Patient- and Provider-Reported Information about Transplantation and Subsequent Waitlisting

Because informed consent requires discussion of alternative treatments, proper consent for dialysis should incorporate discussion about other renal replacement options including kidney transplantation (KT). Accordingly, dialysis providers are required to indicate KT provision of information (KTPI) on CMS Form-2728; however, provider-reported KTPI does not necessarily imply adequate provision of information. Furthermore, the effect of KTPI on pursuit of KT remains unclear. We compared provider-reported KTPI (Form-2728) with patient-reported KTPI (in-person survey of whether a nephrologist or dialysis staff had discussed KT) in a prospective ancillary study of 388 hemodialysis initiates. KTPI was reported by both patient and provider for 56.2% of participants, by provider only for 27.8%, by patient only for 8.3%, and by neither for 7.7%. Among participants with provider-reported KTPI, older age was associated with lack of patient-reported KTPI. Linkage with the Scientific Registry for Transplant Recipients showed that 20.9% of participants were subsequently listed for KT. Patient-reported KTPI was independently associated with a 2.95-fold (95% confidence interval [95% CI], 1.54 to 5.66; P=0.001) higher likelihood of KT listing, whereas provider-reported KTPI was not associated with listing (hazard ratio, 1.18; 95% CI, 0.60 to 2.32; P=0.62). Our findings suggest that patient perception of KTPI is more important for KT listing than provider-reported KTPI. Patient-reported and provider-reported KTPI should be collected for quality assessment in dialysis centers because factors associated with discordance between these metrics might inform interventions to improve this process.     

Assessment of participation outcomes in randomized controlled trials of stroke rehabilitation interventions

In recent years, the importance of understanding the impact of interventions on an individual's ability to participate in social roles after a stroke event has gained much attention. Comprehensive assessment of treatment effectiveness should include a broader range of outcomes, including social participation. This study attempted to determine the degree to which the assessment of social participation has been included in randomized controlled trials of stroke rehabilitation. An extensive literature search was used to identify all randomized controlled trials from 1968 to 2005. Assessment scales used to evaluate study outcomes were recorded and classified based on the International Classification of Functioning Disability and Health (ICF) framework. Studies citing assessment of more than one ICF component were identified. In total, 1447 outcomes were assessed using 489 measurement scales and were cited in 491 identified trials. Both number of studies and assessment of participation outcomes increased over time. Participation assessments accounted for less than 6% of all measurement citations. Around 56.8% of studies reported multicomponent assessment. Of these, 25% included assessment at the level of ICF Participation. In conclusion, the vast body of work within the areas of impairment and function is a cornerstone for rehabilitation. This is certainly reflected in the recorded measurement citations. Despite increasing awareness and a significant increase in participation assessment, relatively few studies include assessment at this level, thereby limiting our understanding with regard to the impact of rehabilitation interventions on more complex areas of social participation.     

Controlled nail trephination for subungual hematoma

An injury to a finger or toe can result in a collection of blood under the nail plate that if unrelieved can cause extreme discomfort due to pressure. In this case, a 47-year-old man developed a subungual hematoma of the right thumb due to a crush injury. Controlled nail trephination was performed using a uniquely designed drill that penetrated the nail plate without breaching the nail bed. The subungual hematoma was successfully drained, and there was a substantial relief in pain over the subsequent 8 hours. This technique appears to be a quick and convenient method of evacuating subungual hematomas with minimal discomfort and minimal risk.