Characteristics, cardiovascular comorbidity and medicines management in patients with type 2 diabetes and CKD: results of the IRIDIEM study.

BACKGROUND: Type 2 diabetes is a leading cause of chronic kidney disease (CKD). The purpose of the Individual Risk-Profiling and Treatment in Diabetes Management (IRIDIEM) study was to evaluate the characteristics of CKD and associated comorbidities in patients with type 2 diabetes and CKD. METHODS: IRIDIEM was conducted as a cross-sectional survey in 109 centres in 11 countries and included 1,205 patients aged >or=50 years with type 2 diabetes for >or=5 years and CKD stage 2-4. RESULTS: 50% of patients were in CKD stage 4; 42% had CKD stage 3, and 4% were in CKD stage 2. Concomitant risk factors for cardiovascular disease and/or progression of CKD included hypertension (92% of patients), proteinuria (74%), hypercholesterolaemia (65%), and hypertriglyceridaemia (44%). Only 64% of patients with hypertension had received antihypertensive medication. Anaemia was present in 34% of patients and increased markedly with advanced CKD stages. Of patients with documented anaemia, only 19% had received epoetin and only 7% had received iron treatment. CONCLUSION: IRIDIEM documents the need to improve adherence to current best practice guidelines for management of cardiorenal risk factors including earlier initiation of antihypertensive treatment, lipid and anaemia management in this high-risk patient population.

Blind Pew sends a black spot: the current haemoglobin controversy.

Two randomised controlled trials of anaemia management published in the last year have fuelled the current haemoglobin controversy and led the United States Food and Drug Administration to issue a public health advisory warning concerning the use of erythropoiesis-stimulating agents and target haemoglobin levels. There is much more to the haemoglobin controversy than purely target haemoglobin levels. This article seeks to outline some of the current issues involved.

Experience of 5-aminosalicylate nephrotoxicity in the United Kingdom.

AIM: To study 5-aminosalicylate nephrotoxicity in patients with inflammatory bowel disease in the UK. METHODS: A detailed postal questionnaire was sent to all 1298 names in the British Society of Gastroenterology database and 290 consultant members of the Renal Association. The British Society of Gastroenterology reported new cases monthly, the Renal Association 6 monthly. Results were expressed as estimated glomerular filtration rate. RESULTS: Retrospective study: cases--British Society of Gastroenterology:Renal Association 202:87, aged 15-76 years. Median peak (range) creatinine (British Society of Gastroenterology:Renal Association) - 300:301 (78-1200) micromol/L. Prospective study - 59 cases, median age 52 years (M:F ratio: 47:12). Median pre-treatment estimated glomerular filtration rate: 76.9 (123.9-39), at diagnosis 28.4 (80.5-3.6, creatinine range: 92-1361 micromol/L), recovery 46.8 [111.2-end stage renal failure] mL/min/1.73 m2. Recovery of renal function was significantly improved for patients treated for < 12 months [n = 10, median recovery estimated glomerular filtration rate 70.5 (92-26.9) vs. > 12 months 38.4 (111.2-end stage renal failure) mL/min/1.73 m2, P = 0.028]. CONCLUSIONS: Regular monitoring of renal function may allow earlier detection of nephrotoxicity, particularly during the first year of therapy. Based on an inflammatory bowel disease prevalence in the United Kingdom of 412 x 10(5) with about 50% on treatment, we estimate that the incidence of clinical nephrotoxicity in patients taking 5-aminosalicylate therapy is approximately one in 4000 patients/year.

Severe acute renal failure in adults: place of care, incidence and outcomes.

BACKGROUND: Department of Health guidelines recommend specialist critical care facilities for patients with severe single-organ failure such as acute renal failure (ARF). Prospective studies examining incidence, causes and outcomes of ARF outside of intensive care settings are lacking. AIM: To determine the incidence, causes, place of care and outcomes of severe single-organ ARF. DESIGN: Prospective observational study. METHODS: For 6 weeks in June-July 2003, renal physicians were contacted daily, and ICUs on alternate days, to identify cases of severe single-organ ARF in the Greater Manchester area. All patients with serum creatinine >or=500 micromol/l and not requiring other organ support were included. Patients with end-stage renal disease were excluded. Survivors were followed up at 90 days and 1 year from admission. Two independent consultant nephrologists assessed each case using anonymized summaries. RESULTS: Eighty-five patients had multi-organ ARF and 28 had severe single-organ ARF (380 and 125 pmp/year, respectively). Of those with single-organ ARF, 10 (36%) had known pre-existing chronic kidney disease. Renal replacement therapy (RRT) was required in 15 (54%). Total bed occupancy on ICUs relating to single-organ ARF was 59 days (range per patient 1-21). At 90 days, 18 (64%) were alive, and 17 (94%) had independent renal function. At 1 year, 4/18 had died, none receiving RRT at the time of death. Survivors all had independent renal function. In 13 (46%) cases there was an unacceptable delay in patient transfer and in 7 (25%), delays in assessment or commencement of RRT may have adversely affected patient outcome. DISCUSSION: The incidence of ARF treated with RRT is rising. Delays in transfer to renal services may result in inappropriate ICU bed use, and may adversely affect patient outcomes. There are serious problems regarding the appropriate use of expensive and limited medical resources in the critical care area, and in providing safe and effective treatment of patients with ARF.

Review article: interstitial nephritis associated with the use of mesalazine in inflammatory bowel disease.

5-Aminosalicylic acid (5-ASA) has replaced sulphasalazine as first line therapy for mild to moderately active inflammatory bowel disease and is widely used. A number of reports have linked oral 5-ASA therapy to chronic tubulo-interstitial nephritis and this relationship is now well established. Despite increasing recognition of the potential for this serious adverse event, guidelines for monitoring renal function in patients prescribed 5-ASA preparations are not widely employed. Whilst the incidence of this adverse event in the population of patients with inflammatory bowel disease treated with mesalazine is low, the morbidity in an affected individual is high with some cases progressing to end-stage renal disease. Routine monitoring of renal function is simple and inexpensive and could prevent this outcome. Based on the available data, serum creatinine should be estimated prior to commencing treatment, monthly for the first 3 months, 3-monthly for the next 9 months, 6-monthly thereafter and annually after 5 years of treatment.

Acute acalculous cholecystitis in acute renal failure.

Acute acalculous cholecystitis developed in 16 of 92 patients with acute renal failure who had no prior or coincidental biliary tract disease. The cause of this complication is considered to be multifactorial. Risk factors include sepsis, previous surgery, trauma, total parential nutrition, intermittent positive pressure ventilation, opiate sedation, multiple transfusions and hypotension. One patient had 5 risk factors, 15 had 6 or more. Diagnosis was based on clinical suspicion, serial ultrasound scanning and serial estimations of white cell count, liver function and C-reactive protein. Four patients were treated conservatively with antibiotics and ultrasound observation, 10 underwent cholecystotomy and 2 patients had cholecystectomy. Eleven patients survived (69% survival). No patient treated by cholecystotomy required further surgery to the biliary tract. Acute acalculous cholecystitis has become a significant complication in our "high risk" acute renal failure population as intensive care has advanced and patients are surviving longer. Prompt and appropriate treatment will prevent it contributing significantly to the already high mortality of acute renal failure. Anticipation is the watchword.

Noninvasive monitoring of renal blood flow characteristics during acute renal failure in man.

Duplex Doppler ultrasound (DDU) was used to study the blood flow characteristics of the renal interlobar artery in 20 subjects with acute renal failure (ARF), 14 subjects with transient impairment of renal function and 23 control subjects with normal function. Renovascular resistance was assessed by pulsatility index (PI) and change in flow velocity by change in mean frequency shift (delta f). The 99% confidence intervals for PI in the three groups were 3.32-5.46, 1.58-2.34 and 0.99-1.33 respectively. Values for delta f were 0.2-0.38, 0.5-0.62 and 0.7-1.02 kHz respectively. Ten ARF patients recovered function, 99% confidence intervals for PI just prior to recovery were 0.9-1.48 and for delta f 0.52-1.02 kHz. There was increased renovascular resistance and reduced intrarenal blood flow velocity at the onset of ARF. These changes persisted during ARF; recovery of function occurred after they returned to normal. Similar, but less marked, changes were found in patients with a transient impairment of function.

Non-specialist management of acute renal failure.

In a 12-month prospective study of the initial management of patients with acute renal failure (ARF) in East Kent (population 593 000), we evaluated the initial management of ARF and assessed what proportion of ARF may have been preventable. Patients were seen and assessed on a daily basis, and were followed until discharge from hospital or death; survivors were subsequently followed for 3 years. Overall, 288 patients developed ARF (486 per million population/year). Mean age at presentation was 73 years (range 14-96). Initial assessment was often suboptimal, and key features in investigation and initial management were often lacking. In 108 cases, ARF was iatrogenic and/or potentially preventable (53 preventable, 99 iatrogenic, 44 both). Overall survival was 56% at discharge from hospital, 35% at 1-year follow-up, 31% at 2 years, and 28% at 3 years. In discharged patients, recovery of function was complete in 69%. A significant proportion of ARF is preventable. Clear guidelines, easily accessible at the point of care, could aid the diagnostic evaluation of the patient with ARF and indicate where referral for a specialist opinion is appropriate.

HIV prevention education for lesbians and bisexual women: a cultural analysis of a community intervention.

AIDS is increasing almost four times as fast among women, yet lesbians and bisexual women are among the least studied, least understood and most elusive populations affected by the AIDS epidemic. This paper reports the results of community-level HIV prevention research designed: (a) to examine the knowledge, perceptions, social contingencies and political constraints affecting the HIV risk taking of lesbians and bisexual women; and (b) to offer them context specific HIV prevention education. The study was a peer educator-based intervention project situated in San Francisco's women's bars, dance clubs, and sex clubs to reach socially and sexually active lesbians and bisexual women in natural settings. Between June 1992 and May 1993, ethnographic interviews were conducted with 626 women attending the bars and clubs; group presentations at these locales reached 1,315 women. The structure of the intervention was effective in prompting interest in HIV prevention information and intent to change behavior. The resultant cultural analysis details risk behaviors lesbians and bisexual women participate in, myriad constraints they face in trying to enact safer behaviors, gaps in knowledge, difficulties comprehending the relevance of HIV prevention, and risk reduction strategies commonly employed.

Maternal role of clerical workers: a feminist analysis.

This paper presents the qualitative findings about women's maternal role from an interview study of role integration and health in a U.S. sample of 87 women clerical workers. The data draws from clerical women's perceptions of the satisfactions and stresses they experience in their roles as mothers, the coping strategies they use, and the resources available to them. The analysis provided is based on participants' descriptions of their subjective experiences as mothers within the larger context of managing domestic responsibilities and fulltime jobs outside their homes. Results suggest that women in clerical jobs find many aspects of their maternal role satisfying, like participating in their children's growth, nurturing them, receiving unconditional love, and finding companionship. However, they identify multiple and pervasive stresses including boundless worries, strained relationships, overload, child care problems, and financial burdens. Many of their coping strategies are solitary in nature, although they also engage in active problem-solving, especially when they have to juggle child care and occupational responsibilities. Many do not view their spouses as sources of emotional and tangible support in childrearing. In addition to an in-depth discussion of qualitative findings, the authors examine implications for social policy, intervention, and future research about multiple roles and health.

Participatory action research for sustaining individual and community change: a model of HIV prevention education.

The authors describe the implementation, results, and evaluations of a participatory action research project in which they used qualitative methods to do HIV prevention education with lesbians and bisexual women. This grassroots project combined collective consciousness-raising, qualitative field interviewing, and individualized HIV prevention education in an experientially intense intervention sustained over a 2-year period in community sites. Systematic data collection about HIV risk taking among lesbians and bisexual women was conjoined with efforts to mobilize the community for behavior change to prevent HIV. A cadre of peer educators conducted 1,189 field interviews and produced 55 HIV prevention presentations with a total of 3,665 women in attendance. Key findings describe the HIV risk taking common in this population and their needs for support in reducing risk. Process evaluations of the project suggest that its combined individual and group approach and its continuity over time were effective. Outcomes suggest that the project positively affected participants' intent to change risk behaviors, supported incremental changes to reduce risk, assisted participants in the interpersonal realm of partner negotiations, and began to change community conventions about sexual expectations and practices.

Stability of parathyroid hormone ex vivo in haemodialysis patients.

BACKGROUND: The stability of parathyroid hormone (PTH) in blood ex vivo is a significant practical problem for laboratories and clinicians. Several studies have suggested that PTH is more stable in blood collected into a potassium edetate (EDTA) preservative. METHODS: To confirm that this was applicable to renal dialysis patients using our assay (Nichols chemiluminescence), we examined PTH stability in 13 patients with end-stage renal failure using three different blood collection tubes. RESULTS: PTH remained stable in EDTA plasma for up to 48 h at room temperature. PTH was significantly reduced in serum collected into plain tubes after 2 h, and after 4 h in serum collected into serum separator tubes, at room temperature. CONCLUSION: In the assessment of renal osteodystrophy, the use of EDTA plasma can confer significant benefit, especially in busy laboratories where rapid frozen separation of blood may be hard to achieve.

Sexuality and safer sex: the issues for lesbians and bisexual women.

UNLABELLED: Nursing interventions to help women reduce their risk of contracting HIV must be designed from an in-depth understanding of the complex sociocultural patterns of sexuality in particular communities and among specific subgroups. OBJECTIVE: In this data collection phase of a community-based HIV prevention project, the objective was to understand HIV risk-taking and HIV risk-reduction activities of lesbians and bisexual women. DESIGN: Qualitative field study. SETTING: Data were collected in women's bars and dance clubs and at selected lesbian/bisexual community events in San Francisco. PARTICIPANTS: Interviews were conducted with 1,189 racially diverse, socially and sexually active lesbians and bisexual women. RESULTS: Inductive content analysis produced two themes: realities of sexual behavior and sexual expressions and their meanings. Realities of sexual behavior included an assumption that women who have sex with other women cannot get HIV, a lack of familiarity with HIV prevention strategies, inconsistent practice of safer sex with men and/or women, and the negative effect of alcohol or drug use on safer sex efforts. Sexual expressions and their meaning included trust in monogamy, a sense that safer sex practices detracted from intimacy and eroticism, the difficulty of negotiating sexual behaviors with men or women, and dealing with partner resistance to safer sex practices. CONCLUSIONS: Specific recommendations for practice are the need for nurses to understand the range and diversity of women's sexual behaviors, to develop skills in conducting inclusive sexual histories, and to develop a comprehensive approach to sexual health.

A descriptive study of the handwashing environment in a long-term care facility.

The authors present a clinical research project accomplished by a nurse during her first year of practice after graduating from a B.S.N. program. In her caregiving at a long-term care facility subacute unit, she was unable to do proper handwashing. The poorly placed pump-style paper towel dispensers were inadequate for the task. She knew that handwashing before and after resident contact is the single most effective infection control measure to prevent nosocomial infections. In consultation with her university professor, she designed and implemented a descriptive study of the facility's handwashing environment. She mapped and measured handwashing areas, explained constrictions the environment placed on handwashing technique, collected random cultures from the sinks and dispenser levers, and illustrated for administrative and auxiliary personnel the basic principles of microbiology. Implications for infection prevention and control in long-term care facilities are discussed in light of increased "high-end skilled nursing" being offered in subacute units.

Inclusion of children in clinical research: lessons learned from mothers of diabetic children.

Nine mothers of diabetic children participated in a qualitative study about the factors that influenced them to consent to have their children involved in clinical research. They were asked to describe how they made decisions about involving their children in research, what motivated them to keep their children in research once they were enrolled, and how they evaluated the clinical studies their children had been in. Results suggest that mothers engage in a personal calculus before making a choice to consent.

Lesbians' health-related experiences of care and noncare.

In this feminist narrative study using in-depth interviews, focus groups, and a multistaged narrative analytic approach, a racially and economically diverse sample of 45 lesbians conveyed their health care experiences. Participants recounted a total of 332 health care interactions across a wide range of health care facilities, health care providers, and health conditions; 23% of these interactions they evaluated positively and 77%, negatively. In their stories, lesbians described the pivotal dimensions of face-to-face health care from their perspective as clients. Each of these interactional dimensions is defined by a fundamental experiential contrast gleaned from their descriptions of caring and noncaring clinical situations. They are as follows: existence: reflection versus facelessness; bodily integrity: intimate care versus intrusion; emotional integrity: sheltered versus shamed; worth: sustained versus abandoned; expression: voiced versus silenced; and power: solidarity versus dominance.

A nursing critique of US welfare system reform.

In 1996, the Aid to Families with Dependent Children program was repealed, and the welfare system in the United States was changed. This article critiques, from a nursing perspective, US welfare system reform. It interrogates dominant ideologies about poverty, welfare, and waged labor; examines federal welfare reform legislation of the 1990s and its programmatic implementation at the state level; discusses global health and safety implications of welfare replacement initiatives; and challenges nurses to political and scholarly action.

Marginalized women's access to health care: a feminist narrative analysis.

In the emergent restructuring of health care, it is imperative to examine marginalized consumers' experiences with access to care so that the process addresses not merely the issue of rising health care costs, but also begins to meet the actual health care needs of diverse communities. This report of a feminist narrative study of access for low-income lesbians from several ethnic/racial groups provides critique of the US health care system from the standpoint of consumers and offers a transformative vision of what a just, effective, and compassionate system might encompass. By generating compelling evidence about the access afforded in current models of health care delivery, this study serves as an example of the significance of its methodological innovations, sampling from the margins, and narrative design.

A critical social reconceptualization of environment in nursing: implications for methodology.

Nursing is being challenged to forge a broader, more comprehensive view of the environment that incorporates social, political, and economic realities. A critical social reconceptualization of the environment offers not only an organizing perspective but an invitation for nursing practice and research to act to transform the environmental conditions that constrain health and human potential. Critical social theory offers a vision for the future wherein innovative nursing knowledge can be used by individuals and communities to alter oppressive environmental circumstances and to increase potential for emancipatory change.