Identification and Prioritization of Quality Indicators for Conservative Kidney Management.

RATIONALE & OBJECTIVE: Conservative kidney management is holistic patient-centered care for patients with kidney failure that focuses on delaying the progression of kidney disease and symptom management, without the provision of renal replacement therapy. Currently there is no consensus as to what constitutes high-quality conservative kidney management. We aimed to develop a set of quality indicators for the conservative management of kidney failure. STUDY DESIGN: Nominal group technique and Delphi survey process. SETTING & PARTICIPANTS: 16 patients and caregivers from Calgary, Canada, participated in 2 nominal group meetings. 91 multidisciplinary health care professionals from 10 countries took part in a Delphi process. ANALYTICAL APPROACH: Nominal group technique study of patients and caregivers was used to identify and prioritize a list of quality indicators. A 4-round Delphi process with health care professionals was used to rate the quality indicators until consensus was reached (defined as a mean rating on the Likert scale ≥7.0 and percent agreement >75%). Quality indicators that met criteria for consensus inclusion in the Delphi survey were ranked, and comparisons were made with nominal group priorities. RESULTS: 99 quality indicators met consensus criteria for inclusion. The most highly rated quality indicator in the Delphi process was the "percentage of patients that die in the place they desire." There was significant discordance between priorities of the nominal groups with that of the Delphi survey, with only 1 quality indicator being shared on each groups' top 10 list of quality indicators. LIMITATIONS: Participants were largely from high-income English-speaking countries, and most already had structured conservative kidney management programs in place, all potentially limiting generalizability. CONCLUSIONS: Quality of conservative kidney management care is important to patients, caregivers, and health care professionals. However, discordant quality indicator priorities between groups suggested that care providers delivering conservative kidney management may not prioritize what is most important to those receiving this care. Conservative kidney management programs and health care providers can improve the applicability of this consensus-based quality indicator list to their program by further developing and evaluating it for use in their program.

Improving supplementary feeding in species conservation.

Supplementary feeding is often a knee-jerk reaction to population declines, and its application is not critically evaluated, leading to polarized views among managers on its usefulness. Here, we advocate a more strategic approach to supplementary feeding so that the choice to use it is clearly justified over, or in combination with, other management actions and the predicted consequences are then critically assessed following implementation. We propose combining methods from a set of specialist disciplines that will allow critical evaluation of the need, benefit, and risks of food supplementation. Through the use of nutritional ecology, population ecology, and structured decision making, conservation managers can make better choices about what and how to feed by estimating consequences on population recovery across a range of possible actions. This structured approach also informs targeted monitoring and more clearly allows supplementary feeding to be integrated in recovery plans and reduces the risk of inefficient decisions. In New Zealand, managers of the endangered Hihi (Notiomystis cincta) often rely on supplementary feeding to support reintroduced populations. On Kapiti island the reintroduced Hihi population has responded well to food supplementation, but the logistics of providing an increasing demand recently outstretched management capacity. To decide whether and how the feeding regime should be revised, managers used a structured decision making approach informed by population responses to alternative feeding regimes. The decision was made to reduce the spatial distribution of feeders and invest saved time in increasing volume of food delivered into a smaller core area. The approach used allowed a transparent and defendable management decision in regard to supplementary feeding, reflecting the multiple objectives of managers and their priorities.

Optimizing treatment outcomes with regorafenib: personalized dosing and other strategies to support patient care.

Regorafenib is an oral multikinase inhibitor that inhibits several kinases relevant to tumor biology in several cancers, including colorectal carcinoma (CRC) and gastrointestinal stromal tumor (GIST). In phase III trials, regorafenib significantly improved overall survival versus placebo in patients with metastatic CRC progressing after all available standard therapies, and significantly prolonged progression-free survival in patients with advanced GIST in whom at least imatinib and sunitinib had failed. Thus, this agent holds promise as a new standard of care for CRC and GIST patients after disease progression following all other approved therapies. The clinical trials reported to date show that this new treatment has a consistent adverse event profile that is quite different from that of traditional cytotoxic chemotherapies. The most common adverse events of regorafenib include dermatologic and mucosal toxicities (especially hand-foot skin reaction, rash, and oral mucositis), constitutional symptoms (e.g., fatigue, nausea, and weight loss), vascular effects (especially hypertension), and gastrointestinal symptoms (e.g., diarrhea). To help health care professionals anticipate and manage the adverse events associated with regorafenib, we describe our experiences in clinical trials and show that such toxicities can be effectively managed with close observation of patients from initiation of dosing, along with prompt appropriate interventions, including dose modifications, if necessary.

Diagnosis and Supportive Management of Fucosidosis: A Case Report.

Fucosidosis is a lysosomal storage disease, resulting from a deficiency of the enzyme alpha-L-fucosidase. We present the case of an affected female with numerous manifestations, clinically and radiographically. In fucosidosis, advanced interventions are not always necessary to have rewarding outcomes. In fact, early diagnosis and management of the symptoms with a multi-systemic supportive care approach can improve the quality of life and may also prolong the life of those patients diagnosed with fucosidosis.

Survey data on work environments and productivity of academic staff of selected public universities in Nigeria.

The article presented a survey data on work environment predictors and productivity of selected academic staff of selected public universities in Southern, Nigeria. The study adopted a quantitative approach with a survey research design to establish the major determinants of work environments in the selected public universities. Data was analysed with the use of structural equation modelling and the field data set is made widely accessible to enable critical or a more comprehensive investigation. The findings identified meaningful work and growth opportunities as predictive factors for maximizing productivity in the sampled institutions.

Symptom burden in lung cancer: management updates.

Lung cancer is recognized to carry a high symptom burden with associated lowered quality of life as compared with other cancers. Research has shown that symptom severity can be a prognostic indicator of poorer clinical outcomes and survival post treatment. The purpose of this paper is to review current literature relative to symptom burden associated with diagnosis, medical and/or surgical intervention, assessment and management updates, and emerging initiatives that promote positive outcomes based on updated evidence. Discussion relative to interdisciplinary coordination of supportive services and palliative care initiation is provided.

Successful management of malignant hyperpyrexia syndrome in a pediatric patient: What to do when dantrolene is not available?

Malignant hyperpyrexia syndrome (MHS) is a rare entity and may not be encountered by the anaesthesiologists throughout their professional career. Whenever it manifests can be a challenging task to manage and prove to be fatal when a timely diagnosis and required therapeutic measures are not taken. Althoughthe dantrolene should be available wherever anaesthesia is practiced, considering the rarity of the syndrome this may not be the scenario always. We are reporting a case of MHS in a pediatric patient to highlight the facts that prompt clinical diagnosis, ongoing supportive treatment, discontinuation of all the anaesthetic agents and and stringent perioperative monitoring along with postoperative oral dantrolene may provide an answer to the MHS crisis in the face of an unavailability of the IV dantrolene; as may be the case in many rural and developing set-ups.

Clinical Outcome of Pregnancy-associated Aplastic Anemia Treated with Supportive Anagement / 대한주산의학회잡지

OBJECTIVE: Pregnancy-associated aplastic anemia remains a rare occurrence. The aim of this study was to examine the maternal and fetal outcomes of pregnancy-associated aplastic anemia treated with supportive care. METHODS: From January 1995 to December 2004, a total of 14 women newly diagnosed with pregnancy-associated aplastic anemia were recruited for the study. RESULTS: Eleven (78%) of the 14 women were diagnosed with pregnancy-associated aplastic anemia during the second or third trimester. There were eight severe cases; three of which were diagnosed at the initial presentation. All 14 women had conservative management with transfusions but not specific immunological or hormonal therapies during pregnancy. Blood transfusions were performed prenatally in seven mothers and perinatally in 13. Of the 12 patients eligible for follow-up, one achieved complete remission and another eight showed partial remission after delivery. During the follow up period, there was no case of maternal-fetal death in our series. The pregnancies were continued uneventfully in most cases. CONCLUSIONS: This study demonstrated favorable maternal and neonatal outcomes with transfusion support alone for pregnancy-associated aplastic anemia. Therefore, pregnancy continuation with meticulous blood support should be considered, rather than therapeutic termination, for women with pregnancy-associated aplastic anemia.