In the "Plant-Based" Era, Patients With Chronic Kidney Disease Should Focus on Eating Healthy.

In the era of plant-based diets, it is important for Nephrology providers to know the evidence regarding their healthfulness in patients with chronic kidney disease (CKD). A whole food, plant-based diet, which emphasizes fresh, minimally processed or refined plant-based foods and limits animal products, has shown benefits for patients with CKD. These include reduced dietary acid load, lower bioavailability of potassium and phosphorus, increased dietary fiber intake, nutritional adequacy, and cardiovascular and mortality benefits. Potential drawbacks include the need for specific knowledge, skills, and cost involved in preparing varied, healthy, and appetizing plant-based meals, leading to lower acceptability and accessibility to certain populations. Liberalization of the standard CKD diet to include healthy, minimally processed foods such as fruits, vegetables, nuts, legumes, and whole grains is likely beneficial, though more research is needed to determine whether a plant-based-only diet is the optimal way to achieve healthier eating in patients with CKD.

Establishing and implementing a health promoting school in rural Cambodia.

Few studies have used a whole-of-school approach in implementing a health promoting schools (HPS) framework. Descriptions of how HPS is being implemented, particularly in low-resourced, developing countries, are limited. This study used an exploratory case study design to examine the planning and implementation of a HPS in a rural Cambodian village. Data were collected via observations of the school, school documentation, and interviews with stakeholders (n = 9). The data were analysed inductively as an iterative process, from initial coding, through to categorizing, leading to concept mapping and then identifying the emergent themes within the stages of school development and implementation of educational and health programming. The case study demonstrated how all six components of the HPS framework can be used to plan and implement a school in a rural village in a developing country. The key elements of implementation were building local and international partnerships, local leadership, and a culture of change and participation. These elements were used to establish a non-profit school that aimed to address the stated health and educational needs of local villagers. This case study adds to the limited evidence on the HPS components and implementation methods that are being applied in low-resourced, developing countries.

Codesigning enhanced models of care for Northern Australian Aboriginal and Torres Strait Islander youth with type 2 diabetes: study protocol.

INTRODUCTION: Premature onset of type 2 diabetes and excess mortality are critical issues internationally, particularly in Indigenous populations. There is an urgent need for developmentally appropriate and culturally safe models of care. We describe the methods for the codesign, implementation and evaluation of enhanced models of care with Aboriginal and Torres Strait Islander youth living with type 2 diabetes across Northern Australia. METHODS AND ANALYSIS: Our mixed-methods approach is informed by the principles of codesign. Across eight sites in four regions, the project brings together the lived experience of Aboriginal and Torres Strait Islander young people (aged 10-25) with type 2 diabetes, their families and communities, and health professionals providing diabetes care through a structured yet flexible codesign process. Participants will help identify and collaborate in the development of a range of multifaceted improvements to current models of care. These may include addressing needs identified in our formative work such as the development of screening and management guidelines, referral pathways, peer support networks, diabetes information resources and training for health professionals in youth type 2 diabetes management. The codesign process will adopt a range of methods including qualitative interviews, focus group discussions, art-based methods and healthcare systems assessments. A developmental evaluation approach will be used to create and refine the components and principles of enhanced models of care. We anticipate that this codesign study will produce new theoretical insights and practice frameworks, resources and approaches for age-appropriate, culturally safe models of care. ETHICS AND DISSEMINATION: The study design was developed in collaboration with Aboriginal and Torres Strait Islander and non-Indigenous researchers, health professionals and health service managers and has received ethical approval across all sites. A range of outputs will be produced to disseminate findings to participants, other stakeholders and the scholarly community using creative and traditional formats.

Personalised recommendations for hospitalised patients with Acute Kidney Injury using a Kidney Action Team (KAT-AKI): protocol and early data of a randomised controlled trial.

INTRODUCTION: Although studies have examined the utility of clinical decision support tools in improving acute kidney injury (AKI) outcomes, no study has evaluated the effect of real-time, personalised AKI recommendations. This study aims to assess the impact of individualised AKI-specific recommendations delivered by trained clinicians and pharmacists immediately after AKI detection in hospitalised patients. METHODS AND ANALYSIS: KAT-AKI is a multicentre randomised investigator-blinded trial being conducted across eight hospitals at two major US hospital systems planning to enrol 4000 patients over 3 years (between 1 November 2021 and 1 November 2024). A real-time electronic AKI alert system informs a dedicated team composed of a physician and pharmacist who independently review the chart in real time, screen for eligibility and provide combined recommendations across the following domains: diagnostics, volume, potassium, acid-base and medications. Recommendations are delivered to the primary team in the alert arm or logged for future analysis in the usual care arm. The planned primary outcome is a composite of AKI progression, dialysis and mortality within 14 days from randomisation. A key secondary outcome is the percentage of recommendations implemented by the primary team within 24 hours from randomisation. The study has enrolled 500 individuals over 8.5 months. Two-thirds were on a medical floor at the time of the alert and 17.8% were in an intensive care unit. Virtually all participants were recommended for at least one diagnostic intervention. More than half (51.6%) had recommendations to discontinue or dose-adjust a medication. The median time from AKI alert to randomisation was 28 (IQR 15.8-51.5) min. ETHICS AND DISSEMINATION: The study was approved by the ethics committee of each study site (Yale University and Johns Hopkins institutional review board (IRB) and a central IRB (BRANY, Biomedical Research Alliance of New York). We are committed to open dissemination of the data through clinicaltrials.gov and sharing of data on an open repository as well as publication in a peer-reviewed journal on completion. TRIAL REGISTRATION NUMBER: NCT04040296.

Hypoglycemia as a Manifestation of Shapiro Syndrome.

Shapiro syndrome is an extremely rare disorder of dysautonomia characterized by paroxysmal episodic hypothermia to below 95°F. Many patients with Shapiro syndrome improve with medical management, though a minority of cases are refractory to treatment. Our patient with adult-onset Shapiro syndrome is an atypical case. Our patient has been refractory to medical treatment as well as chemical sympathectomy. Based on a review of the literature, this is also the first reported case of hypoglycemia with Shapiro syndrome episodes in the absence of other metabolic diseases. This case suggests that hypoglycemia could be a potential manifestation of Shapiro syndrome.

Decision Support Tools for Coronary Artery Calcium Scoring in the Primary Prevention of Cardiovascular Disease Do Not Meet Health Literacy Needs: A Systematic Environmental Scan and Evaluation.

A shared decision-making approach is considered optimal in primary cardiovascular disease (CVD) prevention. Evidence-based patient decision aids can facilitate this but do not always meet patients' health literacy needs. Coronary artery calcium (CAC) scans are increasingly used in addition to traditional cardiovascular risk scores, but the availability of high-quality decision aids to support shared decision-making is unknown. We used an environmental scan methodology to review decision support for CAC scans and assess their suitability for patients with varying health literacy. We systematically searched for freely available web-based decision support tools that included information about CAC scans for primary CVD prevention and were aimed at the public. Eligible materials were independently evaluated using validated tools to assess qualification as a decision aid, understandability, actionability, and readability. We identified 13 eligible materials. Of those, only one qualified as a decision aid, and one item presented quantitative information about the potential harms of CAC scans. None presented quantitative information about both benefits and harms of CAC scans. Mean understandability was 68%, and actionability was 48%. Mean readability (12.8) was much higher than the recommended grade 8 level. Terms used for CAC scans were highly variable. Current materials available to people considering a CAC scan do not meet the criteria to enable informed decision-making, nor do they meet the health literacy needs of the general population. Clinical guidelines, including CAC scans for primary prevention, must be supported by best practice decision aids to support decision-making.

"I Don't Really Know What Diabetes Is": A Qualitative Study Exploring the Experiences of Aboriginal and Torres Strait Islander Young People Aged 10 to 25 Years Living With Type 2 Diabetes in Northern and Central Australia.

OBJECTIVE: Our aim in this study was to gain an understanding of the experiences of Aboriginal and Torres Strait Islander young people aged 10 to 25 years with type 2 diabetes (T2D) living in Northern and Central Australia. METHODS: In this qualitative study we explored participants' experiences of T2D using a social constructionist epistemology and a phenomenologic methodology. Twenty-seven young people participated in semistructured in-depth interviews from 4 primary health-care sites. RESULTS: Three major constructs emerged. Young people experienced a normalisation-shame paradox in response to their diagnosis (partly related to that "everyone has diabetes," as well as the fear that friends "might judge [me]"), had suboptimal levels of understanding of T2D ("I don't really know what diabetes is. I just need somebody to explain to me a bit more") and experienced multiple barriers inhibiting their T2D management. These included complex lives ("I have a rheumatic heart disease […] then they told me that I have diabetes…I have two things") and the availability of support ("[I] talk to my mum…I talk to my aunty too…I don't talk to anyone else"). Successful management requires support from health professionals and family and includes strengthening social networks and educational opportunities. CONCLUSIONS: Our findings reinforce the need for alternative support systems tailored to the specific needs of young Aboriginal and Torres Strait Islander people with T2D. Enhanced models of care must be codesigned with young people and their communities and include a focus on shifting norms and expectations about youth T2D to reduce diabetes stigma and broaden social support and consider the delivery of health information in youth-friendly environments.

Improving systems of prenatal and postpartum care for hyperglycemia in pregnancy: A process evaluation.

OBJECTIVE: To identify successes to date and opportunities for improvement in the implementation of a complex health systems intervention aiming to improve prenatal and postpartum care and health outcomes for women with hyperglycemia in pregnancy in regional and remote Australia. METHODS: A qualitative evaluation, underpinned by the RE-AIM framework (reach, effectiveness, adoption, implementation, maintenance), was conducted mid-intervention. Semi-structured interviews were conducted with the participants, who included clinicians, regional policymakers and managers, and study implementation staff. RESULTS: Interviewees (n = 45) reported that the early phase of the intervention had resulted in the establishment of a clinician network, increased clinician awareness of hyperglycemia in pregnancy, and improvements in management, including earlier referral for specialist care and a focus on improving communication with women. Enablers of implementation included existing relationships with stakeholders and alignment of the intervention with health service priorities. Challenges included engaging remote clinicians and the labor-intensive nature of maintaining a clinical register of women with hyperglycemia in pregnancy. CONCLUSION: The early phase of this health systems intervention has had a positive perceived impact on systems of care for women with hyperglycemia in pregnancy. Findings have informed modifications to the intervention, including the development of a communication and engagement strategy.

My experiences with kidney care: A qualitative study of adults in the Northern Territory of Australia living with chronic kidney disease, dialysis and transplantation.

BACKGROUND: Australian healthcare quality and safety accreditation standards recommend health services partner with health care users, to ensure the highest quality of care. Aboriginal Australians with chronic and end stage kidney disease have high health care access needs. AIM: To describe the experiences of health care users of a large government kidney healthcare service provider. METHODS: Within a government renal health service in the Top-End of the Northern Territory, we undertook a qualitative study involving in-depth interviews with 26 adult clients from urban, regional and remote settings who were living with kidney health conditions. RESULTS: Client characteristics included a mean age of 55 years, 55% female and 81% identifying as Aboriginal. The kidney related conditions of client participants included CKD (11, 42.3%), haemodialysis (12, 46.2%), peritoneal dialysis (1, 3.9%), and transplant (2, 7.7%). Key themes emerging from patient interviews related to perceived gaps for clients and carers including: 1) knowledge gaps about the health condition, 2) the impact of relocation in order to access centrally-based renal care, 3) healthcare staff professionalism and qualities and 4) service environments. Overall, the experiences centred on a greater need for client-centred, respectful and culturally based healthcare support. Clients recommended the need for patient-led collective care, including sustaining an Indigenous Patient Reference Group to support ongoing healthcare service decision processes. Participants included in almost equal proportion, clients with CKD (without dialysis) and clients utilising renal replacement therapy, which adds significant weight to the client-identified recommendations for highest quality of kidney care across a wide spectrum of kidney function. CONCLUSION: Four major themes identified by clients related to their experience with renal care provided by this major regional health care provider: knowledge gaps of their own condition, the lived impacts of relocating to access health care, service environments, and Health Care Provider Quality. An Indigenous Patient Reference Group was one mechanism recommended to support the co-design of preferred care models.

Long-Term Pulmonary Outcomes of a Feasibility Study of Inverse-Planned, Multibeam Intensity Modulated Radiation Therapy in Node-Positive Breast Cancer Patients Receiving Regional Nodal Irradiation.

PURPOSE: Multibeam intensity modulated radiation therapy (IMRT) enhances the therapeutic index by increasing the dosimetric coverage of the targeted tumor tissues while minimizing volumes of adjacent organs receiving high doses of RT. The tradeoff is that a greater volume of lung is exposed to low doses of RT, raising concern about the risk of radiation pneumonitis (RP). METHODS AND MATERIALS: Between July 2010 and January 2013, patients with node-positive breast cancer received inverse-planned, multibeam IMRT to the breast or chest wall and regional nodes, including the internal mammary nodes (IMNs). The primary endpoint was feasibility, predefined by dosimetric treatment planning criteria. Secondary endpoints included the incidence of RP grade 3 or greater and changes in pulmonary function measured with the Common Terminology Criteria for Adverse Events version 3.0 scales, pulmonary function tests and community-acquired pneumonia questionnaires, obtained at baseline and 6 months after IMRT. Clinical follow-up was every 6 months for up to 5 years. RESULTS: Median follow-up was 53.4 months (range, 0-82 months). Of 113 patients enrolled, 104 completed follow-up procedures. Coverage of the breast or chest wall and IMN was comprehensive (median 48.1 Gy and 48.9 Gy, respectively). The median volume of lung receiving a high dose (V20Gy) and a low dose (V5) was 29% and 100%, respectively. The overall rate of respiratory toxicities was 10.6% (11/104), including 1 grade 3 RP event (0.96%). No differences were found in pulmonary function test or community-acquired pneumonia scores after IMRT. The 5-year rates of locoregional recurrence-free, disease-free, and overall survival were 93.2%, 63.6%, and 80.3%, respectively. CONCLUSIONS: Multibeam IMRT in patients with breast cancer receiving regional nodal irradiation was dosimetrically feasible, based on early treatment planning criteria. Despite the large volume of lung receiving low-dose RT, the incidence of grade 3 RP was remarkably low, justifying inverse-planned IMRT as a treatment modality for patients with high-risk breast cancer in whom conventional RT techniques prove inadequate.

Improving health service access and wellbeing of young Aboriginal parents in an urban setting: mixed methods evaluation of an arts-based program.

OBJECTIVES: To evaluate an urban art-based community health program (Ngala Nanga Mai; We Dream) that seeks to improve health, education, empowerment and connectedness of Aboriginal parents by describing paediatric health service attendance, maternal educational engagement, participant growth and empowerment, and worker and participant experiences. METHODS: Mixed methods were used. Qualitative data was collected through interviews and focus groups. Demographics, health service use and child health status were extracted from clinical records. Psycho-social empowerment and wellbeing was measured using the Growth and Empowerment Measure (GEM). A Critical Effectiveness Factor framework that measures factors necessary for success, effectiveness and sustainability was used to assess program quality. RESULTS: Between 2009 and 2012, 92 Aboriginal parents participated. A total of 93.5% of regular participants engaged their children at least once with paediatric health services and 27.1% undertook further education. Empowerment scores significantly improved, despite little change in psychological distress. The program operationalised all 10 Critical Effectiveness Factors for youth wellbeing. CONCLUSIONS: Ngala Nanga Mai creates an environment of social connectedness, strengthened parenting, maternal and child wellbeing and empowerment. It supports increased utilisation of health, education and support services, and early detection of treatable child health issues. IMPLICATIONS: Improving the health of Aboriginal children requires new strategies and learning from innovative programs. Solid baseline data, long-term follow-up data and meaningful health outcome data are critical to improving services and health outcomes at the program level. Ultimately, long-term commitment to adequate resourcing is needed in order to deliver broader improvement of child health outcomes.