Pre‐transplant comorbidity burden and post‐transplant chronic graft‐versus‐host disease

The Haematopoietic Cell Transplantation‐Comorbidity Index (HCT‐CI) was designed as a predictor of non‐relapse mortality after HCT. Chronic graft‐versus‐host disease (GVHD) contributes to mortality after HCT. Here, we investigated whether the HCT‐CI could predict development of chronic GVHD or post‐chronic GVHD mortality. We retrospectively analysed data from 2909 patients treated with allogeneic HCT for malignant and non‐malignant haematological conditions at four institutions. In Cox regression models adjusted for potential confounders, increasing HCT‐CI was not statistically significantly associated with the development of chronic GVHD [hazard ratio (HR) = 1·02, P = 0·34]. Yet, the index was associated with an increased risk of non‐relapse mortality (HR = 1·29, P < 0·0001) as well as overall mortality (HR = 1·25, P < 0·001) following the development of chronic GVHD. The association between HCT‐CI and post‐chronic GVHD mortality was similar regardless of donor type or stem cell source. HCT‐CI scores could be incorporated in the design of clinical trials for treatment of chronic GVHD.     

Lived experience in teaching mental health nursing: Issues of fear and power

Australian mental health policy clearly articulates recovery focus as the underpinning of mental health services. Barriers to achieving a recovery focus are identified in the literature, with negative attitudes of health professionals receiving particular attention. The involvement of people with lived experience of significant mental health challenges and mental health service use is essential to enhancing more positive attitudes. Lived‐experience involvement in the education of nurses is evident; however, it is generally limited and implemented on an ad hoc basis. Overall, there is a paucity of literature on this topic. A qualitative exploratory study was undertaken to elicit the views and perceptions of nurse academics and lived‐experience educators about the inclusion of lived experience in mental health nursing education. One major theme to emerge from the research was issues of fear and power, which included three subthemes: facing fear, demystifying mental illness, and issues of power. Lived‐experience involvement has an important role to play in the education of nurses in addressing fear and demystifying the experience of mental illness. The power that lived‐experience educators exercised in their roles varied considerably, and for many, was limited. Therefore, the effectiveness of lived‐experience involvement requires a more equitable distribution of power.     

Consumer sexual relationships in a Forensic mental health hospital: Perceptions of nurses and consumers

The management of consumer‐related risk is paramount in a secure forensic mental health facility. However, the consequent risk aversion presents a major barrier to consumers forming sexual relationships in a manner that is open and accepted. Investigation of the views of nurses working in forensic mental health settings on this topic is limited, and even more so for consumers of services. This qualitative exploratory study was undertaken to elicit the views of consumers and nurses about forming sexual relationships within this long‐term and secure setting. Individual in‐depth interviews were conducted with 12 nurses and 10 consumers. The benefits of, and barriers to, sexual relationships was identified as a major theme, and these findings are the focus of this paper. Nurse responses included the subthemes ‘supportive factors’ and ‘potential dangers’, reflecting their qualified support. Consumer responses included the subthemes ‘therapeutic’, ‘feeling normal’, ‘restrictions and barriers’, and ‘lack of support and secrecy’. The importance of sexual relationships was clearly articulated, as was the difficulties in forming and maintaining them within the forensic setting. More open discussion about this commonly‐avoided issue and the education of nurses and other health professionals is required.     

A systematic review of the utility of 1.5 versus 3 Tesla magnetic resonance brain imaging in clinical practice and research

Objective

MRI at 3?T is said to be more accurate than 1.5?T MR, but costs and other practical differences mean that it is unclear which to use.

Methods

We systematically reviewed studies comparing diagnostic accuracy at 3?T with 1.5?T. We searched MEDLINE, EMBASE and other sources from 1 January 2000 to 22 October 2010 for studies comparing diagnostic accuracy at 1.5 and 3?T in human neuroimaging. We extracted data on methodology, quality criteria, technical factors, subjects, signal-to-noise, diagnostic accuracy and errors according to QUADAS and STARD criteria.

Results

Amongst 150 studies (4,500 subjects), most were tiny, compared old 1.5?T with new 3?T technology, and only 22 (15?%) described diagnostic accuracy. The 3?T images were often described as “crisper”, but we found little evidence of improved diagnosis. Improvements were limited to research applications [functional MRI (fMRI), spectroscopy, automated lesion detection]. Theoretical doubling of the signal-to-noise ratio was not confirmed, mostly being 25?%. Artefacts were worse and acquisitions took slightly longer at 3?T.

Conclusion

Objective evidence to guide MRI purchasing decisions and routine diagnostic use is lacking. Rigorous evaluation accuracy and practicalities of diagnostic imaging technologies should be the routine, as for pharmacological interventions, to improve effectiveness of healthcare.

Key Points

? Higher field strength MRI may improve image quality and diagnostic accuracy. ? There are few direct comparisons of 1.5 and 3?T MRI. ? Theoretical doubling of the signal-to-noise ratio in practice was only 25?%. ? Objective evidence of improved routine clinical diagnosis is lacking. ? Other aspects of technology improved images more than field strength.     

Survival and transplantation outcomes of children less than 2 years of age with end-stage renal disease

Background

Young children with end-stage renal disease (ESRD) requiring renal replacement therapy (RRT) have traditionally experienced high rates of morbidity and mortality; however, detailed long-term follow-up data is limited.

Methods

Using a population-based retrospective cohort with data from a national organ failure registry and administrative data from Canada’s universal health care system, we analysed the outcomes of 87 children starting RRT (before age 2 years) and followed them until death or date of last contact [median follow-up 4.7 years, interquartile range (IQR) 1.4–9.8). We assessed secular trends in survival and the influence of: (1) age at start of RRT and (2) etiology of ESRD with survival and time to transplantation.

Results

Patients were mostly male (69.0 %) with ESRD predominantly due to renal malformations (54.0 %). Peritoneal dialysis was the most common initial RRT (83.9 %). Fifty-seven (65.5 %) children received a renal transplant (median age at first transplant: 2.7 years, IQR 2.0–3.3). During 490 patient-years of follow-up, there were 23 (26.4 %) deaths, of which 22 occurred in patients who had not received a transplant. Mortality was greater for patients commencing dialysis between 1992 and 1999 and among the youngest children starting RRT (0–3 months). Children with ESRD secondary to renal malformations had better survival than those with ESRD due to other causes. Among the transplanted patients, all but one survived to the end of the observation period.

Conclusion

Children who start RRT before 3 months of age have a high risk of mortality. Among our paediatric patient cohort, mortality rates were much lower among children who had received a renal transplant.     

Long-term risk projection and its application to nephrology research

Measures of kidney disease burden or risk estimates in nephrology research have primarily focused on the concepts of prevalence, annual incidence or relatively short-term risk such as five or ten-year risk. The concept of long-term risk is rarely used in nephrology research. This paper focuses on two long-term risk measures-lifetime risk and life expectancy. Lifetime risk is an epidemiologic measure that expresses the probability that a person who is currently free of the condition will acquire it at some time during the remainder of their expected lifespan. Life expectancy is the expected number of years of life remaining for a given group of individuals at a specified age. Key data required for estimation of lifetime risk and life expectancy are disease incidence and mortality derived by considering age in the time scale in a longitudinal study. Lifetime risks can be estimated from incidence and mortality rates derived from prospective studies whereas mortality rates are required to estimate life expectancy. Although short-term risks are important, long-term risk can be particularly beneficial for future prediction of the burden of kidney disease, and to assist in health planning and public education.     

Prevalence of systemic lupus erythematosus and systemic sclerosis in the First Nations population of Alberta, Canada

Objective

To estimate the population‐based prevalence of systemic lupus erythematosus (SLE) and systemic sclerosis (SSc) in Alberta, Canada, stratified by First Nations status.

Methods

Physician billing claims and hospitalization data for the province of Alberta (1994–2007) were used to ascertain cases of SLE and SSc using 3 case definitions. A latent class Bayesian hierarchical regression model was employed to account for the imperfect sensitivity and specificity of billing and hospitalization data in case ascertainment. We accounted for demographic factors, estimating prevalence rates for the First Nations and non–First Nations populations by sex, age group, and location of residence (urban/rural).

Results

Our model estimated the prevalence of SLE in Alberta to be 27.3 cases per 10,000 females (95% credible interval [95% CrI] 25.9–28.8) and 3.2 cases per 10,000 males (95% CrI 2.6–3.8). The overall prevalence of SSc in Alberta was 5.8 cases per 10,000 females (95% CrI 5.1–6.5) and 1.0 case per 10,000 males (95% CrI 0.7–1.4). First Nations females over 45 years of age had twice the prevalence of either SLE or SSc relative to non–First Nations females. There was also a trend toward higher overall SLE prevalence in urban dwellers, and higher overall SSc prevalence in rural residents.

Conclusion

First Nations females older than 45 years of age have an increased prevalence of either SLE or SSc. This may reflect a true predominance of autoimmune rheumatic diseases in this demographic, or may indicate systematic differences in health care delivery.