Hemodialysis Clinic Social Networks, Sex Differences, and Renal Transplantation.

This study describes patient social networks within a new hemodialysis clinic and models the association between social network participation and kidney transplantation. Survey and observational data collected between August 2012 and February 2015 were used to observe the formation of a social network of 46 hemodialysis patients in a newly opened clinic. Thirty-two (70%) patients formed a social network, discussing health (59%) and transplantation (44%) with other patients. While transplant-eligible women participated in the network less often than men (56% vs. 90%, p = 0.02), women who participated discussed their health more often than men (90% vs. 45.5%, p = 0.02). Patients in the social network completed a median of two steps toward transplantation compared with a median of 0 for socially isolated patients (p = 0.003). Patients also completed more steps if network members were closely connected (ß = 2.23, 95% confidence interval [CI] 0.16-4.29, p = 0.03) and if network members themselves completed more steps (ß = 2.84, 95% CI 0.11-5.57, p = 0.04). The hemodialysis clinic patient social network had a net positive effect on completion of transplant steps, and patients who interacted with each other completed a similar number of steps.

Automated Cellient(™) cytoblocks: better, stronger, faster?

OBJECTIVE: Cytoblocks (CBs), or cell blocks, provide additional morphological detail and a platform for immunocytochemistry (ICC) in cytopathology. The Cellient(™) system produces CBs in 45 minutes using methanol fixation, compared with traditional CBs, which require overnight formalin fixation. This study compares Cellient and traditional CB methods in terms of cellularity, morphology and immunoreactivity, evaluates the potential to add formalin fixation to the Cellient method for ICC studies and determines the optimal sectioning depth for maximal cellularity in Cellient CBs. METHODS: One hundred and sixty CBs were prepared from 40 cytology samples (32 malignant, eight benign) using four processing methods: (A) traditional; (B) Cellient (methanol fixation); (C) Cellient using additional formalin fixation for 30 minutes; (D) Cellient using additional formalin fixation for 60 minutes. Haematoxylin and eosin-stained sections were assessed for cellularity and morphology. ICC was assessed on 14 cases with a panel of antibodies. Three additional Cellient samples were serially sectioned to determine the optimal sectioning depth. Scoring was performed by two independent, blinded reviewers. RESULTS: For malignant cases, morphology was superior with Cellient relative to traditional CBs (P < 0.001). Cellularity was comparable across all methods. ICC was excellent in all groups and the addition of formalin at any stage during the Cellient process did not influence the staining quality. Serial sectioning through Cellient CBs showed optimum cellularity at 30-40 µm with at least 27 sections obtainable. CONCLUSIONS: Cellient CBs provide superior morphology to traditional CBs and, if required, formalin fixation may be added to the Cellient process for ICC. Optimal Cellient CB cellularity is achieved at 30-40 µm, which will impact on the handling of cases in daily practice.

The feasibility of audiologists removing earwax.

Although cerumen management (CM) is routinely performed by audiologists in some countries, this is currently not the case in the Republic of Ireland. This study involved surveying the opinions of Audiologists and Ear Nose and Throat specialists (ENTs) in relation to audiologists conducting CM. In total, 20 ENT Consultants (29%) and 51 audiologists (64%) in the public services responded to an online survey. There was agreement that CM should be within audiologists' remit. However, with regard to risk, opinions were significantly different, with 15 ENTs (75%), compared to 14 audiologists (27%), in agreement that CM management by audiologists was more risky to patients. Nevertheless, 62 respondents (87%) supported future CM training for audiologists. The. overall similarities of opinion between the two groups contrasted to previous studies that reported strong opposition from ENTs with regard to audiologists managing earwax.

Reducing the incidence of TRALI in the UK: the results of screening for donor leucocyte antibodies and the development of national guidelines.

BACKGROUND AND OBJECTIVES: Transfusion-related acute lung injury (TRALI) is associated with the passive transfusion of leucocyte antibodies in blood products. Blood Transfusion Services have adopted a number of different strategies for reducing the incidence of TRALI, but, while these have been successful, TRALI has not been completely eliminated. Many Transfusion Services have introduced leucocyte antibody screening of donors to further reduce TRALI. This report describes the results of donor leucocyte antibody screening within NHS Blood and Transplant and the guidelines that have been developed for Transfusion Services within the United Kingdom (UK) to reduce the incidence of TRALI. MATERIALS AND METHODS: Blood samples from newly recruited female apheresis donors were tested for human leucocyte antigens (HLA) class I and class II antibodies and granulocyte-specific antibodies. RESULTS: A total of 1157 female donors were evaluated. Three hundred and fifteen (27·23%) donors had HLA class I or II antibodies and were returned to red cell component donation. Fifty-seven (6·77%) of the remaining 842 donors were found to have granulocyte-specific antibodies of which 11 (1·31%) had HNA-specific antibodies. A total of 818 donors (70·70%) were accepted for platelet apheresis, 336 donors (29·04%) were returned to red cell component donation, and three donors with HNA-3a antibodies (0·26%) were deferred from therapeutic donation. CONCLUSIONS: Female donors with leucocyte antibodies were identified in a stratified screening programme. Donors with antibodies were either directed to red cell donation or deferred. This process, combined with other measures that have already been introduced, is anticipated to further reduce the incidence of TRALI.

Smoking among males in the UK Armed Forces: changes over a seven year period.

OBJECTIVES: We assessed socio-demographic and military factors associated with smoking among males in the UK Armed Forces; made comparisons with the general population; and, tested the hypothesis that smoking has declined in the Armed Forces. METHODS: Using data from two cross-sectional studies (conducted in 1998 and 2004), we examined the patterns of smoking among regular male UK Service personnel aged 20-49 years and made comparisons with general population data from England, Scotland and Wales. RESULTS: In 2004, the prevalence of smoking among military males aged 20-49 years was 30% (n=2276), compared to 33% within the general population. Among current smokers, the mean number of cigarettes smoked per day was 15 for the military and 14 for the general population. The prevalence of smoking has decreased in lower ranks between 1998 and 2004 by 5.1% in 20-24 year olds to 6.3% in 35-49 year olds. These decreases are similar to those seen within those in the routine, manual or intermediate socio-economic group. CONCLUSIONS: Smoking among males in the UK military is associated with similar factors to those in the general population. As these factors are clustered in younger personnel, policies to decrease smoking should be targeted at younger recruits.

Diuretic lounge and the impact on hospital admissions for treatment of decompensated heart failure.

BACKGROUND: Heart failure is a prevalent condition associated with frequent and costly hospital admissions. Hospitalizations are primarily related to worsening fluid retention and often require admission for decongestion with intravenous diuretics. OBJECTIVE: To assess the safety of an outpatient intravenous diuresis service for heart failure patients, and its impact on emergency admissions and the cost of treatment. METHODS: We conducted a prospective observational cohort registry study on patients referred to the diuretic lounge at our acute hospital between May 2017 and April 2018. RESULTS: We analysed 245 patients treated in the diuretic lounge, of which 190 (77.6%) avoided hospitalization or any adverse events during the 60 days of follow up (77.6% vs. 22.4%; P < 0.001). The diuretic lounge service resulted in a significant decrease in emergency heart failure admissions compared to the previous 12 months (823 vs. 715 per annum; 68.6 ± 10.1 vs. 59.6 ± 14 per month; P = 0.04), and a numerical reduction in readmission rates (17.3% vs. 16.2%). The 13.1% decrease in admissions lead to financial savings of £315 497 per annum and £2921 per admission avoided. During the same time period, at the other acute hospital site in our trust, where no diuretic lounge service is available, the number of admissions did not significantly change (457 vs. 450 per annum; 37.5 ± 7.0 vs. 38.1 ± 7.6 per month; P = 0.81). CONCLUSION: Ambulatory administration of intravenous diuretics reduces emergency admissions and is a safe and cost-effective alternative to treat acute decomposition in heart failure patients.

Development of a Telehealth Intervention to Improve Access to Live Donor Kidney Transplantation.

BACKGROUND: Live donor kidney transplantation (LDKT) is underutilized by patients with end-stage kidney disease due to knowledge, communication, and logistical barriers. MATERIAL AND METHODS: The Talking About Live Kidney Donation Social Worker Intervention (TALK-SWI) is a previously validated intervention demonstrated to improve patients' access to and pursuit of LDKT through in-person delivery of education and social support. To help overcome logistical barriers to LDKT, we adapted TALK-SWI into a telehealth intervention employing digital (ie, tablet, smartphone) and telephone technologies. We studied the usability and acceptability of both the mobile device and telephone counseling portions of the intervention among people with kidney disease. For the digital portion, we assessed critical (ie, inability to complete a task) and non-critical (ie, ability to complete a task utilizing an alternative method) errors participants encountered when using the program and their preferences regarding digital materials. Simultaneously, we assessed participants' satisfaction with telephone-adapted counseling compared to the original, in-person counseling. RESULTS: The 15 participants testing the digital technology made 25 critical errors and 29 non-critical errors, while they easily completed 156 tasks (out of 210). A majority of participants (73%) preferred the tablet/smart phone education application over traditional materials, and most (80%) indicated they would be more likely to utilize the mobile platform over traditional materials. Participants testing the telephone-adapted (n = 45) and in-person (n = 125) social worker counseling all reported high satisfaction with the intervention. CONCLUSION: We successfully adapted a validated educational and behavioral intervention to improve access to LDKT into a usable and acceptable telehealth intervention.

Reverse foam sclerotherapy of the great saphenous vein with sapheno-femoral ligation compared to standard and invagination stripping: a prospective clinical series.

OBJECTIVES: Comparison of Reverse Foam Sclerotherapy of the great saphenous vein (GSV) combed with sapheno-femoral junction (SFJ) ligation to standard (Babcock) stripping and invagination (Pin) stripping in a prospective clinical series. DESIGN: Prospective clinical series. MATERIALS AND METHODS: 90 consecutive limbs of 82 patients with incompetence of the GSV resulting in varicose veins were prospectively randomised into 3 groups of 30, treated by SFJ ligation and either reverse foam sclerotherapy, standard stripping or invagination stripping of the GSV. Outcomes were assessed post-operatively and at 2-weeks follow-up. Peri-operative blood loss (24 hrs), analgesic requirement, bruising and residual varicosities were assessed. Bruising was assessed by both patients and independent assessors using questionnaires. RESULTS: SFJ ligation plus reverse foam sclerotherapy of the GSV was associated with significantly less blood loss, bruising and post-op discomfort than either of the stripping techniques. (p<0.001, Mann-Whitney) CONCLUSION: Standard stripping of the GSV and invagination stripping are not associated with major discomfort and problems in the early post-operative period. SFJ ligation and GSV reverse foam sclerotherapy yielded greater patient satisfaction with less post-op bruising and discomfort and reduced analgesic requirements.

How do experiences in Iraq affect alcohol use among male UK armed forces personnel?

OBJECTIVES: This paper reports on a statistically significant association between alcohol use and deployment to the 2003 Iraq War. It assesses the occupational factors and deployment experiences associated with heavy drinking in regular UK servicemen deployed to Iraq in the first phase of the 2003 Iraq War (Operation TELIC 1, the military codename for the conflict in Iraq). METHODS: A random representative sample of 3578 regular male UK Armed Forces personnel who were deployed to Iraq during Operation TELIC 1 participated in a cross-sectional postal questionnaire study (response rate 61%). Participants completed a questionnaire, between June 2004 and March 2006 (ie, after deployment), about their health, including a measure of alcohol use (Alcohol Use Disorders Identification Test, AUDIT) and questions about their experiences on deployment to Iraq. Heavy drinkers were identified as those scoring 16 or above on the AUDIT. RESULTS: After adjustment for sociodemographic and military factors, and the presence of psychological distress, heavy drinkers were more likely to have had major problems at home during (odds ratio (OR) 1.33, 95% confidence interval (CI) 1.04 to 1.70) and following their deployment (OR 1.68, 95% CI 1.32 to 2.14). Being deployed with their parent unit (OR 1.28, 95% CI 1.02 to 1.61), medium to high in-theatre unit comradeship (medium: OR 1.35, 95% CI 1.04 to 1.77; high: OR 1.35, 95% CI 1.02 to 1.79) and poor unit leadership (OR 1.78, 95% CI 1.37 to 2.31) were also associated with heavy drinking. CONCLUSIONS: Deployment experiences and problems at home during and following deployment, as well as the occupational milieu of the unit, influence personnel's risk of heavy drinking.

A quantitative analysis of tumour characteristics in breast cancer patients with extranodal extension in non-sentinel nodes.

BACKGROUND: The presence of extranodal extension (ENE) is well documented as a predictor of non-sentinel lymph node (NSLN) metastasis. The ACOSOG Z0011 trial (2011) concluded that patients who satisfy criteria including the absence of sentinel lymph node (SLN) ENE can forgo axillary clearance (AC). Currently there are no studies analysing the rate of ENE in NSLN metastasis in which the sentinel node was positive but had no ENE. Determining this incidence will help determine if current paradigms are resulting in residual ENE in NSLN metastasis by forgoing AC based on the Z0011 trial.. METHODS: This study determined incidence of ENE at NSLN metastasis in patients with a positive SLN biopsy without ENE in 162 symptomatic breast cancer patients who underwent AC between 2009 and 2014 at Cork University Hospital Breast Cancer Service, a teaching hospital of University College Cork. RESULTS: Of 965 sentinel node biopsies performed 251 were identified as SLN positive, 162 (64.5%) underwent further AC. Of the 162 patients, 56.8% (92/162) were positive for ENE at SLN, of these 57.6% (53/92) had NSLN metastasis versus 17.1% (12/70) in the ENE-negative group (χ2 test; P < 0.001). On adjusted analysis, ENE at the SLN was a significant predictor of NSLN metastasis (odds ratio [OR] 8.63; 95% confidence interval [CI] 3.26-22.86; P < 0.001). The incidence of NSLN-ENE in patients without SLN-ENE was 1/70 (1.4%) compared with 33.7% (31/92) in patients who had ENE at the SLN (χ2 test; P < 0.001). CONCLUSION: ENE at the SLN is an independent predictor of NSLN involvement; its absence significantly reduces the likelihood of ENE in NSLN metastasis..

Putting patients at the center of kidney care transitions: PREPARE NOW, a cluster randomized controlled trial.

Care for patients transitioning from chronic kidney disease to kidney failure often falls short of meeting patients' needs. The PREPARE NOW study is a cluster randomized controlled trial studying the effectiveness of a pragmatic health system intervention, 'Patient Centered Kidney Transition Care,' a multi-component health system intervention designed to improve patients' preparation for kidney failure treatment. Patient-Centered Kidney Transition Care provides a suite of new electronic health information tools (including a disease registry and risk prediction tools) to help providers recognize patients in need of Kidney Transitions Care and focus their attention on patients' values and treatment preferences. Patient-Centered Kidney Transition Care also adds a 'Kidney Transitions Specialist' to the nephrology health care team to facilitate patients' self-management empowerment, shared-decision making, psychosocial support, care navigation, and health care team communication. The PREPARE NOW study is conducted among eight [8] outpatient nephrology clinics at Geisinger, a large integrated health system in rural Pennsylvania. Four randomly selected nephrology clinics employ the Patient Centered Kidney Transitions Care intervention while four clinics employ usual nephrology care. To assess intervention effectiveness, patient reported, biomedical, and health system outcomes are collected annually over a period of 36 months via telephone questionnaires and electronic health records. The PREPARE NOW Study may provide needed evidence on the effectiveness of patient-centered health system interventions to improve nephrology patients' experiences, capabilities, and clinical outcomes, and it will guide the implementation of similar interventions elsewhere. TRIAL REGISTRATION: NCT02722382.

When pathological and radiological correlation is achieved, excision of fibroadenoma with lobular neoplasia on core biopsy is not warranted.

BACKGROUND: The diagnosis and management of lobular neoplasia (LN) including lobular carcinoma in situ (LCIS) and atypical lobular hyperplasia (ALH) remains controversial. Current management options after a core needle biopsy (CNB) with lobular neoplasia (LN) incorporating both ALH and LCIS include excision biopsy or careful clinical and radiologic follow up. METHODS: A retrospective analysis of the surgical database at Cork University Hospital was performed to identify all core needle biopsies from January 1st 2010 to 31st December 2013 with a diagnosis of FA who subsequently underwent surgical excision biopsy. All cases with associated LN including ALH and classical LCIS were selected. We excluded cases with coexistent ductal carcinoma in situ (DCIS), invasive carcinoma, LN associated with necrosis, pleomorphic lobular carcinoma in situ (PLCIS) or lesions which would require excision in their own right (papilloma, radial scar, atypical ductal hyperplasia (ADH) or flat epithelial atypia (FEA)). Cases in which the radiologic targeted mass was discordant with a diagnosis of FA were also excluded. RESULTS: 2878 consecutive CNB with a diagnosis of FA were identified. 25 cases had a diagnosis of concomitant ALH or classical LCIS. Our study cohort consisted of 21 women with a mean age 53 years (age range 41-70 years). The core biopsy diagnosis was of LCIS and FA in 16 cases and ALH and FA in 5 cases. On excision biopsy, a FA was confirmed in all 21 cases. In addition to the FA, residual LCIS was present in 14 cases with residual ALH in 2 cases. One of the twenty-one cases (4.8%) was upgraded to invasive ductal carcinoma on excision.

Contrast-enhanced ultrasound (CEUS) versus computed tomography angiography (CTA) in detection of endoleaks in post-EVAR patients. Are delayed type II endoleaks being missed? A systematic review and meta-analysis.

PURPOSE: The purpose of this systematic review is to assess the accuracy of contrast-enhanced ultrasound (CEUS) to computed tomography angiography (CTA) for the detection of endoleaks within EVAR surveillance program. MATERIAL AND METHODS: A systematic review in Pubmed, Embase and Cochrane database was performed. Articles assessing diagnostic accuracy and comparative modality (CTA vs. CEUS) for endoleaks in adult patients within surveillance programs were retrieved. Methodological assessment was performed, using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tools. The sensitivity and specificity of data were extracted and statistical analysis was performed using MetaDiSc version 1.4. RESULTS: Eight articles were found eligible (n = 454 patients). The pooled sensitivity of CEUS at detecting endoleak is 0.914 (CI 0.866-0.949) and pooled specificity is 0.782 (CI 0.741-0.820). CONCLUSION: The CEUS with its dynamic nature and longer scanning window demonstrated to be a highly sensitive modality for endoleak detection in comparison to CTA in delayed endoleaks type II.

Kinetic equivalence of stable-isotope-labeled and unlabeled phenytoin.

Stable isotope labeling (SIL) of a drug results in a higher molecular weight than that of the unlabeled drug. SIL tracer doses can be quantitated separately from unlabeled drug by gas chromatography-mass spectrometry (GC-MS) without exposing the patient to radiation. The higher molecular weight of SIL drug could cause a higher energy of activation for (and slowing of) metabolic reactions ("isotope effect"). To evaluate possible isotope effect, three dogs and three men were infused with a mixture containing equal amounts of SIL (2-13C-1,3-15N2) and unlabeled phenytoin (PHT). Plasma and urine were collected at regular intervals. Concentrations of SIL and unlabeled PHT and HPPH (the major metabolite of PHT) were determined by GC-MS. Within each subject there was no trend for concentrations of SIL PHT or HPPH to be higher or lower than concentrations of their unlabeled analogs (greater than 0.20 to 0.90). There was no difference in the distribution and elimination half-lifes (t 1/2s), volume of distribution, volume of central compartment, or clearance of the two forms of PHT. Thus, no isotope effect was found.

Clonazepam. A review of a new anticonvulsant drug.

Clonazepam is a new benzodiazepine anticonvulsant recently approved by the Food and Drug Administration for the treatment of typical absence, infantile myoclonic, atypical absence, myoclonic, and akinetic seizures. It is rapidly absorbed by the oral route and appears to pass quickly from blood to brain. Preliminary results indicate a biological half-life of 22 to 32 hours and a therapeutic serum concentration of 5 to 50 ng/ml. Many studies report tolerance to the anticonvulsant effects with chronic administration. Major side effects of the drug are drowsiness, ataxia, and behavior changes. They tend to be dose related, occur early in the course of therapy, and may subside with chronic administration. Accordingly, the dosage is begun at a low level and increased slowly.

Hemangioblastoma of the spinal cord. Review and report of five cases.

Eighty-five cases of hemangioblastoma of the spinal cord are reviewed, including five new ones. While current views of the incidence, histology, and cytogenesis are presented, the main purpose of this article is to call attention to the identifying clinical and radiological characteristics of these spinal tumors. Median age at onset of symptoms was 30 years. The ratio of men to women was 1.1:1. Presenting symptoms were usually radicular pain or posterior column sensory loss or both. The lesions were most often single (79%), intramedullary (60%), and located in the cervical or thoracic spinal cord. There was associated syringomyelia in 67% of intramedullary cases and meningeal varicosities in 48% of all cases. Lindau disease and hemangioblastomas in other central nervous system locations were present in 33% of cases. The characteristic roentgenographic picture is a densely vascular tumor in association with a larger avascular syrinx and meningeal varicosities. Surgery is the only definitive treatment.

Clinical and EEG estimates of absence seizure frequency.

Absence seizure frequency was estimated in 20 patients (5 to 15 years old) before and after treatment with ethosuximide. Estimates were obtained from mothers' histories, observations by nurses, intensive observation by trained observers, physical and neurological examinations, routine EEG, and 12-hour telemetered EEG. Both before treatment (high seizure frequency) and after treatment (low frequency), telemetered EEG was the most reliable method of estimation, and intensive observation was the next best method. After treatment, the mothers' and nurses' estimates of seizure frequency were significantly less than the telemetered EEG estimates. The neurological examination and routine EEG were sufficient to diagnose absence attacks in all 20 patients and to determine if the attacks were completely controlled by therapy in all but two patients.

Pharmacokinetics of antiepileptic drugs.

Enzymatic biotransformation is the principal determinant of the pharmacokinetic properties of most antiepileptic drugs (AEDs), although some agents are excreted by the kidneys predominantly as unchanged drug. Most AEDs exhibit linear enzyme kinetics, in which changes in daily dose lead to proportional changes in serum concentration if clearance remains constant. There are several important applications of pharmacokinetics in clinical practice. Established therapeutic ranges help guide drug administration to achieve serum concentrations that control seizures without causing intolerable toxicity. Determination of the elimination half-life may provide a basis for selecting a dosing interval and predicting the time to steady-state concentration. However, the traditional concept of administering a drug at intervals equal to one elimination half-life does not apply to some drugs. With vigabatrin, the half-life of biologic activity greatly exceeds the half-life of elimination. In situations in which it is desirable to achieve a steady-state serum concentration immediately, a loading dose can be calculated from a drug's volume of distribution and its desired serum concentration. Many AEDs have the potential to be involved in pharmacokinetic drug interactions when they are co-administered with other AEDs or other medications. These interactions usually involve changes in the rate of biotransformation or in the protein binding of one or both co-administered drugs.

The pharmacokinetics of agents used to treat status epilepticus.

A thorough understanding of the pharmacologic properties of lipid-soluble drugs is essential when using these agents to treat status epilepticus. In addition to physiologic factors, such as blood pressure and cerebral blood flow, pharmacokinetic principles, including half-life, distribution, elimination, and volume of distribution (with special regard to an agent's lipid-solubility rating), should be applied. These factors, in toto, will influence the choice of drug, its loading dose, and its therapeutic dose.

Pharmacology and pharmacokinetics of fosphenytoin.

Fosphenytoin sodium, a phosphate ester prodrug of phenytoin, was developed as a replacement for parenteral phenytoin sodium. Unlike phenytoin, fosphenytoin is freely soluble in aqueous solutions, including standard i.v. solutions, and is rapidly absorbed by the i.m. route. Fosphenytoin is metabolized (conversion half-life of 8 to 15 min) to phenytoin by endogenous phosphatases. Therapeutic free (unbound) and total plasma phenytoin concentrations are consistently attained after i.m. or i.v. administration of fosphenytoin loading doses. Fosphenytoin has fewer local adverse effects (e.g., pain, burning, and itching at the injection site) after i.m. or i.v. administration than parenteral phenytoin. Systemic effects related to the CNS are similar for both preparations, but transient paresthesias are more common with fosphenytoin.