Factors influencing osteopathic medical students' intent to work with underserved populations: Implications for curriculum enhancement

BackgroundFewer medical students are selecting primary care, and medical students' attitudes toward underserved populations may impact their decision to pursue primary care.ObjectiveThis study investigated first year medical students' beliefs and attitudes toward underserved patient populations and how those attitudes might influence their intent to care for the this population as a career choice.MethodsA cross-sectional, correlational research design was used to determine the influence of attitudes and beliefs on osteopathic medical students' intention to provide care to underserved patient populations in future practice. Between 2011 and 2015 data were collected using the Medical Students Attitudes Scale via written questionnaire from 829 first-year attending a large osteopathic medical school in the United States.ResultsMore positive attitudes toward equitable healthcare, greater belief that access to medical care is influenced by socio-cultural-environmental factors (e.g., income, gender), sense of professional responsibility, choice of family medicine as a career, and being female were related to higher levels of intent to work with underserved populations; desire for higher income and choice of surgery as a career choice were associated with less intent. Multivariate modeling successfully explained the 29% of the variance in predicting intention to provide care to the underserved in future practice.ConclusionsWith an increasingly diverse population and increasing health disparities, osteopathic medical schools might consider incorporating changes in their curricula to inculcate cultural competency and social responsibility and foster more compassion among students to care for underserved populations.     

Left ventricular systolic and diastolic function and carotid intima-media thickness in pediatric dialysis patients

Background  Cardiovascular complications are common in patients with end-stage renal disease (ESRD). We aimed to investigate left ventricular (LV) function and carotid intima-media thickness (cIMT) in children and adolescents with ESRD. Methods  This study included 38 ESRD patients (15 hemodialysis and 23 peritoneal dialysis) and 17 age- and sex-matched healthy subjects. Results  The ESRD patients had significantly lower mean mitral E/A ratio, and higher left ventricular mass index (LVMI) and cIMT than the control group. Compared with PD patients, HD patients had worse LV diastolic function. In stepwise linear regression analysis, LVMI (P = 0.043) and hemoglobin (P = 0.015) turned out to be independent variables for predicting diastolic dysfunction (reduced E/A ratio), and the only significant predictor of cIMT was indexed diastolic blood pressure (DBP) (P = 0.035). Conclusion  Cardiovascular structure and function abnormalities are also common in pediatric dialysis patients, as in adults. Furthermore our data indicated that hemodialysis was disadvantageous for preserving LV diastolic function as compared with peritoneal dialysis.     

The relationship between physical work hazards and employee withdrawal: The moderating role of safety compliance

We examined the relationship between physical work hazards and employee withdrawal among a sample of health care employees wherein safety compliance was hypothesized to moderate the relationship between physical work hazards and withdrawal. Health care workers (N = 162) completed an online questionnaire assessing physical work hazards, withdrawal, and indicators of workplace safety. Safety compliance moderated the relationship between patient aggression and withdrawal. Interaction plots revealed that for all significant moderations, the relationship between physical work hazards and withdrawal was weaker for those who reported high levels of compliance. Results shed initial light on the benefits of fostering safety compliance in health care contexts, which can contain exposure to physical work hazards.     

Attitude of primary care nurses toward living kidney donation

INTRODUCTION: Nursing is a fundamental service in caring for the health of the public. The opinion of nurses toward a certain type of donation may have a strong population impact. In this respect, living kidney donation is increasing in Spain; it is important to raise awareness at all levels. The objective here was to analyze the attitudes of primary care nursing personnel toward living kidney donation and to their determinants. MATERIALS AND METHODS: A random sample of primary care nurses stratified by geographical location (six health areas in our community), included 139 nurses from 32 health centres. Attitudes toward living donation were evaluated using a questionnaire with various psychosocial variables. For the distribution of the questionnaires, contact was made with the nursing coordinator in each centre. They were completed anonymously. The chi-squared test and Student's t test were applied. RESULTS: The attitudes toward living kidney donation were favorable in 93% of those questioned (n = 129), mainly when the donation is related (78%, n = 109). Only one nurse was against the idea of donating a kidney from a living person (1%); nine had doubts about this kind of donation (7%). Seventy-six percent (n = 106) have cared for patients awaiting a transplant; however, no relationship was found with attitude toward this type of donation (P = .209). Of all analyzed variables, there was only a significant relationship with concern about possible body mutilation (P < .0005) and partner's opinion about the matter (P < .0005). We wish to highlight that no relationship was found with attitudes toward cadaveric organ donation (P = .712). CONCLUSIONS: Attitudes of primary care nursing personnel toward living kidney donation were favorable, especially if it was related donation.     

Information overload's double-edged sword effect on sense of safety: Examining the moderating role of hypervigilance

Since the COVID-19 pandemic outbreak, long-term overlooked motives concerning a sense of safety have become a primary concern. People's sense of safety largely depends on the information they receive. Indeed, a tsunami of information about the virus has been disseminated by all forms of media to people's electronic devices, thus permeating their lives. This study proposed that the over-abundance of information, known as information overload, could endanger individuals' sense of safety by increasing their rumination about COVID-19. However, it could also enhance their sense of safety by increasing their positive attitudes toward COVID-19 precautions. Furthermore, we proposed that individuals' hypervigilance could strengthen the relationship between information overload and rumination about COVID-19 and attitudes toward COVID-19 precautions. We tested these hypotheses using a cross-sectional survey study (N = 403) in February 2021 and a diary study (N = 98) in July 2021 in China. The results of both studies support the dual mediating paths of the relationship between information overload and sense of safety. We also found that hypervigilance moderated the relationship between information overload and rumination about COVID-19. Overall, our study offers insights into how social media may influence people's sense of safety and how individual differences in hypervigilance play a role in the process.     

Clinical characteristics and outcomes of rural patients with ESRD in Guangxi,China: one dialysis center experience

Objectives  

End-stage renal disease (ESRD) is a serious public health problem in Guangxi, a province of south China. This prospective study evaluated the characteristics and outcome of rural patients with ESRD in a dialysis center of Guangxi, compared with urban patients in the same period.     

Hemodialysis Disparities in African Americans: The Deeply Integrated Concept of Race in the Social Fabric of Our Society

End‐stage renal disease (ESRD) is one of the starkest examples of racial/ethnic disparities in health. Racial/ethnic minorities are 1.5 to nearly 4 times more likely than their non‐Hispanic White counterparts to require renal replacement therapy (RRT), with African Americans suffering from the highest rates of ESRD. Despite improvements over the last 25 years, substantial racial differences are persistent in dialysis quality measures such as RRT modality options, dialysis adequacy, anemia, mineral and bone disease, vascular access, and pre‐ESRD care. This report will outline the current status of racial disparities in key ESRD quality measures and explore the impact of race. While the term race represents a social construct, its association with health is more complex. Multiple individual and community level social determinants of health are defined by the social positioning of race in the U.S., while biologic differences may reflect distinct epigenetic changes and linkages to ancestral geographic origins. Together, these factors conspire to influence dialysis outcomes among African Americans with ESRD.     

No difference in meeting hemoglobin and albumin targets for dialyzed children with urologic disorders

Urologic disorders are the most common cause of chronic kidney disease in children. To determine whether children with urologic etiology of end-stage renal disease (ESRD) fare better than children with ESRD from other causes while on dialysis, we conducted a cross-sectional study of children <18 years receiving peritoneal and hemodialysis in the United States using data from the Centers for Medicare & Medicaid Services 2005 ESRD CPM Project. We compared baseline demographics and the study groups. In multivariate logistic regression analysis of 1,286 subjects, we assessed whether children with urologic disorders had a higher odds of meeting adult KDOQI targets for hemoglobin levels ≥11 g/dl and albumin ≥3.5 BCG/3.2 BCP g/dl. We conducted a subset analysis of 1,136 patients to examine the impact of erythropoietin on hemoglobin targets. Our results did not reveal differences in achievement of adult hemoglobin targets (adjusted OR: 1.27; p value 0.09; CI: 0.97–1.66) or in the subset analysis with erythropoietin (adjusted OR: 1.32; p value 0.06; CI: 0.98–1.78) or albumin targets (adjusted OR: 1.22; p value 0.21; CI: 0.90–1.65) in adjusted analyses. Due to our study’s limitations, it is difficult to determine whether this may result from treatment prior to dialysis initiation or treatment effect of dialysis rather than underlying diagnosis.     

Chronic kidney disease care program improves quality of pre-end-stage renal disease care and reduces medical costs

Aim: Multidisciplinary care of patients with chronic kidney disease (CKD) provides better care outcomes. This study is to evaluate the effectiveness of a CKD care program on pre‐end‐stage renal disease (ESRD) care. Methods: One hundred and forty incident haemodialysis patients were classified into the CKD Care Group (n = 71) and the Nephrologist Care Group (n = 69) according to participation in the CKD care program before dialysis initiation. The ‘total observation period’ was divided into ‘6 months before dialysis’ and ‘at dialysis initiation’. Quality of pre‐ESRD care, service utilization and medical costs were evaluated and compared between groups. Results: The mean estimated glomerular filtration rates at dialysis initiation were low in both groups; but the levels of haematocrit and serum albumin of the CKD Care Group were significantly higher. The percentages of patients initiating dialysis with created vascular access, without insertion of double‐lumen catheter and without hospitalization were 57.7%, 50.7% and 40.8%, respectively, in the CKD Care Group, and 37.7%, 29.0% and 18.8% in the Nephrologist Care Group (P < 0.001). Participation in the CKD care program, though with higher costs during the 6 months before dialysis ($US1428 ± 2049 vs US$675 ± 962/patient, P < 0.001), was significantly associated with lower medical costs at dialysis initiation ($US942 ± 1941 vs $US2410 ± 2481/patient, P < 0.001) and for the total period of observation ($US2674 ± 2780 vs $US3872 ± 3270/patient, P = 0.009). The cost‐saving effect came through the early preparation of vascular access and the lack of hospitalization at dialysis initiation. Conclusion: CKD care programs significantly improve quality of pre‐ESRD care, decrease service utilization and save medical costs.     

Serum Lipid Profile and Plasma Fatty Acids Levels in Hemodialysis Pediatric Patients-Possible Deficiency of Essential Fatty Acids

Polyunsaturated fatty acids (PUFA) are reported to be associated with atherosclerotic and inflammatory diseases because they are the major components of the cytoplasmic membrane and are the precursor fatty acids for prostaglandins and leukotrienes. Aim of this study was to identify PUFA profile (PUFAp) in children with end stage renal disease (ESRD) on hemodialysis (HD). And study its relationship with known cardiovascular and arteriosclerotic risk factors. We examined 44 pediatric HD patients (mean age 11 ± 3.36 years). Plasma lipid profile, plasma fatty acid pattern, serum albumin and hemoglobin were studied in these children. Triglyceride levels were increased in the plasma of ESRD patients compared to the healthy subjects. Plasma PUFA decreased whereas behanic acid (saturated fatty acid) increased in ESRD patients. A lower level of eicosapentaenoic acid was revealed in HD patients with cardiomyopathy (HD-CAD) than those without cardiovascular disease(HD-norm) (0.20 ± 0.01 μ/mL vs. 0.88 ± 0.12 μ/mL, P = 0.01). An inverse correlation was found between the linoleic acid level and serum TG level in children on HD (r = −0.54, P = 0.03). A positive correlation was found between plasma arachidonic acid level and serum albumin (r = 0.86, P = 0.003). A significant positive correlation was revealed between plasma eicosapentaenoic acid concentration and serum hemoglobin level (r = −0.64, P = 0.04). Saturated acid was negatively correlated with serum albumin (r = −0.70, P = 0.03). Children under regular hemodialysis evidence significant abnormalities in serum fatty acid levels together with triglyceride abnormalities, a finding that might be relevant to the risk of cardiovascular disease in this setting.     

Coût de la prise en charge de l’IRCT en France en 2007 et impact potentiel d’une augmentation du recours à la dialyse péritonéale et à la greffe

IntroductionThis study estimates the costs for the national health insurance in 2007 of the patients with end-stage renal disease (ESRD) according to therapies modalities.MethodData for all patients covered by the general health insurance scheme (77% of the French population) from hospital discharge and outpatients reimbursement databases were linked. ESRD therapies were identified using an algorithm mainly based on discharge diagnosis and immunosuppressive drugs refunds.ResultsExtrapolated to all French population at the end of 2007, 60,900 patients had an ESRD therapy: 30,900 were treated on haemodialysis (HD) (51%), 2600 on peritonea dialysis (DP) (4%) and 27,300 had a kidney transplant (45%). Patients with dialysis therapies had more often complementary universal coverage for low earners. According to the French regions, patient treated with DP were between 0 to 26% and 19 to 57% for those with a transplant. The total refund cost for National Health Insurance was four billion € of which 77% for HD. Annual mean costs per patient were 64 k€ for DP, 89 k€ for HD, 86 k€ for the year of transplantation and 20 k€ for the following years. A 25% increase of DP would allow a decrease of the annual cost of 155 millions € and 900 transplantations more each year during 10 years a decrease of 2.5 billions €ConclusionThe increase of ESRD prevalence and its total cost require patients and professionals information and formation about the less expensive and more autonomous therapies and others alternatives facing the lack of kidney transplants from deceased donors.     

Predictive markers of asymptomatic atherosclerosis in end-stage renal disease patients

Objective: Uremia is associated with accelerated atherosclerosis and increased cardiovascular mortality in patients with end-stage renal disease (ESRD). Cardiac injury markers, such as myoglobin, creatine kinase-MB (CK-MB), or troponins, frequently used to recognize acute coronary events, may be falsely elevated in this patient group. In this study, our aim was to (i) test serum levels of myoglobin, CK-MB, and troponin I (cTnI) in ESRD patients without coronary artery disease (CAD) and compare the results with healthy controls and (ii) to investigate the association between these markers and carotid artery intima–media thickness (CA–IMT), high-sensitive C-reactive protein (hs-CRP), and serum uric acid (SUA) levels in ESRD patients. Materials and methods: Fifty-two ESRD patients (25 hemodialysis and 27 peritoneal dialysis) and 17 healthy controls were included in the study. Serum levels of myoglobin, CK-MB, and cTnI were measured and ultrasonographic CA–IMT was determined in all participants. SUA and hs-CRP levels were only measured in the ESRD group. Results: Serum myoglobin, CK-MB levels, and the mean CA–IMT were significantly higher in ESRD group (p < 0.01), whereas cTnI levels were not different compared to healthy controls (p = 0.70). There was also a positive correlation between CA–IMT and cTnI levels (p = 0.003, r = 0.35) and CA–IMT and hs-CRP (p = 0.03, r = 0.30) or SUA levels (p = 0.003, r = 0.43). Conclusion: cTnI may serve as a more sensitive marker in detecting cardiovascular events in patients with renal failure. Besides the traditional risk factors of atherosclerosis, cTnI, hs-CRP, and SUA may have a predictive role in recognizing premature atherosclerosis in ESRD patients.     

Renal Function and Serum Albumin at the Start of Dialysis in 514 Chinese ESRD In-Patients

Background. The dialysis population has grown rapidly in recent decades. Despite the high cost and poor outcomes of dialysis treatment for ESRD, there are scant data about the level of renal function and the relationship of renal function and serum albumin at the start of dialysis in Chinese ESRD patients. Method. We report the level of serum creatinine (Scr), glomerular filtration rate (GFR), and serum albumin (Salb) in 514 ESRD in-patients who began their dialysis treatment between January 2001 through December 2007 at two large dialysis centers in Changsha, Hunan, China. Data were obtained through reviewing the case records of all 514 patients. GFR was predicted by an equation developed from the Modification of Diet in Renal Disease Study. In addition, serum albumin was analyzed in relation to levels of predicted GFR. Results. The mean (SD) and median predialysis serum creatinine was 1121.92 ± 458.24 and 1032 μmol/L. The mean (SD) and median predicted GFR was 4.98 ± 2.24 and 4.47mL/min/1.73m². The proportion of patients with predicted GFR of >10, 5 to 10, and <5 mL/min/1.73m² was 3.7, 36.2, and 60.1%, respectively. The mean predicted GFR was significantly lower among younger patients, uninsured patients, unemployed or farmer patients, patients who were employed, students, patients who selected hemodialysis, patients with ESRD caused by diseases other than diabetes, patients with BUN above the mean, and patients with hemoglobulin beneath the mean. Compared with patients who started with GFR >5mL/min, the patients who started with GFR ≤5mL/min had significantly higher plasma urea and creatinine levels but significantly lower creatinine clearance (mL/min per 1.73m²) and parameters of nutritional status, such as serum albumin, body weight, and BMI. Conclusion. A wide variation existed in renal function at the initiation of dialysis in partial Chinese ESRD patients. Most patients start dialysis at very low levels of predicted GFR. The nutritional status in patients who start dialysis early was better than those in patients who start dialysis when GFR ≤ 5mL/min. Further studies are needed to analyze the impact of level of renal function and nutritional status at the start of dialysis on the outcomes of ESRD.     

Health-related quality of life in pediatric patients with ESRD

As part of creating a pediatric ESRD-specific Health-Related Quality of Life (HRQOL) assessment instrument, we established pilot data with the PedsQL 4.0 Generic Core Scales in 96 pediatric patients with ESRD receiving hemodialysis (HD), peritoneal dialysis (PD) or with a renal transplant (TX). Patient age ranges were: 2–4 (8; PD n=3, TX n=5), 5–7 (12; HD n=9, TX n=3), 8–12 (25; HD n=5, PD n=6, TX n=14), 13–18 (51; HD n=18, PD n=10, TX n=23). PedsQL ESRD data were compared to healthy children (n=131 child report; n=145 parent report) and across HD/PD/TX. For all domains, ESRD patient HRQOL scores were significantly lower than healthy controls. Transplant patients reported better physical and psychosocial health than dialysis patients. No difference was noted between HD and PD patients for any PedsQL domain. Our data demonstrate that the PedsQL 4.0 Generic Core Scales is a useful measurement instrument to screen for HRQOL impairment in pediatric patients with ESRD. We suggest that the ESRD-specific HRQOL instrument in development is needed to help define condition-specific HRQOL differences between modalities.     

The relationship between atherogenic index of plasma and epicardial adipose tissue in hemodialysis and peritoneal dialysis patients

Abstract

Introduction: Epicardial adipose tissue (EAT) is the true visceral fat depot of the heart. The relationship between coronary artery disease and EAT was shown in end-stage renal disease (ESRD) patients. One of the established risk factor in this population is dyslipidemia. We aimed to determine the relationship between atherogenic index of plasma (AIP) and EAT in ESRD patients. Methods: This was a cross-sectional study involving 76 ESRD patients receiving PD or HD for ≥6 months and 42 healthy subjects. EAT was measured by using an electrocardiogram-gated 64-multidetector computed tomography (MDCT). Atherogenic index of plasma was calculated as the logarithmically transformed ratio of the serum trigliseride to HDL-cholesterol. Results: The etiology of ESRD patients was diabetic nephropathy (n?=?16), chronic glomerulonephritis (n?=?10), hypertensive nephropathy (n?=?23), polycystic kidney disease (n?=?7), nephrolithiasis (n?=?5) and unknown (n?=?15). There were no differences with respect to the following variables between ESRD patients and healthy subjects: age; sex; BMI; predialysis levels of DBP; serum levels of albumin, HDL-cholesterol and hemoglobin. However, ESRD patients had higher serum levels of trigliseride, hs-CRP and AIP when compared to healthy subjects. There was a statistically significant relationship between EAT, BMI and AIP in ESRD patients (r?=?0.42, p?<?0.001 and r?=?0.25, p?=?0.028, respectively). The stepwise linear regression analysis revealed that age, as well as BMI were independent predictors of EAT. Conclusion: We found a relationship between EAT as defined by MDCT and AIP in ESRD patients. Further clinical and experimental studies are needed.     

The Relationship between Oxidative Stress,Inflammation, and Atherosclerosis in Renal Transplant and End-Stage Renal Disease Patients

Objectives: Cardiovascular risk is increased in the early stages of chronic kidney disease (CKD) and is also found to be ongoing in renal transplant (Rtx) patients. As a sign of atherosclerosis, increased carotid intima–media thickness (CIMT) has been widely accepted as a strong predictor of cardiovascular disease (CVD) and mortality in the end-stage renal disease (ESRD) patients. Ischemia-modified albumin (IMA), pentraxin-3 (PTX-3), and neutrophil-to-lymphocyte ratio (NLR) were introduced as oxidative stress and inflammatory biomarkers in ESRD. The role of Rtx in terms of atherogenesis, oxidative stress, and inflammation is still unclear. We aimed to investigate the relationship between IMA, PTX-3, NLR, and CIMT in Rtx patients without overt CVD and to compare these results with those obtained from healthy subjects and ESRD patients receiving hemodialysis (HD) and peritoneal dialysis (PD). Design and methods: Cross-sectional analysis in which CIMT measurements, NLR, and serum PTX-3 and IMA levels were assessed in 18 Rtx patients (10 females; mean age: 40.0 ± 13.3 years), 16 PD patients (7 females; 40.2 ± 12.9 years), 14 HD patients (8 females; 46.6 ± 10.7 years), and 19 healthy subjects (9 females; 36.9 ± 8.9 years). Results: IMA, PTX-3, and high-sensitive C-reactive protein (hs-CRP) levels, NLR, and CIMT of Rtx patients were found to be significantly higher compared with healthy subjects (?p = 0.04, p < 0.0001, p < 0.005, p = 0.005, and p = 0.005, respectively). IMA level was positively correlated with hs-CRP and PTX-3 levels, NLR, and CIMT when all participants were included (r = 0.338, p = 0.005; r = 0.485, p < 0.0001; r = 0.304, p = 0.013; and r = 0.499, p < 0.0001, respectively). Conclusion: There has been ongoing inflammation, oxidative stress, and atherosclerosis in Rtx patients.     

Identification of Facilitators and Barriers to Home Dialysis Selection by Canadian Adults with ESRD

Home dialysis (home HD or home PD) remains underutilized in most jurisdictions. Physicians, advanced‐practice nurses, and policy makers working with chronic kidney disease populations can provide insights into patient, healthcare professional, and system‐level barriers to home dialysis selection by suitable patients. We used in‐depth interviews, with a purposive sampling strategy until informational redundancy was achieved, to elicit barriers and facilitators to home dialysis selection from thirteen informants. We triangulated these data against qualitative data collected in a related survey of nephrologist attitudes. We used a modified grounded theory approach to construct a taxonomy of barriers and facilitators. Informants included nephrologists (n = 11), an advanced‐practice nurse, and a health administrator with a provincial renal care organization. We constructed separate taxonomies of barriers and related facilitators that were specific to PD, specific to home HD, and common to both. We distinguished between factors favoring, modifiable factors opposing, and nonmodifiable factors opposing home dialysis selection. Several major themes emerged, including: medical factors, home physical environment, psychological and cognitive factors (knowledge, attitudes, coping styles), social factors (supports, lifestyle), dialysis program, local hospital or regional factors (expertise, resources, local culture), healthcare professional‐related factors (knowledge, attitudes, reimbursement), health system‐related factors (funding models), and exogenous factors (late referral, technology). We identified several modifiable practices at the level of patient, healthcare professional, dialysis facility, and healthcare system to increase appropriate use of home dialysis. We discuss potential facilitating factors, knowledge gaps, and priorities for future research, and propose potential applications for this novel taxonomy of determinants of dialysis modality choice.     

Attitudes toward genetic diagnosis and prenatal diagnosis of X-linked Alport syndrome in China

Aim: Alport syndrome (AS) is a progressive renal disease characterized by hematuria and progressive renal failure. X‐linked dominant AS (XLAS) is the predominant inheritance form caused by mutations in COL4A5 gene. Attitudes toward genetic diagnosis and prenatal diagnosis for Chinese AS families were investigated. Attitudes toward genetic diagnosis and prenatal diagnosis in Chinese XLAS families were evaluated in the current study. Methods: A total of 160 XLAS patients and their 126 healthy family members in China were interviewed. After providing background knowledge counselling and education on AS, their attitudes toward genetic diagnosis and prenatal diagnosis were evaluated by multiple‐choice questionnaire. Results: Majority of the respondents cared mostly about the prognosis and treatment effects of AS (89.9% vs 81.1%) since they considered that the worst outcome of XALS was renal insufficiency (92.3%). Of all the interviewees, 99.3% were interested in genetic research for the discovery of better treatments and more appropriate diagnostic tools (positive attitudes) (89.5% vs 73.2%). About 80% of the participants would accept prenatal testing and subsequent termination of pregnancy in cases of affected foetuses (boys: 86.8% and girls: 74.6%, respectively). Conclusion: Most Chinese XLAS families show positive attitudes and desire new discoveries in treatment and diagnosis. About 80% of respondents would approve prenatal testing with a desire for selective termination of pregnancy rather than predicting the health of a future child.