Fragmentation of care as a barrier to optimal ESKD management

Caring for patients with end-stage kidney disease (ESKD) in the United States is challenging, due in part to the complex epidemiology of the disease's progression as well as the ways in which care is delivered. As CKD progresses toward ESKD, the number of comorbidities increases and care involves multiple healthcare providers from multiple subspecialties. This occurs in the context of a fragmented US healthcare delivery system that is traditionally siloed by provider specialty, organization, as well as systems of payment and administration. This article describes the role of care fragmentation in the delivery of optimal ESKD care and identifies research gaps in the evidence across the continuum of care. We then consider the impact of care fragmentation on ESKD care from the patient and health system perspectives and explore opportunities for system-level interventions aimed at improving care for patients with ESKD.     

Systemic-to-pulmonary artery pressure ratio as a predictor of patient outcome following liver transplantation

AIMTo assess the value of the mean systemic-to-pulmonary artery pressure (MAP/mPAP) ratio for predicting outcomes following orthotopic liver transplant (OLT).METHODSA retrospective data analysis was performed and data (mean arterial blood pressure, mean pulmonary artery pressure and Cardiac Index) were collected at several points during OLT. Outcomes evaluated were duration of postoperative endotracheal intubation [ET; minutes after intensive care unit (ICU) arrival], length of ICU stay, total hospitalization and frequency of immediate postoperative complications. A total of 91 patients were included in the data analysis. Based on the intraoperative course of the MAP/mPAP ratio, 2 hemodynamic responses were identified: Group 1 (MAP/mPAP ratio increase during anhepatic period with postreperfusion recovery, n = 66); and Group 2 (MAP/mPAP ratio with no change during anhepatic period or decreased without recovery, n = 25).RESULTSThe main finding was that the lack of increased MAP/mPAP ratio in the anhepatic period was associated with: (1) longer intubation times; and (2) prolonged ICU stays and total hospitalization time, when compared to patients with an increase in MAP/mPAP ratio during the anhepatic period.CONCLUSIONThe data from this retrospective study should raise awareness to the mean systemic to pulmonary artery pressure ratio as a potential indicator for poor outcome after OLT. Further prospective studies are needed for validation.     

Gene expression analysis in cells of the dentine-pulp complex in healthy and carious teeth

Knowledge of the molecular events that occur in carious disease has so far been constrained due to difficulties in obtaining sufficient quantities of the dental tissues and cells involved. Our histological findings indicate that a pulp-odontoblast cellular complex can be obtained from carious and healthy human teeth when exposed to low-temperatures prior to pulpal extirpation and from rodent teeth processed at room-temperature. In contrast, pulpal tissue extracted from room-temperature processed human teeth and low-temperature processed rodent teeth resulted in the odontoblast layer remaining attached to the pulp chamber. Semi-quantitative RT-PCR (sq-RT-PCR) analysis confirmed that markers previously shown to be preferentially expressed in odontoblasts, namely dentin sialophosphoprotein (DSPP) and Nestin, amplified more readily from the extracted pulp-odontoblast complex, as compared to pulpal tissue alone, in both human and rodent samples. Subsequent gene expression analysis of collagen-1alpha and collagen-3alpha indicated levels were significantly higher in carious pulpal tissue. In addition, analysis characterising the expression of members of the transforming growth factor and bone morphogenic protein families and their receptors indicated in general, that these genes were expressed by healthy odontoblasts and up-regulated in both pulpal cells and odontoblasts in response to carious injury. Use of this temperature-sensitive dental tissue preparation procedure allows detection of differential gene expression in odontoblasts and other pulpal cells in healthy and carious tissue.     

Opinions and attitudes of the UK's GDPs and specialists in oral surgery, oral medicine and surgical dentistry on oral cancer screening

OBJECTIVE: To survey two broad areas of oral cancer awareness and management of patients at risk of oral cancer by specialists in oral surgery, oral medicine, surgical dentistry and general dental practitioners (GDPs) in the UK. The first of these included knowledge and awareness of aetiological factors, changing patterns of disease, and screening/detection programmes including their effectiveness. The second included oral cancer detection methods, advice on avoidance of high-risk activity and self-examination, and referral pattern of GDPs. DESIGN AND METHOD: A pretested, 44-item questionnaire, a covering letter, a brief outline of the research protocol and return, stamped envelope were mailed in March 2003. A sample of 200 GDPs whose names were obtained from the General Dental Council's main list and 305 dental specialist names obtained from specialist's list in surgical dentistry, oral medicine and oral surgery were selected randomly. Information on oral cancer awareness and practice, screening practice and education was obtained. RESULTS: The response rate was 66.9%. The knowledge of the dental specialists was consistent with that in reports of current aetiological studies on oral cancer. However there were gaps in the GDP's knowledge and ascertainment of oral cancer risk factors. Over 70% of the dental specialists provided counselling advice on the risks of tobacco and alcohol habits compared with 41.2% of GDPs. More GDPs (52.4%) than specialists (35.4%) believed that oral cancer screening on a national basis would be effective in decreasing the mortality of oral cancer. Over 95% of all respondents used a visual examination for oral cancer screening and 89.9% of all respondents strongly believed that visual screening is effective in the early detection of oral cancer. CONCLUSION: The results showed that GDPs had knowledge gaps in their awareness of oral cancer risk factors and the application of preventive measures. Most dental health providers in the UK perform visual screening of the oral mucosa for their patients. Opinion was equivocal as to whether a nationally based screening programme similar to cervical cancer would be effective in improving the mortality and morbidity of oral cancer.     

Does the procedure of arthrography affect the range of movement in patients with locking of the temporomandibular joint?

The aim of this study was to investigate whether arthrography itself altered the range of mandibular movements, in a group of patients with locking of the temporomandibular joint (TMJ). The clinical records of a series of 161 patients who were diagnosed with locking of the TMJ were retrospectively analysed. Mouth opening had improved in 57 out of 161 patients (35%). Twenty-three patients (14%) had improved by 5 mm or less. Nineteen patients (11%) had improved by more than 5 mm but less than 10 mm, whereas 15 patients (9%) had improved by more than 10 mm. Of the patients who experienced an improved mouth opening, only nine (15%) had improved from their pre-arthrography restricted maximum opening to beyond the lower limit of normal. This suggests that the injection of contrast medium had an effect on the range of vertical opening in patients with displacement of the disc without reduction.     

Pilot evaluation of paroxetine for treating hot flashes in men

OBJECTIVE: To provide prospective information on the potential utility of paroxetine for treating hot flashes In men receiving androgen ablation therapy for prostate cancer. PATIENTS AND METHODS: Men with symptomatic androgen ablation therapy-related hot flashes were entered into this clinical trial between August 2001 and October 2003. After a baseline week of documentation of the frequency of hot flashes, patients were assigned to receive paroxetine; the initial dosage was 12.5 mg/d, and it was increased to 37.5 mg/d over the ensuing 4 weeks. RESULTS: Of the 24 patients in whom medication was initiated, 18 completed the 5-week study. In these patients, the median frequency of hot flashes decreased from 6.2 per day during the baseline week to 2.5 per day during the last study week. Hot flash scores (frequency x mean severity) during the same period decreased from 10.6 per day to 3.0 per day. Overall, paroxetine was well tolerated by most patients. CONCLUSION: The results from this trial suggest that paroxetine Is an effective agent for diminishing hot flashes in men receiving androgen ablation therapy.