Barriers and facilitators for people with severe mental illness accessing cancer screening: A systematic review.

OBJECTIVE: Evidence suggests that people with severe mental illness (PwSMI) are 2.1 times more likely to die from cancer before the age of 75, compared to people without Severe mental illness (SMI). Yet, cancer screening uptake is low among PwSMI. This mixed-methods systematic review aimed to identify the barriers and facilitators for PwSMI deciding to access and attend primary cancer screening of the cervix, breast and colon. METHODS: Six electronic databases and two grey literature sources were searched, with 1017 records screened against inclusion criteria. Included papers were appraised and data synthesised using the constructs of Normalisation Process Theory. RESULTS: Twenty papers met the inclusion criteria. Factors that impact upon uptake of PwSMI accessing cancer screening were found to include age, gender, race, and income. Common barriers to attending screening included poor communication from healthcare staff, stigmatising attitudes, and accessibility problems such as no access to transportation. While, facilitators included social support from friends, family, and healthcare providers. CONCLUSIONS: Due to ease and privacy, colorectal screening was found to have fewer barriers when compared to cervical and breast screening. The review identified multiple barriers that can be addressed and targeted to support decision-making for cancer screening among PwSMI. The protocol was registered with PROSPERO (CRD42022331781).

A protocol to identify the barriers and facilitators for people with severe mental illness and/or learning disabilities for PErson Centred Cancer Screening Services (PECCS).

OBJECTIVES: To identify the barriers and facilitators that people with severe mental illness and people with learning disabilities may encounter when accessing cancer screening and make recommendations for implementing reasonable adjustments throughout cancer screening services. METHODS AND ANALYSIS: An 18-month sequential, mixed-methods study comprising of two phases of work and underpinned by Normalisation Process Theory, recruiting from across the North-East and North Cumbria. The first phase aims to identify the barriers and facilitators for people with severe mental illness in accessing cervical, breast and colorectal cancer screening. A systematic review of eight databases (Part 1a; PROSPERO registration number: CRD42022331781) alongside semi-structured interviews of up to 36 people with severe mental illness (Part 1b) will occur. Additional characteristics indicating populations whose perspectives may not have been accounted for in the systematic review will be targeted in the interviews. Potential participants will be identified from a range of settings across the North-East and North Cumbria, including through social media and gatekeepers within National Health Service Trusts and charities. Interviews will be analysed using framework analysis, which will be in line with the Normalisation Process Theory. The second phase of the project (part 2a) involves triangulating the results of the systematic review and interviews with existing research previously completed with people with learning disabilities accessing cancer screening. This will be to identify population specific barriers and facilitators across people with learning disabilities and people with severe mental illness to access cancer screening services. Following triangulation, part 2b will include designing and planning a future study involving stakeholders in cancer screening to explore the feasibility, practicality, and priority for implementing the recommendations to improve person centred cancer screening services (PECCS). ETHICS AND DISSEMINATION: This study has received Teesside University ethical approval, Health Research Authority approval (IRAS: 310622) and favourable opinion (REF: 22/PR/0793). Findings will be disseminated through a range of academic and non-academic modes including infographics, blog posts and academic publications.

Needle infiltration of arteriovenous fistulae in hemodialysis: risk factors and consequences.

BACKGROUND: Needle infiltration of arteriovenous fistulae is a common problem in US hemodialysis units. This study evaluated the frequency of fistula infiltration, its risk factors, and clinical consequences of this complication. METHODS: Using a prospective computerized vascular access database, we identified all patients with a major fistula infiltration sufficiently severe to prolong catheter dependence for dialysis. These patients were compared with a control group without fistula infiltration. We also quantified subsequent access outcomes in patients with infiltrations. RESULTS: During a 5-year period, 47 patients had a major fistula infiltration, representing a 5.2% annual rate. On multiple variable logistic regression analysis, the likelihood of fistula infiltration was associated strongly with patient age (odds ratio, 1.039/1-year increment; 95% confidence interval, 1.016 to 1.062; P = 0.0007). Fistula infiltration was not associated with sex, race, diabetic status, peripheral vascular disease, body mass index, or fistula location. New fistulas (< 6 months in age) were more likely in patients with infiltrations compared with patients without infiltrations (43.5% versus 20.5%; odds ratio, 2.98; 95% confidence interval, 1.61 to 5.54; P = 0.0004). Each major fistula infiltration resulted in a mean of 2.4 diagnostic tests, surgery appointments, or interventions. Fistula thrombosis occurred in 12 patients (26%). Median prolongation of catheter dependence for dialysis in patients with major infiltrations was 97 days. CONCLUSION: Needle infiltration of fistulae is more common in older patients and with new fistulae. These infiltrations result in numerous procedures, as well as prolongation of catheter dependence for more than 3 months.

Tunneled catheters in hemodialysis patients: reasons and subsequent outcomes.

BACKGROUND: Reducing the use of tunneled catheters in hemodialysis patients requires concerted efforts to convert them to a usable permanent vascular access. The goal of this study is to evaluate the reasons for tunneled catheter use in our prevalent hemodialysis population and the success in converting them to a permanent vascular access. METHODS: We identified all catheter-dependent hemodialysis patients at our center on a single date. These patients were followed up prospectively during a 1-year period to evaluate access procedures and conversion to permanent access use. RESULTS: Of 458 prevalent hemodialysis patients, 108 patients (23.6%) were dialyzing through cuffed tunneled catheters: 18.5% had no further options for creation of a permanent vascular access, 28.7% had an immature access, 43.5% had access placement pending, and 9.2% had repeatedly refused access surgery. For 78 catheter-dependent patients (excluding patients with no access options and those who refused permanent access surgery), the likelihood of using a permanent access was 53% by 6 months and 80% by 1 year. In patients with an immature access, 50% were using a permanent access at 3 months, and 80%, at 6 months. Of patients with access surgery pending, 45% had access surgery performed within 3 months, and 70%, at 6 months. Finally, of all patients, the likelihood of catheter-related bacteremia was 48% at 6 months. On multivariable analysis, only duration of catheter dependence predicted subsequent use of a permanent access (hazard ratio, 3.11; 95% confidence interval, 1.70 to 5.68; P = 0.0002) for catheter dependence less than versus greater than 6 months. CONCLUSION: Almost one quarter of our hemodialysis population is catheter dependent. Despite concerted efforts, there remain very long delays in achieving a usable permanent access, attributable to delays in both surgical access placement and access maturation. In the interim, this patient population developed a high frequency of catheter-related bacteremia.

Associations with predialysis vascular access management.

BACKGROUND: The Kidney Disease Outcomes Quality Initiative (K/DOQI) guidelines encourage increasing the proportion of arteriovenous fistulae among incident hemodialysis patients. Achieving optimal outcomes requires predialysis out-patient follow-up by a nephrologist, predialysis placement of a vascular access, and adequate maturation of the vascular access. METHODS: We assessed the effect of clinical factors on predialysis vascular access management in all incident hemodialysis patients at a single institution during a 2-year period. RESULTS: Of 157 patients initiating dialysis therapy from January 1, 2001, to December 31, 2002, a total of 73.2% had predialysis follow-up by a nephrologist, 46.5% had predialysis vascular access surgery, and 35.0% initiated their first dialysis session with a permanent access. Among patients using a permanent access on their first dialysis session, 67.3% used a fistula. Patients with diabetes were more likely than those without diabetes to have predialysis nephrology follow-up (81.5% versus 61.5%; P = 0.005), undergo predialysis vascular access surgery (56.5% versus 32.3%; P = 0.003), and initiate their first dialysis session with a fistula or graft (43.5% versus 23.1%; P = 0.008). Duration of predialysis nephrology follow-up was similar between patients with and without diabetes (median, 412 versus 300 days; P = 0.27). Patient age, sex, and race were not predictive of predialysis access management. CONCLUSION: Despite attempts to follow the K/DOQI guidelines, 65% of incident hemodialysis patients initiated their first dialysis treatment with a catheter. Patients with diabetes were significantly more likely to have predialysis follow-up by a nephrologist and thus more likely to initiate their first dialysis session with a permanent access. Emphasis on early referral of patients with chronic kidney disease without diabetes to nephrologists may increase fistula use among incident hemodialysis patients.

Vascular access stenosis: comparison of arteriovenous grafts and fistulas.

BACKGROUND: Vascular access stenosis is a frequent problem in hemodialysis patients. There is little published literature comparing the features of stenosis between arteriovenous fistulas and grafts, relative outcomes of elective angioplasty, and clinical factors predictive of access patency after angioplasty. METHODS: Prospective data were collected for all patients referred for a fistulogram during a 2-year period because of suspected access stenosis. Angioplasty was performed if there was greater than 50% stenosis. For each procedure, we recorded the number and location of stenotic lesions, degree of stenosis (on a scale of 1 to 4), and ratio of access to systemic systolic pressure. All subsequent access procedures were tracked prospectively to calculate intervention-free access survival. Multivariable analysis was used to evaluate clinical factors affecting access patency after angioplasty. RESULTS: Five hundred forty-three fistulograms were obtained: 358 in grafts and 185 in fistulas. The likelihood of finding a significant stenosis was substantially lower in fistulas than grafts (39.4% versus 68.7%; P < 0.001). Among patients with a significant stenosis, those with fistulas were less likely to have 2 or more stenotic lesions (12.5% versus 33.1%; P < 0.001). After angioplasty, degree of stenosis (1.35 +/- 0.70 versus 1.23 +/- 0.52) and access to systemic pressure ratio (0.34 +/- 0.15 versus 0.32 +/- 0.14) were similar between fistulas and grafts. Intervention-free survival was similar for fistulas and grafts (median survival, 7.5 versus 6.2 months; P = 0.36). Using multivariable stepwise proportional hazard regression analysis, only female sex, residual access stenosis, and postangioplasty access pressure ratio greater than 0.4 significantly predicted access survival (P = 0.0006). CONCLUSION: The positive predictive value of clinical evaluation for access stenosis is substantially lower for fistulas than grafts. The technical success of angioplasty and subsequent primary patency are similar for fistulas and grafts. Finally, female sex, residual stenosis, and high postprocedure access pressure ratio are each predictive of shorter access patency after elective angioplasty.

Does heparin coating improve patency or reduce infection of tunneled dialysis catheters?

BACKGROUND AND OBJECTIVES: Tunneled dialysis catheters are prone to frequent malfunction and infection. Catheter thrombosis occurs despite prophylactic anticoagulant locks. Catheter thrombi may also serve as a nidus for catheter infection, thereby increasing the risk of bacteremia. Thus, heparin coating of catheters may reduce thrombosis and infection. This study evaluated whether heparin-coated hemodialysis catheters have fewer infections or greater cumulative survival than noncoated catheters. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We retrospectively queried a prospective access database to analyze the outcomes of 175 tunneled dialysis catheters placed in the internal jugular vein, including 89 heparin-coated catheters and 86 noncoated catheters. The primary outcome was cumulative catheter survival, and the secondary outcome was infection-free catheter survival. RESULTS: The two patient groups were similar in demographics and clinical and catheter features. Catheter-related bacteremia occurred less frequently with heparin-coated catheters than with noncoated catheters (34 versus 60%, P < 0.001). Cumulative catheter survival was similar in heparin-coated and noncoated catheters (hazard ratio, 0.87; 95% confidence interval, 0.55 to 1.36; P = 0.53). On multiple variable survival analysis including catheter type, age, sex, diabetes, coronary artery disease, peripheral vascular disease, cerebrovascular disease, catheter location, and previous catheter, only catheter location predicted cumulative catheter survival (hazard ratio, 2.03; 95% CI, 1.27 to 3.25, with the right internal jugular location being the reference group, P = 0.003). The frequency of thrombolytic instillation was 1.8 per 1000 catheter-days in both groups. CONCLUSIONS: Heparin coating decreases the frequency of catheter-related bacteremia but does not reduce the frequency of catheter malfunction.

Disparities in fistula maturation persist despite preoperative vascular mapping.

BACKGROUND AND OBJECTIVES: Failure to mature (primary failure) of new fistulas remains a major obstacle to increasing the proportion of dialysis patients with fistulas. This failure rate is higher in women than in men, higher in older than in younger patients, and higher in forearm than in upper arm fistulas. These disparities in the frequency of failure to mature may be due in part to marginal vessels in the high-risk groups and should be reduced by routine preoperative vascular mapping. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: A prospective, computerized database was queried retrospectively to evaluate the frequency of primary fistula failure in 205 hemodialysis patients for whom preoperative mapping was obtained. The association between clinical characteristics and risk for primary fistula failure was analyzed by univariate and multiple variable regression analysis. RESULTS: The overall primary fistula failure rate was 40% (82 of 205 patients). On multiple variable logistic regression, three clinical factors were associated with an increased risk for failure to mature among patients who underwent preoperative vascular mapping: Female gender, age > or =65 yr, and forearm location. The primary fistula failure rate varied from 22% in younger men with an upper arm fistula to 78% in older women with a forearm fistula. Dynamic preoperative vascular measurements (change in peak systolic velocity and resistive index after tight fist clenching) did not differ between patients with mature and immature forearm fistulas. CONCLUSION: Disparities in fistula maturation persist despite the use of routine preoperative vascular mapping.

Time to symptomatic vascular stenosis at different locations in patients with arteriovenous grafts.

Most arteriovenous grafts fail due to irreversible thrombosis, superimposed on hemodynamically significant vascular stenosis. Previous studies observed the highest frequency of stenosis at the venous anastomosis, without addressing the timing of stenosis. The present study quantified time to symptomatic stenosis at different vascular locations, and related it to permanent graft failure. A prospective computerized vascular access database was queried retrospectively to identify 309 hemodialysis patients receiving new upper extremity grafts during a 4-year period at a large dialysis center. For each vascular site we calculated the time to symptomatic stenosis using survival techniques. The cumulative likelihood of symptomatic stenosis at 2 years was 67% for venous anastomotic stenosis, 19% for intra-graft stenosis, 16% for venous outlet stenosis, 13% for central vein stenosis, and 5% for arterial anastomotic stenosis. The cumulative risk of graft failure at 2 years was 40%. Stenosis at the venous anastomosis was twice as likely as cumulative graft failure (hazard ratio [HR] 1.95; 95% confidence interval [CI], 1.65-2.52, p < 0.001). In contrast, intra-graft stenosis was half as likely as cumulative graft failure (HR 0.45; 95% CI, 0.36-0.61, p < 0.001). Central vein stenosis was more likely in patients with a previous ipsilateral catheter compared with those without one (HR 2.40; 95% CI, 1.39-5.58, p = 0.004). Symptomatic stenosis occurs much earlier at the venous anastomosis compared with other vascular sites. Moreover, preexisting ipsilateral internal jugular dialysis catheters more than double the risk of central vein stenosis.

Aneurysm formation in arteriovenous grafts: associations and clinical significance.

Aneurysms are a common complication of arteriovenous grafts in hemodialysis patients, resulting from repetitive needle sticks in the graft material. Although aneurysms are thought to contribute to graft failure, there are no prospective studies evaluating their risk factors or impact on graft survival. The present study evaluated aneurysms in 117 hemodialysis outpatients with upper extremity grafts at a university-affiliated dialysis center. An arterial aneurysm was defined as a cannulation site defect diameter (difference between arterial cannulation site diameter and normal graft diameter) above the median value for the study population (0.63 cm). Subsequent graft outcomes were determined by retrospective analysis of a prospective vascular access database. Thrombosis-free graft survival was compared among patient subgroups using Cox proportional hazards models. Patients with an arterial aneurysm had significantly longer median graft age, when compared with those not having a aneurysm (888 vs. 588 days, p = 0.01). However, the two groups did not differ in patient age, sex, diabetes, body mass index, or graft location. The hazard ratio for graft thrombosis was 0.45 (95% confidence interval, 0.25-0.82, p = 0.009) for grafts with an arterial aneurysm, when compared with those without a defect (1-year graft survival of 71 vs. 50%). Graft age was not associated with the likelihood of graft thrombosis (p = 0.12). In contrast to the prevailing wisdom, arterial aneurysms are associated with improved graft survival.

Comparison of survival of upper arm arteriovenous fistulas and grafts after failed forearm fistula.

Although arteriovenous fistulas are considered superior to grafts, it is unknown whether that is true in the subset of patients with a previous failed fistula. For investigation of this question, a prospective vascular access database was queried retrospectively to compare the outcomes of 59 fistulas and 51 grafts that were placed in the upper arm after primary failure of an initial forearm fistula. Primary access failure was higher for subsequent fistulas than for subsequent grafts (44 versus 20%; P = 0.006). Fistulas required more interventions than grafts before their successful use (0.42 versus 0.16 per patient; P = 0.04). The time to catheter-free dialysis was longer for fistulas than for grafts (131 versus 34 d; P < 0.0001) and was associated with more episodes of bacteremia before permanent access use (1.3 versus 0.4 per patient; P = 0.003). Cumulative survival (from placement to permanent failure) was higher for fistulas than for grafts when primary failures were excluded (hazard ratio 0.51; 95% confidence interval 0.27 to 0.94; P = 0.03), but similar when primary failures were included (hazard ratio 0.99; 95% confidence interval 0.61 to 1.62; P = 0.97). Fistulas required fewer interventions to maintain long-term patency for dialysis after maturation (0.73 versus 2.38 per year; P < 0.001). In conclusion, as compared with grafts, subsequent upper arm fistulas are associated with a higher primary failure rate, more interventions to achieve maturation, longer catheter dependence, and more frequent catheter-related bacteremia. However, once the access is usable for dialysis, fistulas have superior cumulative patency than do grafts and require fewer interventions to maintain patency.

Percutaneous renal biopsy: comparison of blind and real-time ultrasound-guided technique.

The use of real-time ultrasound-guided renal biopsy is believed to be superior to blind biopsy, but there are few reports comparing the two techniques. The goal of the present study was to compare the outcomes of ultrasound-guided and blind renal biopsies at a single teaching institution, in terms of adequacy of tissue yield and frequency of hemorrhagic complications. We reviewed retrospectively the outcomes of all patients undergoing a percutaneous native kidney biopsy during a 2-year period (January 1, 2004 to December 31, 2005). Of 129 renal biopsies, 65 were ultrasound-guided and 64 were performed by the blind technique. All biopsies were performed by nephrology fellows under direct faculty supervision. The two patient groups were comparable in terms of age, sex, race, diabetes, hypertension, serum creatinine, and hematocrit. The mean number of glomeruli per biopsy was higher in the ultrasound-guided group than in the patients with a blind biopsy (18 +/- 9 versus 11 +/- 9, p = 0.0001). An inadequate tissue sample requiring repeat biopsy occurred in 0% of the ultrasound-guided biopsies and 16% of the blind biopsies (p = 0.0006). Large hematomas requiring vascular intervention or transfusion were less frequent in the ultrasound-guided biopsies (0% versus 11%, p = 0.006). The hematocrit 24 hours postbiopsy was higher in the ultrasound-guided biopsies when compared with the blind biopsies (32 +/- 5% versus 30 +/- 4%, p = 0.04). When compared with blind renal biopsy, real-time ultrasound-guided percutaneous renal biopsy provides a superior yield of kidney tissue and results in fewer hemorrhagic complications. Real-time ultrasound-guided renal biopsy is the preferred technique.

Increased risk of infection associated with polyurethane dialysis grafts.

Conventional polytetrafluoroethylene (PTFE) dialysis grafts cannot be cannulated for 2-3 weeks following their creation. Polyurethane grafts, made of a self-sealing material, can be cannulated within 24 hours of implantation, representing a potential advantage in patients with limited catheter options. However, early cannulation may increase the risk of graft infection. We retrospectively queried a prospective, computerized access database to identify 31 patients receiving a polyurethane graft, and 56 date-matched controls with a PTFE graft. Survival techniques were used to plot graft survival. Thrombosis-free graft survival (from creation to first thrombosis or failure) was similar for polyurethane and PTFE grafts (1-year survival, 28%, vs. 32%, p = 0.98). Cumulative graft survival (from creation to permanent failure) was also similar (1-year survival 42% vs. 52%, p = 0.40). Finally, the cumulative risk of graft infection was 37.5% for polyurethane thigh grafts, 23% for polyurethane upper extremity grafts, 21% for PTFE thigh grafts, and 5% for PTFE upper extremity grafts (p = 0.06 for polyurethane vs. PTFE grafts). The likelihood of thrombosis and failure is similar for polyurethane and PTFE grafts. However, polyurethane grafts may have a higher risk of infection, particularly when they are placed in the thigh. In patients with an access emergency, implantation of a polyurethane graft incurs a tradeoff between earlier cannulation and a higher risk of infection.

Comparison of arteriovenous grafts in the thigh and upper extremities in hemodialysis patients.

Placement of a thigh graft is an option in hemodialysis patients who have exhausted all upper extremity sites for permanent vascular access. The outcome of thigh grafts has been reported only in retrospective studies. The outcomes of 409 grafts placed at a single institution during a 3.5-yr period were evaluated prospectively, including 63 thigh grafts (15% of the total). Information was recorded on surgical complications, dates of radiologic and surgical interventions, and date of graft failure. The technical failure rate was approximately twice as high for thigh grafts, as compared with upper extremity grafts (12.7 versus 5.8%; P = 0.046). Intervention-free survival was similar for thigh and upper extremity grafts (median, 3.9 versus 3.5 mo; P = 0.55). Thrombosis-free survival was also comparable for thigh and upper extremity grafts (median, 5.7 versus 5.5 mo; P = 0.94). Cumulative survival (time to permanent failure) was similar for thigh and upper extremity grafts (median, 14.8 versus 20.8 mo; P = 0.62). When technical failures were excluded, the median cumulative survival was 27.6 mo for thigh grafts and 22.5 mo for upper extremity grafts (P = 0.72). The frequency of angioplasty (0.28 versus 0.57 per year), thrombectomy (1.58 versus 0.94 per year), surgical revision (0.28 versus 0.18 per year), and total intervention rate (2.15 versus 1.70 per year) was similar between thigh and upper extremity grafts. Access loss as a result of infection tended to be higher for thigh grafts than for upper extremity grafts (11.1 versus 5.2%; P = 0.07). In conclusion, placement of thigh grafts should be considered a viable option among hemodialysis patients who have exhausted all options for a permanent vascular access in both upper extremities.

Management of hemodialysis catheter-related bacteremia with an adjunctive antibiotic lock solution.

BACKGROUND: Tunneled dialysis catheters are complicated by frequent systemic infections. Standard therapy of catheter-associated bacteremia involves both systemic antibiotics and catheter replacement. Recent data suggest that biofilms in the catheter lumen are responsible for the bacteremia, and that instillation of an antibiotic lock (highly concentrated antibiotic solution) into the catheter lumen after dialysis sessions can eradicate the biofilm. METHODS: We analyzed prospectively the efficacy of an antibiotic lock protocol, in conjunction with systemic antibiotics, for treatment of patients with dialysis catheter-associated bacteremia without catheter removal. Protocol success was defined as resolution of fever and negative surveillance cultures one week following completion of the protocol. Protocol failure was defined as persistence of fever or surveillance cultures positive for any pathogen. In addition, infection-free catheter survival was compared to that observed in institutional historical control patients treated with catheter replacement. RESULTS: Blood cultures were positive in 98 of 129 of episodes (76%) in which patients dialyzing with a catheter had fever or chills. Protocol success occurred in 40 of 79 infected patients (51%) treated with the antibiotic lock. Protocol failure occurred in 39 cases (49%): 7 had persistent fever, 15 had positive surveillance cultures (9 for Candida and 6 for bacteria), and 17 required catheter removal due to malfunction. Each of the pathogens in the surveillance cultures was different from the original pathogen in that patient. Eight of the 9 secondary Candida infections and all 6 secondary bacterial infections resolved after catheter exchange and specific antimicrobial treatment. Overall catheter survival with the antibiotic lock protocol was similar to that observed among patients managed with catheter replacement (median survival, 64 vs. 54 days, P = 0.24). CONCLUSIONS: Use of an antibiotic lock, in conjunction with systemic antibiotic therapy, can eradicate catheter-associated bacteremia while salvaging the catheter in about one half of cases. Moreover, this management approach offers clinical advantages over routine catheter exchange.