“What matters to you?”: The relevance of patient priorities in dialysis care for assessment and clinical practice

Background

Dialysis patients are confronted with numerous, complex problems, which make it difficult to identify individual patient's most prominent problems. The objectives of this study were to (1) identify dialysis patients' most prominent problems from a patient perspective and (2) to calculate disease-specific norms for questionnaires measuring these problems.

Methods

One hundred seventy-five patients treated with hemodialysis or peritoneal dialysis completed a priority list on several domains of functioning (e.g., physical health, mental health, social functioning, and daily activities) and a set of matching questionnaires assessing patient functioning on these domains. Patient priorities were assessed by calculating the importance ranking of each domain on the priority list. Subsequently, disease-specific norm scores were calculated for all questionnaires, both for the overall sample and stratified by patient characteristics.

Results

Fatigue was listed as patients' most prominent problem. Priorities differed between male and female patients, younger and older patients, and home and center dialysis patients, which was also reflected in their scores on the corresponding domains of functioning. Therefore, next to general norm scores, we calculated corrections to the general norms to take account of patient characteristics (i.e., sex, age, and dialysis type).

Conclusions

Results highlight the importance of having attention for the specific priorities and needs of each individual patient. Adequate disease-specific, norm-based assessment is not only necessary for diagnostic procedures but is an essential element of patient-centered care: It will help to better understand and respect individual patient needs and tailor treatment accordingly.     

Audit and Re-audit of the CSP Core Standards of Physiotherapy Practice

The third edition of the Core Standards of PhysiotherapyPractice has been piloted in eight sites, representing the whole breadth of the physiotherapy profession. Part of the pilot involved auditing patient records and soliciting patient feedback using a questionnaire, both in two stages. The first audit was carried out before physiotherapists had knowledge of the content of the new standards. The re-audit was carried out after a period of awareness-raising and implementation of any changes arising from the first audit. All audit criteria including the patient feedback were specifically generated from the standards.Significant and important improvements were reported from the patient record audits, especially in the standards relating to recording of patients' expectations, patients' goals, and use of outcome measures.The patient feedback questionnaire showed a consistently high level of achievement but less real change between the two audits. Some issues around consent improved, as did privacy. Performance against some criteria deteriorated, although not significantly, for example patients' perceptions of the effectiveness of treatment. Documentation in patient records has shown important improvements as a result of the new standards. Feedback from patients suggests little change in conformance with those standards and criteria more appropriately measured by patients.Audit is a useful tool for disseminating and implementing national standards when carried out in partnership with physiotherapy managers.     

Radiotherapy is not indicated in patients with vulvar squamous cell carcinoma and only one occult intracapsular groin node metastasis

ObjectiveMost guidelines advise no adjuvant radiotherapy in vulvar squamous cell carcinoma and a single occult intracapsular lymph node metastasis. However, several recent studies have questioned the validity of this recommendation. The aim of this study was to analyze the groin recurrence rate in patients with a single intracapsular positive lymph node treated without adjuvant radiotherapy.MethodsPatients with a single clinically occult intracapsular lymph node metastasis, treated without adjuvant radiotherapy, formed the basis for this study. Groin recurrences, and the risk of death, were analyzed in relation to the size of the metastasis in the lymph node and the lymph node ratio. Data were analyzed using SPSS, version 26.0 for Windows.ResultsAfter a median follow-up of 64 months, one of 96 patients (1%) was diagnosed with an isolated groin recurrence and another two (2.1%) were diagnosed with a combination of a local and a groin recurrence. The only isolated groin recurrence occurred in a contralateral lymph node negative groin. Size of the metastasis and lymph node ratio had no impact on the groin recurrence risk, nor on survival. The 5-year actuarial disease-specific and overall survivals were 79% and 62.5% respectively. The 5-year actuarial groin recurrence-free survival was 97%.ConclusionBecause of the low risk of groin recurrence and the excellent groin recurrence-free survival, we recommend that adjuvant radiotherapy to the groin in patients with vulvar squamous cell carcinoma and a single occult intracapsular lymph node metastasis can be safely omitted to prevent unnecessary toxicity and morbidity.     

Is C-reactive protein associated with influenza A or B in primary care patients with influenza-like illness? A cross-sectional study

Objective Identifying influenza A or B as cause of influenza-like illness (ILI) is a challenge due to non-specific symptoms. An accurate, cheap and easy to use biomarker might enhance targeting influenza-specific management in primary care. The aim of this study was to investigate if C-reactive protein (CRP) is associated with influenza A or B, confirmed with PCR testing, in patients presenting with ILI.Design Cross-sectional study.Setting Primary care in Lithuania, Norway and Sweden.Subjects A total of 277 patients at least 1 year of age consulting primary care with ILI during seasonal influenza epidemics.Main outcome measures Capillary blood CRP analysed as a point-of-care test and detection of influenza A or B on nasopharyngeal swabs in adults, and nasal and pharyngeal swabs in children using PCR.Results The prevalence of positive tests for influenza A among patients was 44% (121/277) and the prevalence of influenza B was 21% (58/277). Patients with influenza A infection could not be identified based on CRP concentration. However, increasing CRP concentration in steps of 10 mg/L was associated with a significantly lower risk for influenza B with an adjusted odds ratio of 0.42 (0.25–0.70; p<.001). Signs of more severe symptoms like shortness of breath, sweats or chills and dizziness were associated with higher CRP.Conclusions There was no association between CRP and influenza A. Increased concentration of CRP was associated with a lower risk for having influenza B, a finding that lacks clinical usefulness. Hence, CRP testing should be avoided in ILI, unless bacterial pneumonia is suspected.

Key points

• Identifying influenza A or B as cause of influenza-like illness (ILI) is a challenge due to non-specific symptoms. There was no association between concentration of CRP and influenza A.
• Increased concentration of CRP was associated with a lower risk for having influenza B, a finding that lacks clinical usefulness.
• A consequence is that CRP testing should be avoided in ILI, unless bacterial pneumonia or similar is suspected.

     

Spread of Excitation in Chronically Lesioned Mouse Hippocampus Determined by Laser Scanning Microscopy

Fast optical recordings by means of laser scanning microscopy in conjunction with a voltage-sensitive dye (RH 414) were performed to monitor the spatio-temporal spread of neuronal activity in CA3/CA4-lesioned C57BL6 mouse hippocampal slices prepared approximately 3 months after intracerebroventricular kainic acid (KA) injection. The aim of our study was to assess the effects of a circumscribed neuronal loss on the propagation of electrical activity along the trisynaptic hippocampal circuit. Both in physiological bathing solution and in bicuculline (10 μM), hilar stimulation failed to activate the downstream pathway, so that, under these conditions, the chronically disinhibited CA1 region appeared to be effectively isolated from burst activity arising upstream; however, epileptiform discharges evoked in zero Mg²⁺solution were reliably transmitted from the dentate gyrus to the CA1 region. That these bursts were indeed spreading across the lesion, and not along newly formed connections (e.g., between dentate gyrus and CA1), was confirmed by acute transection experiments of the Schaffer collateral/commissural pathway, which completely abolished translesional burst propagation. The fact that the surviving CA3–CA1 connections are unable to trigger epileptiform bursts after suppression of GABAergic inhibition suggests that the lesioned region might serve as a filter that shields hyperexcitable CA1 neurons from epileptic activity arising upstream, in particular from chronically disinhibited granule cells of the dentate gyrus. An impaired GABAergic inhibition will thus only have minor facilitating effects on seizure propagation in the hippocampus of CA3-lesioned animals.