Intimate and sexual feelings in psychotherapy: educational topic or still taboo?

BACKGROUND: Intimate and sexual feelings are common within psychotherapy, with negative outcomes when not managed adequately. AIMS: This study aims to investigate the understudied topic of these intimate and sexual feelings in basic education and psychotherapy training programs. METHOD: In this convergent mixed method study, both a survey (N = 786) and 8 focus groups (N = 36) were conducted among psychotherapists in Flanders, Belgium (November 2016 - June 2018), using inferential and thematic analyses respectively. RESULTS: The majority indicates that dealing with intimate and sexual feelings towards clients was hardly part of either their basic education or psychotherapy training. Talking about such feelings with peers or supervisors remained difficult because of concerns about being judged. Therapists indicating this topic was addressed in some way in their training indicated more often that they did not perceive it as a taboo topic. Therapists advocated a more open discussion and reflection on this topic. Education and training, as well as support from renowned key figures in their field, were regarded as important incentives to initiate change. CONCLUSION: Psychotherapy training should focus on how to deal with intimate and sexual feelings, referring to introspection and exploration of these feelings in a more integrated way during training.

Managing Romantic and Sexual Feelings Towards Clients in the Psychotherapy Room in Flanders (Belgium).

It is important that therapists manage adequately their romantic and sexual feelings toward clients as it can negatively affect the psychotherapeutic relationship and may even pose a risk of sexual abuse. This study explores how psychotherapists in Flanders (Belgium) manage such feelings, by conducting both a survey (using 105 of 786 respondents for analyses, as they reported romantic feelings) and focus groups (with a total of 36 participants). Results show that most therapists never consider starting a romantic relationship with a client. They reflect profoundly on their feelings, dwell on possible consequences, while maintaining strict boundaries. Although therapists themselves highly recommend referring the client to a colleague if feelings become too intense, this rarely happens in practice. Most therapists consider talking about their romantic and sexual feelings towards clients as something very important, but only a third have disclosed their feelings in supervision, peer-supervision, or in personal therapy. Therapists indicate there is still hesitance about this due to fear of condemnation.

How Therapists Experience and Manage Patients' Romantic and Sexual Feelings for Them.

OBJECTIVE: Many therapists will one day be confronted with a patient who develops romantic or sexual feelings toward them. Studies on this topic often remain theoretical in nature and less often focus on how therapists manage such situations. Therefore, this study aimed to investigate how therapists experience this occurrence and manage their feelings. METHODS: Eight focus groups were conducted with 36 participants in Flanders (Belgium). Both therapists-in-training and therapists-in-practice participated, having different educational backgrounds. The data were explored using the principles of thematic analysis. RESULTS: Therapists indicated that they try to dissuade any further development of their patients' romantic or sexual feelings by using strategies such as emphasizing their personal relational status, adjusting their appearance, and avoiding any physical contact with their patients. Some therapists question their own professional behavior, feeling guilty, confused, or insecure, wondering if they may have, in some way, provoked these feelings. Therapists who are at an earlier stage in their careers experience more difficulties managing their patients' romantic or sexual feelings toward them and worry they will not be considered a good professional therapist if such a situation occurs. CONCLUSIONS: Educational programs in psychotherapy should be more cognizant of the incidence of patients' developing romantic or sexual feelings toward therapists and provide more comprehensive and practical instruction on how to cope with such feelings.

Dealing with sexual boundary violation in mental healthcare institutions by government policies: the case of Flanders, Belgium.

BACKGROUND: To prevent sexual boundary violations (SBV) in mental health care institutions overall governments require these institutions to report SBV incidents to a central registry and to develop institutional guidelines how to react. In Europe SBV policies are only recently developed or implemented, as is also the case in Flanders (Belgium). The implementation of a new institutional policy is always a challenge and can encounter resistance, especially when it concerns SBV, because they remain delicate and complex. METHOD: This study evaluated the extent to which mandatory policies on SBV have been implemented in mental health care institutions in Flanders, and possible factors for (non-)implementation of these policies. An online survey was sent to the executives of all mental health care institutions in Flanders (N = 162). RESULTS: In total 56 executives of mental health care institutions filled out the survey (response rate 35%). Results showed that the implementation of an SBV policy in mental health care institutions is unfortunately inadequate and not all SBV incidents were reported to the central registry. Type of institution and opinions on the SBV policy were related to the (non-)implementation of the requirements. CONCLUSIONS: It is recommended that governments regularly communicate with mental health care institutions to better understand the concerns and difficulties concerning implementation of the required SBV policy and to support/stimulate an organisational culture of more openness and safety on this topic.

Intimacy in Psychotherapy: An Exploratory Survey Among Therapists.

A certain level of intimacy is necessary in psychotherapeutic relationships for them to be effective, but it can sometimes develop further into more intimate feelings and behaviors related to friendship and sexuality, into friendship, or even into sexual relationships. In this study, a self-administered questionnaire was sent to psychotherapists in Flanders (Belgium), asking about the occurrence of these situations. It provides an overview of these occurrences and comparative data to view for generational and cultural differences with previous studies. A response rate of 40% was obtained (N = 786): 69% of respondents were female therapists and none were transgender. A total of 758 therapists stated that they had actually provided psychotherapy and were included for further analysis. Three percent started a sexual relationship with a current and/or former client, 3.7% started a friendship during therapy, and 13.4% started a friendship after therapy. About seven out of ten therapists found a client sexually attractive, a quarter fantasized about a romantic relationship, and a fifth gave a goodbye hug at the end of a session (22%). In general, more male therapists reported sexual feelings and behaviors than female therapists. Older therapists more often behaved informally and started friendships with former clients compared to younger colleagues. Psychiatrists reported sexual feelings and fantasies less often than non-psychiatrists, and behavioral therapists reported this less frequently than person-centered and psychoanalytic therapists. Overall, prevalence rates of intimate feelings and behaviors related to friendship and sexuality are lower than those in previous studies.

Sexual Feelings Toward Clients in the Psychotherapeutic Relationship: The Taboo Revealed.

Talking about sexual feelings toward clients is still difficult for many mental health professionals. This is unfortunate, because exploring and talking about these feelings with peers (especially senior ones) or supervisors can help professionals to recognize, acknowledge, accept, and handle these feelings well. This focus group study explores the various factors that contribute to psychotherapists' hesitancy to talk about these feelings. The analysis revealed two important impeding factors: the psychotherapists felt discomfortable and a safe environment was lacking. Young, less experienced psychotherapists and psychiatrists seemed to be most vulnerable. Furthermore, more profound sexual feelings were "disguised" in some cases by using a more acceptable narrative, such as " intimate feelings," which possibly also impeded acknowledgment and discussion of these feelings. These insights might help to open up the way for psychotherapists to explore and come forward with their sexual feelings and experiences.

Psychotherapists' attitudes to intimate and informal behaviour towards clients.

BACKGROUND: To avoid harming or exploiting a client, sexual and non-sexual dual relationship is generally considered as unacceptable in the psychotherapeutic relationship. However, little is known about what therapists themselves constitute as (un)acceptable intimate and informal behaviour (IIB). METHODS: A survey among psychotherapists in Flanders (Belgium) was conducted. Opinions about the acceptability of IIB were asked. Based on these opinions attitude groups could be determined. RESULTS: In total, 786 therapists completed and returned the questionnaire (response rate: 39.8%). Therapists could be divided into three attitude groups. Almost half of the therapists belonged to the 'rather restrictive group', a third to the 'rather socially permissive group' and a fifth to the 'rather sexually permissive group'. Being categorised as 'rather sexually permissive' is predominantly related to being male and non-heterosexual, whereas being 'rather restrictive' or 'rather socially permissive' is mainly due to the type of psychotherapy training. The 'rather sexually permissive' therapists more often found a client sexually attractive during the last year and fantasised more often about a romantic relationship with a client, but they did not more often started a sexual relationship. CONCLUSIONS: Most therapists in Flanders are rather restrictive in their attitude to IIB, pointing to a high sense of morality. Having a rather sexually permissive attitude is predominantly related to more personal characteristics of the therapists, but these therapists did not start a sexual relationship more often.

Six years of measuring patient experiences in Belgium: Limited improvement and lack of association with improvement strategies.

OBJECTIVE: To examine trends in patient experiences in the period 2014-2019, describe improvement strategies implemented by hospitals in the same period, and study associations between patient experiences and implemented strategies. DESIGN: Multi-center retrospective region-wide observational design. SETTING: Flanders, Belgium. PARTICIPANTS: 44 out of 46 Flemish acute-care hospitals publicly reporting patient experiences via the Flemish Patient Survey (FPS). MAIN OUTCOME MEASURE(S): Primary outcomes were the two global FPS ratings: percentage of patients rating the hospital 9 or 10 and percentage of patients definitely recommending the hospital. Secondary outcomes were the average top-box score percentages for each of the 8 remaining dimensions of the FPS. RESULTS: Between 2014 and 2019, there was a significant improvement in patients scoring the hospital 9 or 10 (56% to 61%) and patients definitely recommending (67% to 70%) the hospital. Significant increases in patient experiences over time were also observed in other dimensions, except for the dimension discharge. Hospital key informants reported various improvement strategies related to patient experiences with care and the FPS. Feedback to nursing wards (n = 44, 100%) and clinicians (n = 39, 89%) were most common. Overall, most improvement strategies were not or only weakly associated with patient experience ratings in 2019 and changes in ratings over time. Still, positive associations were discovered between the strategies 'nursing ward interventions' and 'hospital wide education' and recommendation of the hospital. CONCLUSIONS: Patient experiences have improved modestly in Flemish acute-care hospitals. Hospitals report to have invested in patient experience improvement strategies but positive associations between such strategies and FPS scores are weak, although there is potential in further exploring nursing ward interventions and hospital wide education. Hospitals should continue their efforts to improve the patient's experience, but with a more targeted approach, taking the lessons learned on the efficacy of strategies into consideration.

New Instrument to Measure Hospital Patient Experiences in Flanders.

Implementing a standardized patient experience survey may initiate a process to apply pressure on hospitals to attend to improving patient experiences. In Flanders, Belgium, the Flemish Patient Survey was developed between 2011 and 2015. A preliminary version was developed from a scoping review and patient and expert focus groups, and included 27 items for eight hypothesized dimensions: 'preparing for hospital stay', 'information and communication', 'coordination', 'respect', 'privacy', 'safe care', pain management', and 'participation'. Exploratory factor analysis for 1076 patients in 17 hospitals found that the data did not fit the dimensions. Adaptations in item wording and response categories were based on the US Hospital Consumer Assessment of Healthcare Providers and Systems. The revised version showed excellent model fit in 22,143 patients in 37 hospitals. Multiple group analysis pointed to evidence of measurement invariance over time across mode of administration, type of nursing unit, and various patient characteristics. Fostering a collaborative approach thus proved successful in implementing a standardized patient experience survey. The most recent findings (2016) illustrate substandard performance and a need for patient-mix adjustment. The Flemish government developed a dedicated website to make findings publicly available and the federal government currently considers patient experiences in devising a pay-for-quality scheme.

Associations between physical activity and the built environment in patients with schizophrenia: a multi-centre study.

OBJECTIVE: This study investigated the variance in walking, moderate and vigorous physical activity (PA), explained by neighbourhood design and other environmental variables above and beyond the variance accounted for by demographical variables. METHOD: A total of 138 patients (46♀) with schizophrenia (mean age = 41.2 ± 12.5 years) from 13 different centres in Belgium were included in this 4-month cross-sectional study. The built environment was rated using the Instruments for Assessing Levels of Physical Activity and Fitness (ALPHA) environmental questionnaire, which was validated first. PA levels were assessed with the International Physical Activity Questionnaire. RESULTS: Validity coefficients for the ALPHA ranged between 0.44 and 0.86 and test-retest reliability intraclass correlation coefficients ranged between 0.64 and 0.84. Regression analyses showed that environmental variables were related to all types of PA. The variance explained by the models including demographic and environmental variables ranged from 20% for vigorous PA up to 68% for walking. Minutes of walking (r=0.63, P<.001) and of moderate-intensity PA (r = 0.43, P<.001) were related to emotional satisfaction with the environment. Moderate-intensity PA was also related to the presence of PA supplies at home (r=0.49, P<.001). CONCLUSION: Neighbourhood design and other environmental variables show significant associations with multiple types of PA in patients with schizophrenia.

The Cognitive Biases Questionnaire for Psychosis (CBQ-P) and the Davos Assessment of Cognitive Biases (DACOBS): validation in a Flemish sample of psychotic patients and healthy controls.

OBJECTIVE: A large body of research has demonstrated the importance of cognitive biases in the development and maintenance of psychosis. Self-report scales for routine clinical practice have been developed only recently. Two new instruments on cognitive biases are evaluated: the Cognitive Biases Questionnaire for Psychosis and the Davos Assessment of Cognitive Biases Scale. METHODS: In a Flemish sample of 98 patients diagnosed with schizophrenia and 152 healthy controls, we investigated (1) the factor structure, (2) the reliability (internal consistency), (3) the discriminative power and (4) the convergent validity of the Dutch CBQ-P and the DACOBS. RESULTS: Using Confirmatory Factor Analysis, a 1-factor solution provided the best fit for the CBQ-P, and a 3-factor solution for the DACOBS. The CBQ-P Total Scale and the three scales of the DACOBS showed good internal consistencies. The CBQ-P Total Scale and all three DACOBS subscales were able to differentiate between healthy controls and patients diagnosed with schizophrenia, when controlling for age and years of education. The CBQ-P and DACOBS scales showed moderate correlations, confirming the convergent validity of both scales. CONCLUSIONS: The CPQ-P and DACOBS appear to be psychometrical sound instruments to assess general thinking bias in psychosis within a Flemish population. Implications for future research are discussed.

An impaired health related muscular fitness contributes to a reduced walking capacity in patients with schizophrenia: a cross-sectional study.

BACKGROUND: Patients with schizophrenia report muscle weakness. The relation of this muscle weakness with performing daily life activities such as walking is however not yet studied. The aim of this study was to quantify walking capacity and health related muscular fitness in patients with schizophrenia compared with age-, gender and body mass index (BMI)-matched healthy controls. Secondly, we identified variables that could explain the variability in walking capacity and in health related muscular fitness in patients with schizophrenia. METHODS: A total of 100 patients with schizophrenia and 40 healthy volunteers were initially screened. Eighty patients with schizophrenia (36.8±10.0 years) and the 40 age-, gender- and body mass index (BMI)-matched healthy volunteers (37.1±10.3 years) were finally included. All participants performed a standing broad jump test (SBJ) and a six-minute walk test (6MWT) and filled out the International Physical Activity Questionnaire. Patients additionally had a fasting metabolic laboratory screening and were assessed for psychiatric symptoms. RESULTS: Patients with schizophrenia did have lower 6MWT (17.9%, p<0.001) [effect size (ES)=-1.01] and SBJ (14.1%, p<0.001) (ES=-0.57) scores. Patients were also less physically active (1291.0±1201.8 metabolic equivalent-minutes/week versus 2463.1±1365.3, p<0.001) (ES=-0.91) than controls. Schizophrenia patients with metabolic syndrome (MetS) (35%) had a 23.9% lower (p<0.001) SBJ-score and 22.4% (p<0.001) lower 6MWT-score than those without MetS. In multiple regression analysis, 71.8% of the variance in 6MWT was explained by muscular fitness, BMI, presence of MetS and physical activity participation, while 53.9% of the variance in SBJ-score was explained by age, illness duration, BMI and physical activity participation. CONCLUSIONS: The walking capacity and health-related muscular fitness are impaired in patients with schizophrenia and both should be a major focus in daily clinical practice and future research.

A review of physical activity correlates in patients with bipolar disorder.

BACKGROUND: Existing studies do suggest that physical activity interventions may be feasible and have a role in promoting mental and physical health in patients with bipolar disorder. The present review evaluates systematically quantitative studies of correlates of physical activity in patients with bipolar disorder. METHODS: We searched EMBASE, PsycINFO, PubMed, and CINAHL from their inception, combining the medical subject headings 'bipolar disorder' or 'mania' or 'manic depression' with 'physical activity' or 'physical inactivity' or 'exercise'. RESULTS: Out of 40 potentially eligible studies, 11 papers evaluating 26 correlates were included. Correlates that were associated with lower physical activity participation were lower self-efficacy, presence of medical co-morbidity, lower educational status and social isolation. Less consistent variables associated with lower physical activity participation included higher BMI, older age, financial strains, not being connected to a health care service, and minority ethnicity. A larger study sample size was related to a higher proportion of significant associations (p=0.04). Current gaps in literature which need to be examined more in detail are the role of psychiatric symptoms, environmental and policy-level factors. LIMITATIONS: The diversity of physical activity measures and subject samples prevented us to perform a meta-analysis. CONCLUSIONS: All significant correlates should be confirmed in prospective studies and interventions to improve the modifiable variables should be developed and evaluated. The reviewed data also demonstrate that validation studies on physical activity measurements are highly needed.

Temperature and concentration distribution within the Genius dialysate container.

BACKGROUND: The Genius single-pass batch system, using a closed dialysate container, is increasingly applied for dialysis treatment. Although fluid separation between fresh and spent dialysate is maintained in the container during standard dialysis, dialysate mixing may occur under certain clinical conditions. An in vitro study showed that differences in dialysate temperature and solute content between fresh and spent dialysate determine the occurrence and moment of dialysate mixing. METHODS: To better understand the maintenance of separation of fresh and spent dialysate in the prevention of mixing, a mathematical model of the 75 l Genius container was developed and the general fluid, mass and heat transfer equations were solved, simulating a dialysis session of 300 min with 1 g/l urea as starting 'blood' urea concentration and 36.2 degrees C starting dialysate temperature. Boundary and initial conditions were chosen according to two different strategies applied in previous in vitro tests, with spontaneous cooling of the reservoir on the one hand and heating of the spent dialysate to maintain an equal temperature as the fresh dialysate on the other. RESULTS: Our simulation data show that dialysate inside the container is cooling down near the container wall in both scenarios and near the central glass tube in the setup with spontaneous cooling. In the setup with heating of spent dialysate, the upper layers are heated near the central tube. Since density stratification is maintained at each time point, solutes will rise towards warmer zones. This is halfway between the container axis and wall for spontaneous cooling and, even to a larger extent, near the central tube for simulations with heated spent dialysate. Hence, the contaminated volume in the case of heating is much larger than theoretically supposed. CONCLUSIONS: These computer simulations unravel temperature and concentration distribution inside the container, offering insight into the complicated mixing phenomenon and indicate that temperature is a major impacting factor.

The influence of current stress on dissociative experiences: an exploratory study in a non-clinical population.

In this study, the relationship between current stress, as perceived by an individual, and dissociative phenomena is explored. All subjects were in an acute and naturally caused stress-situation-sudden threat of dismissal from their jobs in a large multinational corporation. Dissociation and stress were measured at two different times over three months. Since information campaigns and psychological support programs were offered to all participants, levels of stress were expected to decrease significantly. The data show that dissociative experiences are elevated when subjects experience high levels of current stress, though scores fall within the normal non-pathological range. Furthermore, it appears that a decrease in stress level is associated with a significant decrease of dissociative symptoms. The results support a one-directional causal relationship: a decrease in perceived stress leads to a decrease in dissociative phenomena.

Comparison of the hemodynamics in 6mm and 4-7 mm hemodialysis grafts by means of CFD.

The aim of our study is to investigate with computational fluid dynamics (CFD) whether different arterial anastomotic geometries result in a different hemodynamics at the arterial (AA) and venous anastomosis (VA) of hemodialysis vascular access grafts. We have studied a 6mm graft (CD) and a 4-7 mm graft (TG). A validated three-dimensional CFD model is developed to simulate flow in the two graft types. Only the arterial anastomosis (AA) geometry differs. The boundary conditions applied are a periodic velocity signal at the arterial inlet and a periodic pressure wave at the venous outlet. Flow rate is set to 1,000 ml/min. The time dependent Navier-Stokes equations are solved. Wall shear stress (WSS), wall shear stress gradient (WSSG) and pressure gradient (PG) are calculated. Anastomotic flow is asymmetric although the anastomosis geometry is symmetric. The hemodynamic parameters, WSS, WSSG and PG, values at the suture line of the arterial anastomosis of the TG are at least twice as much as in the CD. Comparing the parameters at the two AA indicate that little flow rate increase introduces the risk of hemolysis in the TG whereas the CD is completely free of hemolysis. The hemodynamic parameter values at the venous anastomosis of the CD are 24 till 35% higher compared to the values of the TG. WSS values (> 3 Pa) in the VA are in the critical range for stenosis development in both graft geometries. The zones where the parameters reach extreme values correspond to the locations where intimal hyperplasia formation is reported in literature. In all anastomoses, the hemodynamic parameter levels are in the range where leucocytes and platelets get activated. Our simulations confirm clinical results where TG did not show a better outcome when compared to the CD.

Hemodynamics and complications encountered with arteriovenous fistulas and grafts as vascular access for hemodialysis: a review.

This review article describes the current state of affairs concerning in vivo, in vitro and in numero studies on the hemodynamics in vascular access for hemodialysis. The use and complications of autogenous and non-autogenous fistulas and catheters and access port devices are explained in the first part. The major hemodynamic complications are stenosis, initiated by intimal hyperplasia development, and thrombosis. The different in literature proposed conceivable causes of intimal hyperplasia development like surgical interventions, compliance mismatch, wall shear stress (WSS) and shear rate, vessel wall thrill and blood pressure are discussed on the basis of in vivo, in vitro and in numero studies.

Experimental analysis of the hemodynamics in punctured vascular access grafts.

The hemodynamics in the vascular access graft are influenced by the flow aspirated and injected through the two needles during hemodialysis. For the first time, the impact of needle flow on vascular access performance, measured in an in vitro set up, is reported. A vascular access model, consisting of a loop polytetrafluoroethylene graft sewn to a compliant artery and vein, simulated the patient. The extracorporeal circuit was connected to the model. Three mean access flow rates (QG; 500, 1,000, and 1,500 ml/min) and five roller pump flow rates (Q(R); 0, 200, 300, 400, and 500 ml/min) were studied. Mean, systolic, and diastolic pressure and according pressure drops were derived at 14 loci. Systolic, diastolic, and mean pressures drop along the graft decreased with increasing Q(R) and decreasing Q(G). At Q(R) = 500 ml/min and Q(G) = 500 ml/min, the mean pressure drop over the graft was negative (-10 mm Hg), indicating a reversed pressure profile, originating at the puncture site of the venous needle. Mean pressure in the venous outlet segment was about 100 mm Hg compared with only 75 mm Hg without needle flow. The combination of a low Q(G) (500 ml/min) and high Q(R) (> 300 ml/min) must be avoided because venous pressures can rise to 100 mm Hg and load the venous system. The results of this in vitro setup indicate that high Q(R) (> 400 ml/min) should be avoided at Q(G) up to 1,000 ml/min; however, in vivo tests have to be performed to prove this thesis. This study demonstrates the need for a well-functioning vascular access (Q(G) > 600 ml/ min) to perform adequate dialysis and to avoid venous system loading.

Kinetic behavior of urea is different from that of other water-soluble compounds: the case of the guanidino compounds.

BACKGROUND: Although patients with renal failure retain a large variety of solutes, urea is virtually the only currently applied marker for adequacy of dialysis. Only a limited number of other compounds have up until now been investigated regarding their intradialytic kinetics. Scant data suggest that large solutes show a kinetic behavior that is different from urea. The question investigated in this study was whether other small water-soluble solutes, such as some guanidino compounds, show a kinetic behavior comparable or dissimilar to that of urea. METHODS: This study included 7 stable conventional hemodialysis patients without native kidney function undergoing low flux polysulphone dialysis (F8 and F10HPS). Blood samples were collected from the inlet and outlet bloodlines immediately before the dialysis session, after 5, 15, 30, 120 minutes, and immediately after discontinuation of the session. Plasma concentrations of urea, creatinine (CTN), creatine (CT), guanidinosuccinic acid (GSA), guanidinoacetic acid (GAA), guanidine (G), and methylguanidine (MG) were used to calculate corresponding dialyzer clearances. A two-pool kinetic model was fitted to the measured plasma concentration profiles, resulting in the calculation of the perfused volume (V(1)), the total distribution volume (V(tot)), and the intercompartmental clearance (K(12)); solute generation and overall ultrafiltration were determined independently. RESULTS: No significant differences were observed between V(1) and K(12) for urea (6.4 +/- 3.3 L and 822 +/- 345 mL/min, respectively) and for the guanidino compounds. However, with respect to V(tot), GSA was distributed in a smaller volume (30.6 +/- 4.2 L) compared to urea (42.7 +/- 6.0L) (P < 0.001), while CTN, CT, GAA, G, and MG showed significantly higher volumes (54.0 +/- 5.9 L, 98.0 +/- 52.3 L, 123.8 +/- 66.9 L, 89.7 +/- 21.4 L, 102.6 +/- 33.9 L, respectively; P= 0.004, = 0.033, = 0.003, < 0.001, = 0.001, respectively). These differences resulted in divergent effective solute removal: 67% (urea), 58% (CTN), 42% (CT), 76% (GSA), 37% (GAA), 43% (G), and 42% (MG). CONCLUSION: The kinetics of the guanidino compounds under study are different from that of urea; hence, urea kinetics are not representative for the removal of other uremic solutes, even if they are small and water-soluble like urea.

Assessment of stenosis in vascular access grafts.

The major complication that occurs with grafts used as vascular access for hemodialysis, is stenosis at the venous anastomosis or in the draining vein. 75% area stenosis is considered significant as thrombotic occlusion may occur. The aim of this experimental study was to evaluate invasive and noninvasive indices to detect significant stenoses in a vascular access graft. A compliant underarm loop graft in vitro model was built and studied with 50, 65, 80, and 90% stenosis at flow rates of 500, 1000, and 1500 mL/min. Flow in the system was pulsatile. Velocity was measured with ultrasound Doppler and the pressure was measured invasively. The resistance index (RI), p(venous line)/MAP, and the newly introduced pressure ratio (PR) were calculated and compared. A stenosis can be suspected when a high frequency ultrasound velocity signal develops at the venous anastomosis. RI > 1 confirms a very severe stenosis (90%). The parameter PR < 8% confirms significant stenoses showing its clinical relevancy.