest quartile for ratings of wanting to turn away, odds (OR) ratio = 4.15, 95% confidence intervals (CIs) = 1.63-10.5, p = .003, and also were substantially less likely to be in the highest quartile for wanting to comfort a distressed infant face, OR = 0.22, 95% CIs = 0.09-0.54, p < .001. Findings are consistent with there being both a heightened avoidant and a reduced comforting response toward distressed infants in depressed pregnant women, providing some support that depression disrupts maternal preparations at a conscious level.

Estimation of Pediatric Dosage of Antimalarial Drugs, Using Pharmacokinetic and Physiological Approach.

Most of the individuals who die of malaria in sub-Saharan Africa are children. It is, therefore, important for this age group to have access to the right treatment and correct dose. Artemether-lumefantrine is one of the fixed dose combination therapies that was approved by the World Health Organization to treat malaria. However, the current recommended dose has been reported to cause underexposure or overexposure in some children. The aim of this article was, therefore, to estimate the doses that can mimic adult exposure. The availability of more and reliable pharmacokinetic data is essential to accurately estimate appropriate dosage regimens. The doses in this study were estimated using the physiological information from children and some pharmacokinetic data from adults due to the lack of pediatric pharmacokinetic data in the literature. Depending on the approach that was used to calculate the dose, the results showed that some children were underexposed, and others were overexposed. This can lead to treatment failure, toxicity, and even death. Therefore, when designing a dosage regimen, it is important to know and include the distinctions in physiology at various phases of development that influence the pharmacokinetics of various drugs in order to estimate the dose in young children. The physiology at each time point during the growth of a child may influence how the drug is absorbed, gets distributed, metabolized, and eliminated. From the results, there is a very clear need to conduct a clinical study to further verify if the suggested (i.e., 0.34 mg/kg for artemether and 6 mg/kg for lumefantrine) doses could be clinically efficacious.

Radiation protection value to the operator from augmented reality smart glasses in interventional fluoroscopy procedures using phantoms.

INTRODUCTION: Smart glasses can be adapted to display radiographic images to allow clinician's gaze not to be directionally fixed or predetermined by computer monitor location. This study presents an analysis of eye lens dose during interventional fluoroscopy guided procedures, comparing fixed monitor positions against the use of smart glasses. METHODS: Using a head phantom (simulating the clinician), thermoluminescent dosimeters and lead shielded glasses, the dose to the eye was measured for different head 'rotations and tilts' for: gaze directed towards the main scattering source (patient/primary beam) to represent potential gaze direction if smart glasses are used; gaze directed to a range of potential computer monitor positions. An anthropomorphic pelvis phantom was utilised to simulate the patient. Accumulated dose rates (µGy s-1) from five 10-second exposures at 75 kV 25.2 mAs were recorded. RESULTS: An average DAP reading of 758.84 cGy cm2 was measured during each 10 second exposure. Whilst wearing lead shielded glasses a 6.10 - fold reduction in dose rate to the lens is possible (p < 0.05). Influence of the direction of gaze by the clinician demonstrated a wide range of dose rate reduction from 3.13% (p = 0.16) to 143.69% (p < 0.05) when the clinician's gaze was towards the main scattering source. Increased dose rate to the clinician's eyes was received despite wearing lead shielded glasses, as the angle of gaze moved 45° and 90° from 0°. CONCLUSION: If the clinician's gaze is directed towards the main scattering source a potential exists for reducing eye lens dose compared with fixed location computer monitors. Introduction of lead lined smart glasses into interventional radiology may lead to improvements in patient care, reducing the need for the clinician to look away from the patient to observe a radiographic image.

Expectations of outcomes in patients with colorectal cancer.

BACKGROUND: Understanding patients' expectations of their treatment is critical to ensure appropriate treatment decisions, and to explore how expectations influence coping, quality of life and well-being. This study aimed to examine these issues related to treatment in patients with colorectal cancer. METHODS: A literature search from January 1946 to September 2016 was performed to identify available data regarding patients' expectations of outcomes following colorectal cancer treatment. A narrative synthesis of the evidence was planned. RESULTS: Of 4337 items initially identified, 20 articles were included in the review. In studies presenting data on overall and short-term survival, patients considerably overestimated prognosis. Patients also had unrealistic expectations of the negative aspects of chemotherapy and stomas. There was marked discordance between patients' and clinicians' expectations regarding chemotherapy, end-of-life care, bowel function and psychosocial outcomes. Level of education was the most consistent factor influencing the accuracy of patients' expectations. CONCLUSION: Patients with colorectal cancer frequently have unrealistic expectations of treatment. Marked disparities exist between patients' and clinicians' expectations of outcomes.

The longitudinal association between weight change and health-related quality of life in adults and children: a systematic review.

This systematic review examined longitudinal associations between weight change (weight gain and loss) and both physical and mental aspects of health-related quality of life (HRQOL) compared with stable weight in adults and children of the general population. MEDLINE, EMBASE, PsycINFO and PubMed databases were searched. Longitudinal observational studies measuring HRQOL with six predefined instruments were synthesized according to type of association: weight change and change in HRQOL (change-on-change association) and weight change and HRQOL at follow-up (predictive association). Twenty studies of adults (n = 15) or children (n = 5) were included. Fifteen studies used the SF-12 or SF-36. Results of nine studies in adults examining the change-on-change association were combined through a tallying of 606 analyses. Weight gain was most often associated with reduced physical, but not mental HRQOL, across all baseline body mass index categories and in both men and women. Weight loss may be associated with improved physical, but not mental HRQOL, among adults with overweight and obesity. Weight gain was more strongly associated with HRQOL than weight loss, implicating a greater need for preventative strategies to tackle obesity. Results in children and for the predictive association generally reflected these findings but require further research.

Quantitative analysis of residual protein contamination on reprocessed surgical instruments.

'Ready-for-use' instruments from surgical instrument trays were examined after routine cleaning and sterilization in a blinded study. These reprocessed instruments originated from five National Health Service hospital trust sterile service departments in England and Wales. Determination of residual protein and peptide contamination was carried out by acid stripping of the instrument surfaces, hydrolysis of the constituent amino acids and quantitative total amino acid analysis. One hundred and twenty instruments were analysed, and the median levels of residual protein contamination per instrument for the individual trays were 267, 260, 163, 456 and 756 microg. Scanning electron microscopy and energy dispersive X-ray spectroscopic analyses of the instruments showed that tissue deposits were localized on surfaces, but there was no significant correlation between overall protein soiling and instrument complexity. The highest levels of residual contamination were found on instruments used for tonsillectomy and adenoid surgery.

Sequence and crystallization of Escherichia coli dethiobiotin synthetase, the penultimate enzyme of biotin biosynthesis.

The enzyme dethiobiotin synthetase (EC 6.3.3.3) has been cloned and over-expressed in Escherichia coli in such a way that milligram quantities are available. The purified enzyme has been subjected to a number of physical and chemical studies, sequenced and most notably it has been crystallized in a form that is suitable for X-ray structure determination. The cell dimensions are a = 72.8 A, b = 49.2 A, c = 61.4 A, beta = 106.2 degrees. The systematic absences are consistent with the monoclinic space group C2 with one polypeptide chain in the asymmetric unit.

Effects of glycosylated recombinant human granulocyte colony-stimulating factor after high-dose cytarabine-based induction chemotherapy for adult acute myeloid leukaemia.

The Australian Leukaemia Study Group (ALSG) investigated whether G-CSF would accelerate haemopoietic recovery after induction treatment for acute myeloid leukaemia (AML) intensified with high-dose cytarabine, and therefore improve response rates and survival. Patients were randomised to receive lenograstim (glycosylated recombinant human G-CSF) 5 microg per kg body weight subcutaneously daily from day 8 after starting chemotherapy, or no cytokine, following chemotherapy with cytarabine 3 g/m2 every 12 h on days 1, 3, 5, and 7, together with idarubicin 9 or 12 mg/m2 on days 1, 2, and 3, plus etoposide 75 mg/m2 on days 1 to 7 inclusive. Patients had untreated AML, and were aged 16 to 60 years. Overall, 54 evaluable patients were randomised to receive lenograstim and 58 to no cytokine. Patients in the lenograstim arm had a significantly shorter duration of neutropenia <0.5 x 10(9)/l compared to patients in the no cytokine arm (median 18 vs 22 days; P = 0.0005), and also shorter duration of total leucopenia <1.0 x 10(9)/l (17 vs 19 days; P = 0.0002), as well as a reduction in duration of treatment with therapeutic intravenous antibiotics (20 vs 24 days; P= 0.015) and a trend to reduced number of days with fever >38.0 degrees C (9 vs 12 days; P = 0.18). There were no differences between the two groups in platelet recovery, red cell or platelet transfusions, or non-haematological toxicities. For patients achieving CR after their first induction course, a reduction in the time to the start of the next course of therapy was observed in the lenograstim arm, from a median of 40.5 days to a median of 36 days (P = 0.082). The overall complete response rates to chemotherapy were similar, 81% in the lenograstim arm vs 75% for the no cytokine arm (P = 0.5), and there was no significant difference in the survival durations. We conclude that the granulopoietic stimulating effect of G-CSF is observed after induction therapy for AML intensified by high-dose cytarabine, resulting in an improvement in a number of clinically important parameters with no major adverse effects.

Immunolocalisation of 14-3-3 isoforms in normal and scrapie-infected murine brain.

The appearance of 14-3-3 proteins in the cerebrospinal fluid is characteristic of some neurodegenerative conditions which include sporadic Creutzfeldt-Jakob disease. Although 14-3-3 proteins are physiochemically well characterised and are known to be present in neuronal cells little is known of the neuroanatomical localisation of the individual isoforms. Using 14-3-3 isoform specific antibodies we have examined the distribution of the isoforms in normal murine brain and the changes observed during neurodegeneration as a result of ME7 scrapie infection. In normal brain there are two major patterns of immunolabelling. The beta, gamma, eta and zeta isoforms which exhibit a similar distribution pattern showing labelling of neuronal cell bodies often in particular anatomical nuclei. However the individual isoforms exhibit variation revealing subtle differences in location. The tau isoform was found only in the hippocampus and medulla, and the epsilon isoform was found throughout grey matter of the CNS. In the scrapie-infected murine brain, where severe pathological changes occur during the course of the disease, significant differences in the 14-3-3 isoform distribution were observed in the hippocampus and in the thalamus. Importantly, both the 14-3-3 eta isoform and prion protein were seen in the same neurones in both the cerebellar roof nuclei and in the lateral hypothalamic nuclei. Our study of 14-3-3 isoform distribution in adult murine brain clearly demonstrates a heterogeneous pattern of neurolocation for specific 14-3-3 isoforms. The fact that isoform labelling in terminal scrapie CNS is lost in some brain areas, but increases in others, suggests that the processing of these proteins during neurodegeneration may be much more complex than previously recognised.

Plasma cleaning of dental instruments.

The theoretical risk of prion transmission via surgical instruments is of current public and professional concern. These concerns are further heightened by reports of the strong surface affinity of the prion protein, and that the removal of organic material by conventional sterilization is often inadequate. Recent reports of contamination on sterilized endodontic files are of particular relevance given the close contact that these instruments may make with peripheral nerve tissue. In this paper, we report the effective use of a commercial gas plasma etcher in the cleaning of endodontic files. A representative sample of cleaned, sterilized, files was screened, using scanning electron microscopy and energy-dispersive X-ray analysis, to determine the level of contamination before plasma cleaning. The files were then exposed for a short-term to a low-pressure oxygen-argon plasma, before being re-examined. In all cases, the amount of organic material (in particular that which may have comprised protein) was reduced to a level below the detection limit of the instrument. This work suggests that plasma cleaning offers a safe and effective method for decontamination of dental instruments, thus reducing the risk of iatrogenic transmission of disease during dental procedures. Furthermore, whilst this study focuses on dental files, the findings indicate that the method may be readily extended to the decontamination of general surgical instruments.

Accountability and responsibility.

What can you do if the most appropriate treatment does not comply with a guideline, policy or procedure? A tissue viability team was faced with this dilemma when considering treatment options for an open wound in a woman with cancer.

Clinical governance. 2: Obtaining consent in wound care: what are the key issues?

When undertaking a therapeutic intervention, healthcare professionals must ensure that they receive informed consent from the patient in order to protect both the individual and themselves.

Clinical governance. 1: Evidence-based practice.

Practitioners have a responsibility to ensure their practice is based on sound clinical evidence and that the care delivered is of a high quality. What are the best ways of achieving this in the reality of the modern NHS?

The effectiveness of staff support: evaluating active support training using a conditional probability approach.

Active Support, a package of procedures which includes activity planning, support planning, and training on providing effective assistance, was introduced in five community residences serving 19 adults with severe mental retardation following a multiple baseline design. Real-time observational data were collected on the level of assistance residents received from staff and their engagement in activity. Active Support was shown in a companion paper (Jones et al., 1999) to increase the levels of assistance residents received and their engagement in activity. Increased assistance was particularly experienced by the behaviorally less able and the disparity in activity between the more and less able was reduced. In the analysis presented here, the effectiveness of assistance was evaluated before and after Active Support training by calculating the likelihood of engagement occurring given the occurrence of assistance. This likelihood was represented by the statistic, Yule's Q. Yule's Q significantly increased following Active Support training, an increase that was maintained at follow-up. The increased effectiveness of assistance was related to other research findings on the relationship between staff: resident interaction patterns and resident behavior.

A comparison of two hydrocolloid sheet dressings.

This article examines the clinical application of hydrocolloid dressings as a whole. Two thin hydrocolloid sheets - Tegasorb thin and Duoderm extra thin - were essayed in the clinical area, and compared for their ease of application and removal, conformability, wear time and patient comfort. Both dressings were found to be highly acceptable in clinical practice, with advantages and disadvantages to each type of dressing. There was a high level of patient acceptability and no adverse reactions were noted during this evaluation. Pain reduction was noted by patients with superficial pressure sores and trauma wounds that were treated with thin hydrocolloid sheets.

Developments in wound care for difficult to manage wounds.

Research and development in wound healing has ensured that issues relating to chronic wound management remain high in the nursing agenda. Since the advent of modern wound dressings, which retain a moist wound healing environment, work has continued to progress into more advanced, interactive products which aim to alter the wound bed in order to promote a suitable environment for cell migration and growth. Rapid wound healing is advocated and necessary to reduce morbidity and mortality in patients with large chronic wounds and to reduce the financial and manpower implications of long-term wound care in the hospital or community setting. Vacuum-assisted closure, artificial skins, growth factors and larval therapy are discussed in order to give an overview of some of the emerging practices being adopted for difficult to manage wounds.

An evaluation of the Parema four-layer bandage system.

This article gives an overview of the treatment and causes of venous leg ulcers and focuses on a new four-layer bandage system (K-Four from Parema) which can be used in the treatment of these ulcers. The article features preliminary observations of this new system, which was used on 10 patients who had previously worn multilayer compression.

Understanding and managing cellulitis.

Cellulitis is a relatively common emergency in acute and community care settings, and can be a source of significant pain and anxiety for affected patients. This article examines the management of patients with generalised cellulitis--an infection of the skin and subcutaneous tissues, which is exacerbated by the presence of damaged skin, poor circulation or diabetes mellitus. Appropriate dressing regimens for the management of wounds resulting from this infection are discussed. Localised cellulitis that develops as a result of an existing wound infection is not covered in this article.