Haemoglobin at time of referral prior to dialysis predicts survival: an association of haemoglobin with long-term outcomes

Haemoglobin (Hgb) levels are known to be associated with numerousadverse outcomes in both chronic kidney disease (CKD) and non-CKDpatients. This analysis evaluates the association of baseline haemoglobinlevels on survival in CKD patients, who are followed by nephrologists,irrespective of glomerular filtration rate (GFR), prior to initiationof renal replacement therapy (RRT) and erythropoietin hormonereplacement therapy. Analysis of data from the provincial database (PROMIS, PatientRegistration and Outcome Management Information System) in BritishColumbia, Canada, was undertaken. Records used for the analysisincluded all CKD patients at first registration: GFR <60ml/min/1.73 m², not yet on dialysis, starting from May 1998to October 2002, and who had complete data (defined as age andgender, diabetic status, eGFR and Hgb levels). The primary objective of this study was to determine the associationof Hgb and survival controlling for eGFR at first registrationvalue, age, gender and diabetic status. Multivariate Cox proportionalhazards analysis with time to death as outcome variable wasperformed. The cohort included 3028 patients: the mean age was 65 years,28% were diabetic, and the mean eGFR in the cohort was 21 ml/min/1.73m². The cohort is representative of the BC CKD and dialysispopulation regarding ethnicity: 64% Caucasian, 32% Asian. Medianfollow-up was 27 months, 1 year survival was 0.92, 2 year survivalwas 0.85. Hgb at initial registration is a statistically independentpredictor of survival (RR = 0.875 for every 10 g/l, 95% CI:0.835–0.917, P = 0.0001), after adjusting for age, gender,diabetic status and baseline eGFR. Further analysis, controllingfor RRT, demonstrated a similar association between Hgb andsurvival (RR = 0.853 for every 10 g/l, 95% CI: 0.799–0.910,P = 0.0001), after adjusting for above variables. Substantialvariation in Hgb values exists at all GFR levels. These findings underscore the importance of evaluating Hgb atall GFR levels, and the need to study the impact of modificationof Hgb at different GFR levels on survival.     

User satisfaction with a real-time automated feedback system for general practitioners: a quantitative and qualitative study.

OBJECTIVE: The GRIF automated feedback system produces real-time comments on the appropriateness of diagnostic tests ordered by general practitioners (GPs) based on recommendations from accepted national and regional practice guidelines. We investigated the experiences of GPs with this system and, more specifically, with the recommendations produced by the system as well as their views on using this system in daily practice. SETTING: We tested the GRIF system in an experiment in a laboratory setting and in a daily practice trial. STUDY PARTICIPANTS: General practitioners. INTERVENTION: In the laboratory experiment, GPs used the GRIF system to assess the appropriateness of 30 request forms. Each of the GPs was confronted with requests they had submitted to the diagnostic unit of the hospital in the past. In the field trial, the GRIF system was applied during patient consultations for 1 year. MAIN OUTCOME MEASURES: We measured GPs' satisfaction with the system using a questionnaire, and also conducted group discussions (in the laboratory experiment) and in-depth interviews (in the field trial) to elicit GPs' opinions of and experiences with the system. In addition, we explored GPs' reasons for not accepting the comments offered by the GRIF system. RESULTS: The results show that the GPs in the laboratory experiment had more positive attitudes towards the system compared with participants in the field trial. All discussion groups and most of the GPs in the field trial regarded receiving the immediate feedback during the test ordering process as an important advantage. The most frequently mentioned reason to reject the recommendation was disagreement with the content and/or the recommendations in the practice guidelines. CONCLUSION: Apart from securing agreement on guideline content, a prerequisite for using GRIF in daily practice on a large scale is that more attention is paid to promotion of the guidelines and their adoption, and stimulation of a positive attitude towards the practice guidelines among the users.     

Bilateral malignant glaucoma.

Two cases of bilateral malignant glaucoma are presented. In one case the condition developed sequentially in the two eyes; pars plana vitrectomy was eventually needed in the operated eye, whereas the condition responded to medical treatment in the fellow eye. In the second case the two eyes were involved simultaneously nearly 1 year after surgery, and the glaucoma responded to medical treatment.     

Does work with visual display units impair visual activities after work?

It is well established that visual display unit (VDU) operators complain of visual fatigue and visual stress during after-work hours. The present study was divided into two parts. In the first part, standard eye examinations were performed on a group of VDU workers (n = 32) and a control group (n = 15); those subjects who were found to have correct vision (n = 16 and 13, respectively) participated in the second part. The eye examinations revealed that on the average, the VDU workers suffered more than twice as many visual impairments as the controls. In those with correct vision, the near point of accommodation was measured at the beginning of the workday at the start of the week, and at the end of the workday, four days later. In the VDU group, the decrease in accommodation was uniformally distributed between zero and 1.0 diopter, whereas among the non-VDU workers, 77% of the decrease was between zero and 0.25 diopter. The dynamic range of accommodation in the VDU workers on the second examination was smaller than on the first. We conclude that some of the visual stress and visual fatigue that developed at work hindered visual activities after work.     

The Breast Cancer Screening Program in Rhode Island.

The Rhode Island Department of Health has undertaken a Breast Cancer Screening Program which incorporates assessment, policy development, and assurance functions, following the model proposed in the Institute of Medicine (IOM) report, The Future of Public Health. With the community's help, projects have been implemented to increase screening capacity with dedicated, state-of-the-art equipment, to increase screening accessibility, to publicize the need for mammography, and to minimize false test results. In the program's first 15 months, the proportion of women ages 40 and over who were screened with mammography according to current guidelines increased from 35 to 46 percent (from 38 to 49 percent among women ages 40-49; from 31 to 43 percent among women ages 50 and over), including 15 percent who received their first screening mammogram. Providers' recommendations and knowledge of screening guidelines were important in explaining first-time use. The Department plans to apply the IOM model in other program areas. Its adoption by others is urged.