Survey study of trends in adult nephrology advanced training in Australia and New Zealand.

BACKGROUND: There has been considerable growth in nephrology advanced trainee numbers in Australia and New Zealand, with uncertain effects on clinical experience, competence and employment outcomes. AIMS: To review the perceived adequacy and temporal trends of advanced training in nephrology in Australia and New Zealand by evaluating training experiences, personal views on important aspects of training and nephrology, career paths and early employment outcomes. METHODS: An online survey was distributed to members of the Australian and New Zealand Society of Nephrology through email in December 2020. Responses were sought from current trainees and from nephrologists qualifying since 2014. Likert scale proportions were calculated and group comparisons made using the Chi-squared test. RESULTS: A total of 88 participants returned the survey yielding a response rate of 32%, with a representative sample of trainees and consultants from across Australia and New Zealand. Training was reported as adequate in most aspects of clinical nephrology, although 88% of respondents felt poorly prepared for entering private practice and 61% reported inadequate training in kidney histopathology. Exposure to clinical procedures was variable, with adequate training in percutaneous kidney biopsy, but mostly inadequate training in dialysis access insertion. Sixty-nine percent of nephrologists completed their advanced training entirely in large urban centres and 85% worked in an urban area after training. Only 23% of consultants were engaged in full-time clinical employment in their first-year post-training and 78% were undertaking at least one of dual specialty training or a higher degree by research. Demand for subspecialty fellowships was high. CONCLUSION: Trainees and nephrologists in Australia and New Zealand are currently satisfied with their training in most aspects of nephrology; however, some clinical experiences are perceived as inadequate and early career paths after advanced training are increasingly diverse.

Suspension and resumption of kidney transplant programmes during the COVID-19 pandemic: perspectives from patients, caregivers and potential living donors - a qualitative study.

Many countries have suspended kidney transplantation programmes during the COVID-19 pandemic because of concerns for patient safety and the shortage of healthcare resources. This study aimed to describe patient, family member and potential donor perspectives on the suspension and resumption of kidney transplant programmes due to COVID-19. We conducted seven online focus groups involving 31 adult kidney transplant candidates (n = 22), caregivers (n = 4) and potential donors (n = 5). Transcripts were analysed thematically. We identified five themes: cascading disappointments and devastation (with subthemes of shattering hope, succumbing to defeat, regret and guilt); helplessness and vulnerability (fear of declining health, confronted by the threat of and change in dialysis, disconnected from health care, susceptibility to infective complications); stress from uncertainty (confusion from conflicting information, unable to forward plan), exacerbating burdens (incurring extra financial costs, intensifying caregiver responsibilities), and sustaining health through the delay (protecting eligibility, relying on social support, adapting to emerging modalities of care). During the suspension of kidney transplantation programmes, patients felt medically vulnerable because of declining health, susceptibility to infection and reduced access to care. There is a need to address health vulnerabilities, disappointment, uncertainty and additional burdens arising from the suspension of kidney transplantation programmes.

Lack of impact of donor age on patient survival for renal transplant recipients ≥60years.

There has been an increase in the number of older patients on the transplant waiting list and acceptance of older donor kidneys. Although kidneys from older donors have been associated with poorer graft outcomes, whether there is a differential impact of donor age on outcomes in older recipients remains unclear. The aim of this study was to evaluate the effect of donor age on graft and patient survival in renal transplant (RT) recipients ≥60years. Using the Australia and New Zealand Dialysis and Transplant Registry, outcomes of 1,037 RT recipients ≥60years between 1995 and 2009 were analyzed. Donor age groups were categorized into 0-20, >20-40, >40-60, and >60years. Compared with recipients receiving donor kidneys >60years, those receiving donor kidneys >20-40years had lower risk of acute rejection (odds ratio 0.46, 95% CI 0.27, 0.79; P<0.01) and death-censored graft failure (HR 0.37, 95% CI 0.19, 0.72; P<0.01). There was no association between donor age groups and death. With a corresponding growth in the availability of older donor kidneys and the observed lack of association between donor age and patient survival in RT recipients ≥60years, preferential allocation of older donor kidneys to RT recipients ≥60years may not disadvantage the life expectancy of these patients.

A review of utility-based allocation strategies to maximize graft years of deceased donor kidneys.

With the continuing shortage of deceased donor kidneys coupled with a growing number of older potential recipients, there has been a greater acceptance of using older donor kidneys, including increased utility of expanded criteria donor (ECD) kidneys. In this review, we will look at the impact of using ECD kidneys on graft and patient survival, and to identify modifiable factors that may improve transplant outcomes in recipients receiving ECD kidneys. In addition, we will discuss whether the implementation of utility-based allocation strategies to maximize graft outcomes is an appropriate way forward to provide a better balance between utility and equity in the distribution of deceased donor kidneys.

Developing tailored immunization materials for concerned mothers.

The objectives of this study were to (i) identify 'Worried' and 'Fencesitter' mothers through the use of screening questions; (ii) obtain detailed information from participants about their attitudes and beliefs regarding vaccines and their interactions with their child's main health care provider, including availability of immunization information; (iii) solicit comments on draft educational materials that were developed specifically for this study and (iv) solicit comments on revised educational materials. Focus groups of mothers were conducted in two phases (Phase 1: n = 17 groups; Phase 2: n = 12 groups) and in three cities across the United States. Phase 1 focus group discussions suggested that perceived necessity and safety of vaccines contributed to mothers' attitudes about having their child receive immunizations. Participants relied on their children's main health care provider for immunization information; however, mothers often perceived that providers did not supply enough information about vaccinations. In Phase 2, comments on the revised educational materials (brochures) were generally positive, with many mothers noting that the new brochures provided more relevant information and conveyed it in a respectful way. Science-based tailored immunization materials may assist health care providers in addressing unique information needs and may improve vaccine acceptance among specific types of mothers.

Randomized, controlled trial of topical exit-site application of honey (Medihoney) versus mupirocin for the prevention of catheter-associated infections in hemodialysis patients.

The clinical usefulness of hemodialysis catheters is limited by increased infectious morbidity and mortality. Topical antiseptic agents, such as mupirocin, are effective at reducing this risk but have been reported to select for antibiotic-resistant strains. The aim of the present study was to determine the efficacy and the safety of exit-site application of a standardized antibacterial honey versus mupirocin in preventing catheter-associated infections. A randomized, controlled trial was performed comparing the effect of thrice-weekly exit-site application of Medihoney versus mupirocin on infection rates in patients who were receiving hemodialysis via tunneled, cuffed central venous catheters. A total of 101 patients were enrolled. The incidences of catheter-associated bacteremias in honey-treated (n = 51) and mupirocin-treated (n = 50) patients were comparable (0.97 versus 0.85 episodes per 1000 catheter-days, respectively; NS). On Cox proportional hazards model analysis, the use of honey was not significantly associated with bacteremia-free survival (unadjusted hazard ratio, 0.94; 95% confidence interval, 0.27 to 3.24; P = 0.92). No exit-site infections occurred. During the study period, 2% of staphylococcal isolates within the hospital were mupirocin resistant. Thrice-weekly application of standardized antibacterial honey to hemodialysis catheter exit sites was safe, cheap, and effective and resulted in a comparable rate of catheter-associated infection to that obtained with mupirocin (although the study was not adequately powered to assess therapeutic equivalence). The effectiveness of honey against antibiotic-resistant microorganisms and its low likelihood of selecting for further resistant strains suggest that this agent may represent a satisfactory alternative means of chemoprophylaxis in patients with central venous catheters.

West Nile virus risk assessment and the bridge vector paradigm.

In the northeast United States, control of West Nile virus (WNV) vectors has been unfocused because of a lack of accurate knowledge about the roles different mosquitoes play in WNV transmission. We analyzed the risk posed by 10 species of mosquitoes for transmitting WNV to humans by using a novel risk-assessment measure that combines information on the abundance, infection prevalence, vector competence, and biting behavior of vectors. This analysis suggests that 2 species (Culex pipiens L. and Cx. restuans Theobald [Diptera: Cilicidae]) not previously considered important in transmitting WNV to humans may be responsible for up to 80% of human WNV infections in this region. This finding suggests that control efforts should be focused on these species which may reduce effects on nontarget wetland organisms. Our risk measure has broad applicability to other regions and diseases and can be adapted for use as a predictive tool of future human WNV infections.

Psychological determinants of willingness to taste and purchase genetically modified food.

Decreasing acceptance of biotechnologies over time has been reported in Europe. Studies claim that attitudes are negative, even hostile, and that people are very worried about genetic engineering in food and medicine. However, such studies are mostly based on surveys and these have significant methodological problems, such as low response rates, which may indicate that only those with strong views respond, thus biasing the sample. Here an alternative method, involving "topic-blind" recruitment of participants and a behavioral measure (food tasting), was used. We show that in a topic-blind sample of 100 individuals, 93% willingly tasted and ate what they believed to be genetically modified (GM) food in an experimental setting, and 48% said they would buy GM food in the future, results that are surprising in the context of other reports about attitudes and intentions toward GM food. Purchasers and nonpurchasers differed in their attitudes toward GM food on key risk-related scales (particularly on a dread-not dread scale--a measure of integral affect--and an ethical-unethical scale). Despite these differences, however, and despite their negative attitude, most nonpurchasers (85.7%) still tasted the GM apple. Incidental affect (state stress and trait worry) was not found to influence risk-related judgments about GM food. Integral affect (dread of GM plants and animals used for food) and concerns about the future risks of GM animals in food were found to be key predictors of willingness to purchase GM food.

A comprehensive approach to percutaneous injury prevention during phlebotomy: results of a multicenter study, 1993-1995.

OBJECTIVE: To examine a comprehensive approach for preventing percutaneous injuries associated with phlebotomy procedures. DESIGN AND SETTING: From 1993 through 1995, personnel at 10 university-affiliated hospitals enhanced surveillance and assessed underreporting of percutaneous injuries; selected, implemented, and evaluated the efficacy of phlebotomy devices with safety features (ie, engineered sharps injury prevention devices [ESIPDs]); and assessed healthcare worker satisfaction with ESIPDs. Investigators also evaluated the preventability of a subset of percutaneous injuries and conducted an audit of sharps disposal containers to quantify activation rates for devices with safety features. RESULTS: The three selected phlebotomy devices with safety features reduced percutaneous injury rates compared with conventional devices. Activation rates varied according to ease of use, healthcare worker preference for ESIPDs, perceived "patient adverse events," and device-specific training. CONCLUSIONS: Device-specific features and healthcare worker training and involvement in the selection of ESIPDs affect the activation rates for ESIPDs and therefore their efficacy. The implementation of ESIPDs is a useful measure in a comprehensive program to reduce percutaneous injuries associated with phlebotomy procedures.

A randomized controlled trial of topical exit site mupirocin application in patients with tunnelled, cuffed haemodialysis catheters.

BACKGROUND: Central venous catheters are frequently needed for the provision of haemodialysis, but their clinical usefulness is severely limited by infectious complications. The risk of such infections can be reduced by topical application of mupirocin to the exit sites of non-cuffed catheters or by the use of tunnelled, cuffed catheters. Whether mupirocin offers any additional protection against infection in patients with tunnelled, cuffed haemodialysis catheters has not been studied. METHODS: An open-label, randomized controlled trial was performed comparing the effect of thrice-weekly exit site application of mupirocin (mupirocin group) vs no ointment (control group) on infection rates and catheter survival in patients receiving haemodialysis via a newly inserted, tunnelled, cuffed central venous catheter. All patients were followed until catheter removal and were monitored for the development of exit site infections and catheter-associated bacteraemias. RESULTS: Fifty patients were enrolled in the study. Both the mupirocin (n=27) and control (n=23) groups were similar at baseline with respect to demographic characteristics, comorbid illnesses and causes of renal failure. Compared with controls, mupirocin-treated patients experienced significantly fewer catheter-related bacteraemias (7 vs 35%, P<0.01) and a longer time to first bacteraemia (log rank score 8.68, P<0.01). The beneficial effect of mupirocin was entirely attributable to a reduction in staphylococcal infection (log rank 10.69, P=0.001) and was still observed when only patients without prior nasal Staphylococcus aureus carriage were included in the analysis (log rank score 6.33, P=0.01). Median catheter survival was also significantly longer in the mupirocin group (108 vs 31 days, log rank score 5.9, P<0.05). Mupirocin use was not associated with any adverse patient effects or the induction of antimicrobial resistance. CONCLUSIONS: Thrice-weekly application of mupirocin to tunnelled, cuffed haemodialysis catheter exit sites is associated with a marked reduction in line-related sepsis and a prolongation of catheter survival.