Effect of shared care on blood pressure in patients with chronic kidney disease: a cluster randomised controlled trial

Background

Chronic kidney disease (CKD) is highly prevalent in patients with diabetes or hypertension in primary care. A shared care model could improve quality of care in these patients

Aim

To assess the effect of a shared care model in managing patients with CKD who also have diabetes or hypertension.

Design and setting

A cluster randomised controlled trial in nine general practices in The Netherlands.

Method

Five practices were allocated to the shared care model and four practices to usual care for 1 year. Primary outcome was the achievement of blood pressure targets (130/80 mmHg) and lowering of blood pressure in patients with diabetes mellitus or hypertension and an estimated glomerular filtration rate (eGFR)<60ml/min/1.73m².

Results

Data of 90 intervention and 74 control patients could be analysed. Blood pressure in the intervention group decreased with 8.1 (95% CI = 4.8 to 11.3)/1.1 (95% CI = −1.0 to 3.2) compared to −0.2 (95% CI = −3.8 to 3.3)/−0.5 (95% CI = −2.9 to 1.8) in the control group. Use of lipid-lowering drugs, angiotensin-system inhibitors and vitamin D was higher in the intervention group than in the control group (73% versus 51%, 81% versus 64%, and 15% versus 1%, respectively, [P = 0.004, P = 0.01, and P = 0.002]).

Conclusion

A shared care model between GP, nurse practitioner and nephrologist is beneficial in reducing systolic blood pressure in patients with CKD in primary care.     

Mothers’ attachment styles and their children’s self-reported security,as related to maternal socialization of children’s positive affect regulation

This study investigated how mothers’ attachment was related to their responses to their own and their children’s positive events and positive affect (PA). Ninety-seven mothers reported on their attachment and their responses to their own and their 7–12-year-old children’s positive events and emotions. Children reported on their mothers’ responses to the children’s positive events and their attachment security with their mothers. The results indicated that more avoidant mothers reported less intense PA in response to their own and their children’s positive events. More avoidant mothers also were less likely to encourage their children to savor positive events (through expressing PA, reflecting on PA or themselves, giving rewards, and affectionate responses). Mothers higher on anxiety reported greater likelihood of dampening (e.g., minimizing the event’s importance) their own positive events and reported being more likely to feel discomfort and to reprimand their children for expressing PA. Children’s security was predicted by mothers’ lower likelihood of encouraging children’s dampening and of reprimanding children for PA displays. This study advances the literature on how mothers’ attachment is related to the ways in which they regulate their own and their children’s PA, which may have implications for children’s attachment and developing PA regulation.     

Structural Brain Changes following Long-Term 6° Head-Down Tilt Bed Rest as an Analog for Spaceflight

BACKGROUND AND PURPOSE:Following long-term spaceflight, a subset of the National Aeronautics and Space Administration astronauts present with visual impairment and increased intracranial pressure, known as visual impairment and intracranial pressure syndrome. We investigated structural brain changes following long-term head-down tilt bed rest as a spaceflight analog.MATERIALS AND METHODS:Volumetric analysis was performed on structural pre- and post–bed rest brain MR images.RESULTS:Comparing post–bed rest to pre–bed rest images, we found the following: 1) no significant group differences in GM, WM, CSF, or ventricular volumes; 2) shift of the center of mass of the brain upward and posterior rotation of the brain relative to the skull; 3) a significant correlation between posterior brain rotation and changes in ventricular volume; and 4) significant increases in brain tissue density in regions at the vertex, including the frontoparietal lobes, with contraction of adjacent extra-axial CSF spaces, and significant decreases in tissue density in areas along the base of the brain, including the orbitofrontal cortex.CONCLUSIONS:We observed widespread morphologic changes with brain tissue redistribution in response to gravity changes; possible associated functional changes are unknown. The observation that ventricular change is correlated to posterior brain rotation suggests an alteration in CSF homeostasis. Ultimately, to elucidate any structural changes that may play a role in visual impairment and intracranial pressure syndrome, volumetric analysis of pre- and postflight structural scans of astronauts is needed.

Following long-term missions aboard the International Space Station, increased intracranial pressure and papilledema have been documented in the National Aeronautics and Space Administration (NASA) astronauts. In 1 report¹ investigating 7 astronauts following 6 months of spaceflight, all astronauts demonstrated ophthalmologic findings, with disc edema in 5 astronauts and globe flattening in 5. Lumbar punctures were performed in 4 of these astronauts with opening pressures of 21–28.5 cm H₂O¹. In the 1 astronaut who underwent repeated lumbar punctures, the opening pressure remained elevated 19 months following spaceflight at 22 cm H₂O¹. The etiology of these findings is currently unclear; however, it has been hypothesized that they may result from loss of gravitational hydrostatic pressure gradients and large cephalad fluid shifts. NASA has coined the term “visual impairment and intracranial pressure [VIIP] syndrome” to describe this constellation of signs and symptoms in astronauts and has likened VIIP syndrome to Earth-based idiopathic intracranial hypertension (IIH) or pseudotumor cerebri.A traditional ground-based analog used by NASA and other international space agencies to study physiologic changes associated with long-term spaceflight has been to place healthy subjects in 6° head-down tilt bed rest for varying periods.^2,3 Anecdotally, Russian scientists first devised the head-down-tilt protocol in the early 1970s on the basis of reports by Russian cosmonauts who had the sensation of slipping off the foot of the bed on return to Earth after long-duration missions.³ The foot of the bed was raised until it felt horizontal to help the cosmonauts sleep.³ As an analog for spaceflight, the reduction in Gz gravitational stimuli during bed rest results in an upward shift of body fluids, unloading the upright weight of the body, reduced work against the force of gravity, and lower extremity inactivity.³ As a result, many of the physiologic changes of spaceflight can be reproduced, including decreased cardiac output, orthostatic intolerance, muscle atrophy, and bone loss. This model has been applied extensively to investigate cardiovascular and musculoskeletal deconditioning, immunologic response, and cognitive functioning.^2,3We previously acquired structural MR imaging brain scans of subjects participating in a NASA-sponsored long-term bed rest study.⁴ Given the recent interest in intracranial adaptation to spaceflight, we decided to perform a volumetric analysis of the structural MR imaging dataset to assess any potential alterations in brain structure or CSF distribution that may shed light on the spectrum of findings noted in VIIP syndrome. The results of this analysis are presented here.     

Identification of a human B-cell/myeloid common progenitor by the absence of CXCR4

CXCR4 is a chemokine receptor required for hematopoietic stem cell engraftment and B-cell development. This study found that a small fraction of primitive CD34(+)/CD19(+) B-cell progenitors do not express CXCR4. These CD34(+)/CD19(+)/CXCR4(-) cells were also remarkable for the relative lack of primitive myeloid or lymphoid surface markers. When placed in B-lymphocyte culture conditions these cells matured to express CXCR4 and other surface antigens characteristic of B cells. Surprisingly, when placed in a myeloid culture environment, the CXCR4(-) B-cell progenitors could differentiate into granulocyte, macrophage, and erythroid cells at a high frequency. These data define a novel B-cell/myeloid common progenitor (termed the BMP) and imply a less restrictive pathway of myeloid versus lymphoid development than previously postulated.     

New abnormalities in the morphology, cell surface receptors, and electrolyte metabolism of In(Lu) erythrocytes

The In(Lu) phenotype is inherited as an autosomal dominant trait and is characterized by suppression of the Lutheran, P1, i, and Aua erythrocyte blood group antigens. We have developed a monoclonal antibody (L21) that strongly agglutinates all erythrocytes except In(Lu), and we have identified eight In(Lu) individuals among 42,000 blood donors tested. Studies of two families confirmed the dominant mode of inheritance and revealed several new features of this phenotype. The erythrocytes of all five affected individuals from the two families exhibited diminished hemagglutination by the lectin concanavalin A, although they reacted normally with several other lectins. The erythrocytes of two affected individuals in one family exhibited marked acanthocytosis. The erythrocytes of the proposita of the other family exhibited a mild degree of poikilocytosis, but the cells of the other two affected individuals in this family had normal morphology. The osmotic fragility of fresh In(Lu) erythrocytes was normal, but after incubation for 24 hours at 37 degrees C in plasma the In(Lu) cells exhibited a marked increase in resistance to osmotic lysis. During the incubation period the erythrocytes lost K+ and their total cation content was diminished. These data indicate that in addition to the suppression of blood group antigens noted previously, the In(Lu) phenotype includes a variety of morphological abnormalities and a defect in electrolyte metabolism. The use of L21 and similar monoclonal antibodies provides a more sensitive means of detecting In(Lu) erythrocytes than typing with human anti-Lub antisera.