Overcoming barriers to maintain hemodialysis adequacy amongst hemodialysis patients in hospital: a best practice implementation project.

OBJECTIVE: The aim of this evidence implementation project was to identify the barriers and omissions affecting adequacy of hemodialysis and to develop implementable strategies to maintain hemodialysis adequacy among hemodialysis patients with end-stage renal disease. INTRODUCTION: Assessing adequacy of hemodialysis and improving quality of life are important issues for patients with end-stage renal disease. However, they are often inadequately addressed, and evidence-based practices are not always followed. METHODS: A clinical audit was undertaken using the Joanna Briggs Institute Practical Application of Clinical Evidence System and Getting Research into Practice approaches. Seven audit criteria that represent best practice recommendations for maintaining hemodialysis adequacy among hemodialysis patients were used. A baseline audit was performed, which was followed by the implementation of multiple improvement strategies over 20 weeks and the outcomes finalized using a follow-up audit to determine the change to be implemented in practice. RESULTS: The baseline audit results showed that most audit criteria were less than 77% in practice. The compliance rates for nurses who had received education regarding hemodialysis, checking the prescription order for each patient at each session, and using the prescribed dialyzer for every session were determined to have reached 100% at the follow-up audit. The compliance rates for completion prehemodialysis checks, using a sterile technique when inserting an arteriovenous catheter, matching a blood flow rate with the prescription, and maintaining a blood flow rate throughout the treatment session were found to be 73-95% at the follow-up audit. The most significant finding was the proportion of hemodialysis patients with inadequate urea reduction ratio was reduced from 4.6 to 3.2% after implementation of the best practice approaches. CONCLUSION: The implementation of institution-specific evidence-based resources brought about immediate improvements in hemodialysis adequacy management and practice. A variety of strategies contributed to the success of this implementation project, such as scenario simulation education, Objective Structured Clinical Examination, the interrelation response system Kahoot, the use of hemodialysis International Organization for Standardization job descriptions, regular weekly audits, and collaboration with physicians when caring for patients during clinical practice.

The risks of ubiquinone and ß-carotene deficiency and metabolic disorders in patients with oral cancer.

BACKGROUND: Cancer development is mediated by oxidative stress and inflammation, which may correlate with metabolic disorders. The aim of this study was to evaluate antioxidant vitamins status and metabolic parameters in patients with oral cancer according to tumor-node-metastasis (TNM) stages. METHODS: A total of 194 patients with oral cancer were enrolled in this study. The patients were stratified for four groups according to cancer stages and that the statistics are comparisons across these groups. The levels of antioxidant vitamins (ubiquinone, ß-carotene, vitamin A and E), metabolic parameters, oxidative stress, antioxidant enzymes activity, and inflammatory markers were measured. RESULTS: More than half of the subjects had high blood pressure, central obesity, hyperglycemia, and hyperlipidemia regardless of TNM stage. With regard to antioxidant vitamins status, 46 and 94% of patients had ß-carotene and ubiquinone deficiency, respectively. Patients in T3 and T4 stages had significantly lower antioxidant enzyme (catalase, p = 0.03) activity and higher inflammatory markers levels (high sensitivity C-reactive protein and interleukin-6, p < 0.01) than patients in the other stages. In addition, the level of ß-carotene was negatively associated with waist circumference, and ubiquinone was positively associated with the level of high-density lipoprotein cholesterol (p < 0.05). Higher ß-carotene and ubiquinone levels were negatively associated with hypertriglyceridemia and the risk of metabolic syndrome (p < 0.05). CONCLUSIONS: A high proportion of patients with oral cancer had ubiquinone or ß-carotene deficiency and metabolic disorders. The level of ubiquinone or ß-carotene was negatively associated with the risk of central obesity, hypertriglyceridemia, and metabolic syndrome. Since patients with oral cancer suffer from high oxidative stress and inflammation (particularly in the T3 and T4 stages), supplementation with antioxidant vitamins such as ubiquinone or ß-carotene could be preferentially applied.

Relationship of Oxidative Stress, Inflammation, and the Risk of Metabolic Syndrome in Patients with Oral Cancer.

Oral cancer is the fifth leading cause of cancer death in Taiwan, and the prevalence of metabolic syndrome (MS) has also increased globally. The purpose of this study was to investigate the correlations between the components of MS and oxidative stress and inflammation in patients with oral cancer based on their areca-nut-chewing habits. Two hundred patients diagnosed with oral cancer were recruited, and metabolic parameters, oxidative stress, antioxidant enzyme activities, and inflammatory markers were measured. 63% of the subjects have concomitant MS. Subjects who had an areca-nut-chewing habit had significantly higher levels of fasting glucose (p = 0.04), oxidative stress (p = 0.02), and inflammatory markers (p = 0.02) than those who never chewed. High-density lipoprotein-cholesterol level (p = 0.03) and superoxidase dismutase activity (p = 0.02) were significantly lower in individuals who had chewed or were currently chewers. Areca-nut-chewing habit was associated with the increased risks for MS and hypertriglyceridemia; the components of MS were positively correlated with oxidative stress and inflammation. In conclusion, patients with oral cancer who had an areca-nut-chewing habit exhibited higher levels of oxidative stress and inflammation, which might be related to an increased risk of MS.

Pulmonary hypertension in patients on chronic hemodialysis and with heart failure.

Pulmonary hypertension (PH) is linked to chronic kidney disease. However, few studies have examined the prevalence, risk factors, or outcomes of PH in patients with chronic hemodialysis and concomitant heart failure. This retrospective cohort study enrolled 160 patients with a history of acute decompensated heart failure after maintenance hemodialysis therapy. All patients were prospectively observed until December 2013 or death. PH was defined as pulmonary artery systolic pressure >35 mmHg, as determined through echocardiography. Fifty-one (32%) patients had PH, more of whom were female (70% vs. 52%, P = 0.04). The patients with PH had a lower body mass index (21.8 vs. 23.0, P = 0.03), higher cardiothoracic ratio (55% vs. 52%, P = 0.006), larger left atrium (38.5 vs. 35.7 mm, P = 0.01), and an increased proportion of mitral regurgitation (MR) (73% vs. 38%, P < 0.001) compared with the patients who did not have PH. In the multivariate regression analysis, MR was associated most strongly with PH (odds ratio 3.75, 95% confidence interval [CI]: 1.67-8.43, P = 0.001). In the multivariate Cox proportional hazard models, PH was related independently to all-cause mortality (hazard ratio [HR], 3.11; 95% CI, 1.53-6.31; P = 0.002) and combined cardiovascular events (HR, 2.71; 95% CI, 1.66-4.44; P < 0.001) after the model was adjusted for conventional cardiovascular risk factors. PH is related to MR and independently associated with increased all-cause mortality and cardiovascular events in patients with chronic hemodialysis and heart failure.