Vascular stiffness in incident peritoneal dialysis patients over time.

OBJECTIVE: Vascular stiffness is prevalent in end-stage renal disease patients and predicts adverse events. This study describes the prevalence of vascular stiffness and its associated factors in a cohort of incident peritoneal dialysis (PD) patients. METHODS: In a prospective observational study of 50 patients, carotid-femoral pulse wave velocity (PWV) were conducted at baseline, 3, 6 and 12 months after initiation of PD. Aortic calcification scores (ACS) were derived using plain lateral abdominal films. We examined the association of significant changes in PWV (defined as 1 m/s or 15% change from baseline) over 6 months in conjunction with demographic and clinical data. RESULTS: The mean age was 58 years, 67% were male, and 48% were Caucasian. One third was diabetic, and 23% had pre-existing cardiovascular disease. Median eGFR was 8.7 ml/ min. ACS was strongly correlated with PWV (r = 0.62, p < 0.0001). Over 6 months, 42% demonstrated significant increases, while 23% demonstrated decreases in their PWV. Factors shown to be associated with increasing PWV were Caucasian race (OR = 4.50; CI: 0.97 - 20.83), higher phosphate (OR = 8.36; CI: 1.10 - 63.51) and a lower baseline PWV (OR = 0.67; CI: 0.45 - 0.99). Decrease in PWV was associated with the absence of calcium based phosphate binder usage (OR = 0.11; CI: 0.02 - 0.73). Changes in weight and PWV at 12 months were significantly correlated (p = 0.007, r = 0.57). CONCLUSION: In this group of incident PD patients, we demonstrate a lower prevalence of vascular calcification than in hemodialysis patients, a correlation of calcification with PWV, and an important finding that PWV can change in either direction over a short period of time, which are associated with modifiable risk factors.

Evaluation of intraperitoneal vancomycin in peritoneal dialysis-associated peritonitis.

BACKGROUND: Intraperitoneal (IP) vancomycin is recommended as one of the treatment options for gram-positive coverage in the management of peritoneal dialysis (PD)-associated peritonitis. There is a lack of literature supporting the optimal dose and approach to vancomycin therapeutic drug-level monitoring. METHODS: A retrospective chart review was conducted using the BC Renal Agency PROMIS Database and our hospital records from 1 June 2011 to 1 July 2019. Adult patients with PD-associated peritonitis who received IP vancomycin and had at least one serum vancomycin level drawn were included. All patients received a loading dose of 30 mg/kg, which was repeated every 3-5 days depending on PD modality. Serum vancomycin levels were drawn prior to the second vancomycin dose, then at the discretion of the prescriber. The primary end point was the rate of therapeutic serum vancomycin levels ≥15 mg/L. RESULTS: Twenty-three episodes of PD-associated peritonitis in 20 patients met the eligibility criteria. Only 15/23 serum vancomycin levels were drawn appropriately after the first dose. Sixty per cent of these levels were subtherapeutic at <15 mg/L. All subsequent serum vancomycin levels were above the therapeutic target. Most peritonitis episodes (78%) achieved resolution of infection. Residual kidney function was not significantly correlated with serum vancomycin levels (p = 0.19). CONCLUSIONS: An IP vancomycin regimen of 30 mg/kg every 3-5 days resulted in subtherapeutic serum vancomycin levels in most patients following the loading dose but therapeutic levels thereafter. A large percentage of vancomycin levels were drawn inappropriately due to misalignment of outpatient follow-up visits and timing of blood work.

iTRAQ proteomics of sentinel lymph nodes for identification of extracellular matrix proteins to flag metastasis in early breast cancer.

Patients with early breast cancer are affected by metastasis to axillary lymph nodes. Metastasis to these nodes is crucial for staging and quality of surgery. Sentinel Lymph Node Biopsy that is currently used to assess lymph node metastasis is not effective. This necessitates identification of biomarkers that can flag metastasis. Early stage breast cancer patients were recruited. Surgical resection of breast was followed by identification of sentinel lymph nodes. Fresh frozen section biopsy was used to assign metastatic and non-metastatic sentinel lymph nodes. Discovery phase included iTRAQ proteomics coupled with mass spectrometric analysis to identify differentially expressed proteins. Data is available via ProteomeXchange with identifier PXD027668. Validation was done by bioinformatic analysis and ELISA. There were 2398 unique protein groups and 109 differentially expressed proteins comparing metastatic and non-metastatic lymph nodes. Forty nine proteins were up-regulated, and sixty proteins that were down regulated in metastatic group. Bioinformatic analysis showed ECM-receptor interaction pathways to be implicated in lymph node metastasis. ELISA confirmed up-regulation of ECM proteins in metastatic lymph nodes. ECM proteins have requisite parameters to be developed as a diagnostic tool to assess status of sentinel lymph nodes to guide surgical intervention in early breast cancer.

Systematic Evaluation of a Provincial Initiative to Improve Transition to Home Dialysis Therapies.

BACKGROUND: The transition from choosing to initiating home dialysis therapies (HDTs) is not clearly standardized for patients and staff, causing increased anxiety and suboptimal self-management for chronic kidney disease (CKD) patients. At BC Renal, a "Transition to HDTs" guidebook (the Guide) was designed, outlining a step-wise approach to transitioning to HDTs for patients, to help address some of these concerns. OBJECTIVE: We used the Logic Model evaluation framework to assess the value of the Guide to improve patient and staff experience with transitioning to HDTs. DESIGN: This is a prospective cohort quality improvement study. SETTING: This study took place at home dialysis programs in British Columbia, Canada, with 2 pilot sites and 2 control sites. PATIENTS: Patients above age 18 who attended kidney care clinics and identified HDT as their renal replacement treatment of choice were included in this study. MEASUREMENTS: Patient demographics were obtained from British Columbia Renal Patient Records and Outcomes Management Information System, with differences analyzed using Mann-Whitney U test and chi-square test where applicable. Patient surveys were based on Likert rating scales, analyzed using Cochran-Armitage trend test. All tests were 2-sided, with P < .05 considered significant. METHODS: The study enrolled patients from December 2018 to April 2019 at 2 pilot and 2 control sites. Patients were followed up for 8 months. The intervention strategies included (1) training of front-line staff to use the Guide and (2) dissemination of the guide to patients. Evaluation tools measuring data at baseline and at the 8-month point included (1) qualitative and quantitative patient surveys, (2) qualitative staff surveys, (3) structured feedback session with renal care staff, and (4) transition rate and time between choosing and starting a HDT. RESULTS: In total, 108 patients were enrolled: 43 patients at pilot sites and 65 in control sites. Twenty-three of 65 in control vs 18 of 43 in pilot transitioned to a HDT by 8-month follow-up. Transition time was 80 vs 89 days in pilot vs control group, but it was not statistically different (P = .37). The proportion of patients that transitioned to a HDT was 42% vs 35% in pilot vs control group (P = .497). Patients' anxiety, illness knowledge, and activation of resources were not significantly different between patients who successfully transitioned at control and pilot sites. During interviews, patients confirmed that the Guide was effective and helped retain knowledge. The staff felt that the intervention did not increase their workload and that the Guide was a good communication tool, but was used inconsistently. LIMITATIONS: We had a small sample size and limited number of patients enrolled who chose home hemodialysis, with none in the control group. The results are therefore more applicable to peritoneal dialysis. CONCLUSIONS: The Logic Model was useful to evaluate our multi-intervention strategy. While there were no statistically significant differences in transition time, rate, and patient anxiety with or without the Guide, qualitative opinions from patients indicate that the Guide was a useful supplement. In addition, feedback from renal care staff suggested that the Guide served as a framework for communicating the transition process with patients, and was perceived as a useful tool. Future work is required to standardize the Guide's utilization. TRIAL REGISTRATION: As this is a quality improvement evaluation study, trial registration is not applicable.

CONTEXTE: L'absence de normalisation, tant pour les patients que pour les soignants, dans la procédure de transition entre le choix de la dialyse à domicile (DD) comme thérapie de remplacement rénal et l'initiation du traitement engendre de l'anxiété et se traduit par une autogestion sous-optimale de la maladie chez les patients atteints d'IRC. Un guide de « transition vers la DD ¼ (le Guide) a été élaboré par le BC Renal. Ce document destiné aux patients décrit une approche de transition par étapes et répond à certaines préoccupations. OBJECTIF: Le cadre d'évaluation du modèle logique a été utilisé pour mesurer la capacité du Guide à améliorer l'expérience des patients et du personnel soignant lors de la transition vers la DD. TYPE D'ÉTUDE: Une étude de cohorte prospective mesurant la qualité de l'amélioration. CADRE: L'étude s'est tenue dans le cadre du programme de DD de la Colombie-Britannique (Canada), sur deux sites pilotes et deux sites contrôles. SUJETS: Les patients adultes qui fréquentaient les cliniques de santé rénale sélectionnées et qui avaient choisi la DD comme thérapie de remplacement rénal ont été inclus. MESURES: Les caractéristiques démographiques des patients ont été obtenues à partir de la base de données PROMIS (Renal Patient Records and Outcomes Management Information System) de la Colombie-Britannique. Selon le cas, les tests U de Mann-Whitney ou de chi-deux ont servi à analyser les différences. Les enquêtes menées auprès des patients étaient basées sur les échelles de notation de Likert et ont été analysées à l'aide du test de tendance Cochran-Armitage. Tous les tests étaient bilatéraux et un résultat de p inférieur à 0,05 a été considéré comme significatif. MÉTHODOLOGIE: L'étude a inclus des patients entre décembre 2018 et avril 2019 dans deux sites pilotes et deux sites contrôles, et le suivi s'est étalé sur huit mois. Les stratégies d'intervention visaient la formation du personnel de première ligne à l'utilisation du Guide et la diffusion de celui-ci aux patients. L'expérience des participants a été évaluée à l'inclusion et après huit mois de suivi à l'aide des outils suivants: (1) enquêtes qualificatives et quantitatives auprès des patients, (2) enquêtes qualitatives auprès des soignants, (3) séances de rétroaction structurées avec les soignants, (4) taux de transition et temps écoulé entre le choix de la DD comme modalité et l'initiation de la procédure. RÉSULTATS: L'étude porte sur un total de 108 patients (43 en site pilote et 65 en site contrôle). Au cours des huit mois de suivi, 23 patients des sites contrôles et 18 patients des sites pilotes ont fait la transition vers la DD. Le temps écoulé entre la décision et l'initiation de la DD s'établissait à 80 et 89 jours (pilotes vs contrôles), une différence qui n'a pas été considérée significative (P = 0,37). La proportion de patients qui sont passés à la DD était de 42 % et de 35 % (pilotes vs contrôles [P = 0,497]). Le niveau d'anxiété du patient, les connaissances à l'égard de la maladie et l'activation des ressources n'ont pas été jugés significativement différents entre les patients qui avaient réussi la transition, indépendamment du site. Au cours des entretiens, les patients ont confirmé que le Guide était efficace et qu'il aidait à retenir les connaissances. Les soignants ont quant à eux mentionné que les interventions n'augmentent pas leur charge de travail et que le Guide est un bon outil de communication, mais qu'il est utilisé de manière inconstante. LIMITES: L'échantillon de patients est faible; peu de sujets avaient choisi l'hémodialyse comme modalité, dont aucun dans le groupe contrôle. Nos résultats s'appliquent donc davantage à la dialyse péritonéale. CONCLUSION: Le modèle logique s'est avéré utile pour évaluer notre stratégie à interventions multiples. Bien que nous n'ayons pu observer de différences significatives dans le taux de transition, le temps requis pour procéder et le niveau d'anxiété du patient (avec ou sans le Guide), les avis qualitatifs des patients suggèrent que le Guide est un complément utile. La rétroaction du personnel soignant indique qu'il sert de cadre pour discuter du processus de transition avec les patients, et qu'il est perçu comme un outil utile. D'autres études sont requises pour normaliser l'utilisation du Guide. ENREGISTREMENT DE L'ESSAI: Il s'agit d'une étude mesurant la qualité de l'amélioration de l'expérience, l'enregistrement n'est donc pas requis.

Vascular access planning in peritoneal dialysis patients.

Peritoneal dialysis (PD) is a well-established renal replacement therapy for end-stage renal disease patients. Nonetheless, on an annual basis, at least 10% of patients shift from PD to hemodialysis for a variety of reasons. Thus the issue of vascular access creation needs to be addressed for this small but significant group of patients. Despite the relatively consistent number of dropouts, the creation of an arteriovenous fistula prior to transfer remains suboptimal, and variable from center to center. Literature for this specific area is poor and dated. Guidelines seem to suggest vascular access creation in high-risk failure patients, but they have no detailed criteria to select patients that would likely fail PD and therefore take advantage of a backup access. There is a need to better understand and predict patients that require conversion to hemodialysis to develop a plan that focuses on wellness and maximum quality of life in the lifecycle of PD patients. This review addresses the issue of vascular access planning in adult PD patients, presents the available literature on the topic and the current guidelines and recommendations, and describes a research agenda to guide decision making in clinical practice.

[Combined spinal-epidural analgesia in labour: its effects on delivery outcome]. / Analgesia combinada raquiperidural em trabalho de parto: seus efeitos sobre o desfecho do parto.

BACKGROUND AND OBJECTIVES: Combined spinal-epidural (CSE) has become an increasingly popular alternative to traditional labour epidural due to its rapid onset and reliable analgesia provided. This was a prospective, convenient sampling study to determine the effects of CSE analgesia on labour outcome. METHODS: One hundred and ten healthy primigravida parturients with a singleton pregnancy of ≥37 weeks gestation and in the active phase of labour were studied. They were enrolled to the CSE (n=55) or Non-CSE (n=55) group based on whether they consented to CSE analgesia. Non-CSE parturients were offered other methods of labour analgesia. The duration of the first and second stage of labour, rate of instrumental vaginal delivery and emergency cesarean section, and Apgar scores were compared. RESULTS: The mean duration of the first and second stage of labour was not significantly different between both groups. Instrumental delivery rates between the groups were not significantly different (CSE group, 11% versus Non-CSE group, 16%). The slightly higher incidence of cesarean section in the CSE group (16% versus 15% in the Non-CSE group) was not statistically significant. Neonatal outcome in terms of Apgar score of less than 7 at 1 and 5min was similar in both groups. CONCLUSION: There were no significant differences in the duration of labour, rate of instrumental vaginal delivery and emergency cesarean section, and neonatal outcome in parturients who received compared to those who did not receive CSE for labour analgesia.

Combined spinal-epidural analgesia in labour: its effects on delivery outcome.

BACKGROUND AND OBJECTIVES: Combined spinal-epidural (CSE) has become an increasingly popular alternative to traditional labour epidural due to its rapid onset and reliable analgesia provided. This was a prospective, convenient sampling study to determine the effects of CSE analgesia on labour outcome. METHODS: One hundred and ten healthy primigravida parturients with a singleton pregnancy of ≥37 weeks gestation and in the active phase of labour were studied. They were enrolled to the CSE (n=55) or Non-CSE (n=55) group based on whether they consented to CSE analgesia. Non-CSE parturients were offered other methods of labour analgesia. The duration of the first and second stage of labour, rate of instrumental vaginal delivery and emergency cesarean section, and Apgar scores were compared. RESULTS: The mean duration of the first and second stage of labour was not significantly different between both groups. Instrumental delivery rates between the groups were not significantly different (CSE group, 11% versus Non-CSE group, 16%). The slightly higher incidence of cesarean section in the CSE group (16% versus 15% in the Non-CSE group) was not statistically significant. Neonatal outcome in terms of Apgar score of less than 7 at 1 and 5min was similar in both groups. CONCLUSION: There were no significant differences in the duration of labour, rate of instrumental vaginal delivery and emergency cesarean section, and neonatal outcome in parturients who received compared to those who did not receive CSE for labour analgesia.

Gastrointestinal hemorrhage: The prehospital recognition, assessment & management of patients with a GI bleed.

Gastrointestinal hemorrhage may result from an upper or a lower source. It may present in many different ways; however, prehospital management is similar regardless of cause. It's imperative to recognize that a seemingly stable GI bleed can become hemodynamically unstable at any time. The prehospital provider, therefore, should understand the pathophysiology, signs, symptoms and therapeutic interventions for patients with GI bleeds to be better prepared to manage any such emergency when it arises.

Studies on heavy metal removal efficiency and antibacterial activity of chitosan prepared from shrimp shell waste.

Chitosan, a natural biopolymer composed of a linear polysaccharide of α (1-4)-linked 2-amino 2-deoxy ß-D glucopyranose was synthesized by deacetylation of chitin, which is one of the major structural elements, that forms the exoskeleton of crustacean shrimps. The present study was undertaken to prepare chitosan from shrimp shell waste. The physiochemical properties like degree of deacetylation (74.82 %), ash content (2.28 %), and yield (17 %) of prepared chitosan indicated that that shrimp shell waste is a good source of chitosan. Functional property like water-binding capacity (1,136 %) and fat-binding capacity (772 %) of prepared chitosan are in total concurrence with commercially available chitosan. Fourier Transform Infra Red spectrum shows characteristic peaks of amide at 1,629.85 cm-1 and hydroxyl at 3,450.65 cm-1. X-ray diffraction pattern was employed to characterize the crystallinity of prepared chitosan and it indicated two characteristic peaks at 10° and 20° at (2θ). Scanning electron microscopy analysis was performed to determine the surface morphology. Heavy metal removal efficiency of prepared chitosan was determined using atomic absorption spectrophotometer. Chitosan was found to be effective in removing metal ions Cu(II), Zn(II), Fe(II) and Cr(IV) from industrial effluent. Antibacterial activity of the prepared chitosan was also determined against Xanthomonas sp. isolated from leaves affected with citrus canker.

Combined spinal-epidural analgesia in labour: its effects on delivery outcome / Analgesia combinada raquiperidural em trabalho de parto: seus efeitos sobre o desfecho do parto

ABSTRACT BACKGROUND AND OBJECTIVES: Combined spinal-epidural (CSE) has become an increasingly popular alternative to traditional labour epidural due to its rapid onset and reliable analgesia provided. This was a prospective, convenient sampling study to determine the effects of CSE analgesia on labour outcome. METHODS: One hundred and ten healthy primigravida parturients with a singleton pregnancy of ≥37 weeks gestation and in the active phase of labour were studied. They were enrolled to the CSE (n = 55) or Non-CSE (n = 55) group based on whether they consented to CSE analgesia. Non-CSE parturients were offered other methods of labour analgesia. The duration of the first and second stage of labour, rate of instrumental vaginal delivery and emergency cesarean section, and Apgar scores were compared. RESULTS: The mean duration of the first and second stage of labour was not significantly different between both groups. Instrumental delivery rates between the groups were not significantly different (CSE group, 11% versus Non-CSE group, 16%). The slightly higher incidence of cesarean section in the CSE group (16% versus 15% in the Non-CSE group) was not statistically significant. Neonatal outcome in terms of Apgar score of less than 7 at 1 and 5 min was similar in both groups. CONCLUSION: There were no significant differences in the duration of labour, rate of instrumental vaginal delivery and emergency cesarean section, and neonatal outcome in parturients who received compared to those who did not receive CSE for labour analgesia.

RESUMO JUSTIFICATIVA E OBJETIVOS: A analgesia combinada raquiperidural (RP) tornou-se uma opção cada vez mais popular para o trabalho de parto tradicional devido ao seu rápido início de ação e ao resultado confiável. Este foi um estudo prospectivo de amostragem conveniente para determinar os efeitos da RP sobre o desfecho do parto. MÉTODOS: Foram incluídas 110 parturientes primigestas saudáveis, com gestação única de ≥ 37 semanas e na fase ativa do trabalho de parto. As pacientes foram designadas para os grupos RP (n = 55) ou não RP (n = 55) com base em seus consentimentos para a analgesia combinada RP. As parturientes do grupo não RP receberam outros métodos de analgesia para o parto. As durações do primeiro e segundo estágio do trabalho de parto, as taxas de parto vaginal instrumental e cesariana de emergência e os escores de Apgar foram comparados. RESULTADOS: A média de duração do primeiro e segundo estágio do trabalho de parto não foi significativamente diferente entre os dois grupos. As taxas de parto instrumental não foram significativamente diferentes entre os grupos, RP (11%) versus não RP (16%). A incidência ligeiramente maior de cesariana no grupo RP (16% versus 15% no não RP) não foi estatisticamente significativa. O desfecho neonatal em termos de índice de Apgar foi inferior a 7. CONCLUSÃO: Não houve diferenças significativas em relação à duração do trabalho, às taxas de parto vaginal instrumental e cesariana de emergência e ao desfecho neonatal em parturientes que receberam RP para analgesia de parto em comparação com aquelas que não receberam.