Self-management in patients with end stage renal disease: exploring domains and dimensions.

The management and appropriate treatment of chronic disease are ongoing challenges in health care. As the population ages, the prevalence of chronic disease can be expected to increase. Since by definition there is no cure for chronic disease, controlling, minimizing, or managing its negative effects becomes a primary goal. In the self-management perspective, it is neither clinicians nor health care systems who must accomplish the bulk of chronic disease management but rather the patients themselves. Moreover, self-management has been shown to be associated with improved outcomes. Self-management is comprised of two domains: self-management of health care and self management of everyday life. Self-management of health care includes self-care activity, partnership in care, communication, self-care self-efficacy, and adherence. Self-management of everyday life entails achieving/maintaining "normality" in everyday roles and functioning. End stage renal disease (ESRD) is a chronic disease for which self-management is particularly relevant. Understanding the components of self-management may help patients and clinicians to embrace this approach, to enter the mutual relationship it requires, and to maximize positive outcomes for patients with ESRD.     

Chronic thrombotic microangiopathy associated with antineoplastic therapy with minimal hematologic effects

OBJECTIVE: To describe 6 patients who developed progressive renal failure and renal thrombotic microangiopathy (TM) not accompanied by the characteristic hematologic disturbances of TM syndromes. PATIENTS AND METHODS: Portions of renal biopsy specimens from each patient were examined by light and electron microscopy for histopathologic evidence of TM. Antecedent clinical events, laboratory evidence of hemolysis and thrombocytopenia, and clinical outcome were documented. Medical records were reviewed and clinical data, including laboratory values, treatment, and outcome, were recorded. RESULTS: In each case, a slowly progressive uremia evolved after radiation and/or chemotherapy without laboratory evidence of acute hemolysis or thrombocytopenia. Renal biopsy specimens in all cases showed TM and tubulointerstitial scarring, suggesting both acute and chronic renal injury. Two of the 6 patients underwent plasma exchange therapy without improvement of renal function. Three patients treated with angiotensin-converting enzyme inhibitors for coexisting systemic hypertension remained stable or had mild improvement in renal function. CONCLUSIONS: A small subset of patients treated for malignancy developed slowly evolving uremia associated with renal TM without marked hematologic abnormalities. In the absence of thrombocytopenia and other typical laboratory findings, the diagnosis of renal TM may be overlooked.     

Molecular ontogeny of donor-derived follicular lymphomas occurring after hematopoietic cell transplantation

The relative timing of genetic alterations that contribute to follicular lymphoma remains unknown. We analyzed a donor-recipient pair who both developed grade 2/3A follicular lymphoma 7 years after allogeneic transplantation and donor lymphocyte infusions. Both patients harbored identical BCL2/IGH rearrangements also present in 1 in 2,000 cells in the donor lymphocyte infusion, and the same V(D)J rearrangement, which underwent somatic hypermutation both before and after clonal divergence. Exome sequencing of both follicular lymphomas identified 15 shared mutations, of which 14 (including alterations in EP300 and KLHL6) were recovered from the donor lymphocyte infusion by ultra-deep sequencing (average read coverage, 361,723), indicating acquisition at least 7 years before clinical presentation. Six additional mutations were present in only one follicular lymphoma and not the donor lymphocyte infusion, including an ARID1A premature stop, indicating later acquisition during clonal divergence. Thus, ultrasensitive sequencing can map clonal evolution within rare subpopulations during human lymphomagenesis in vivo. SIGNIFICANCE: For the first time, we define the molecular ontogeny of follicular lymphoma during clonal evolution in vivo. By using ultrasensitive mutation detection, we mapped the time-course of somatic alterations after passage of a malignant ancestor by hematopoietic cell transplantation.     

Postnatal Leptin Levels Correlate with Breast Milk Leptin Content in Infants Born before 32 Weeks Gestation

Perinatal leptin deficiency and reduced intake of mother’s milk may contribute to the development of childhood obesity. Preterm infants have reduced leptin production, and they are at heightened risk of neonatal leptin deficiency. Because fresh human milk contains significantly more leptin than donor milk, we used a cross-over design to determine if blood leptin levels in maternal milk-fed preterm infants fall during conversion to donor human milk. Infants born between 22 0/7 and 31 6/7 weeks gestation on exclusive maternal milk feedings were enrolled into a 21-day cross-over trial. On days 1–7 and 15–21, infants were fed maternal milk, and on days 8–14, infants were fed donor milk. On day 1, study infants had a mean postmenstrual age of 33 weeks. Plasma leptin correlated with milk leptin, and leptin levels in maternal milk far exceed the leptin levels of donor milk. Plasma leptin did not increase during donor milk administration, but it did following resumption of maternal milk (p < 0.05). In this crossover trial, preterm infant blood leptin levels correlated with milk leptin content. This suggests that preterm infants can enterally absorb leptin from human milk, and leptin-rich breast milk may be a targeted therapy for the prevention of obesity.     

Getting better without memory

Does the tendency to adjust appraisals of ourselves in the past and future in order to maintain a favourable view of ourselves in the present require episodic memory? A developmental amnesic person with impaired episodic memory (HC) was compared with two groups of age-matched controls on tasks assessing the Big Five personality traits and social competence in relation to the past, present and future. Consistent with previous research, controls believed that their personality had changed more in the past 5 years than it will change in the next 5 years (i.e. the end-of-history illusion), and rated their present and future selves as more socially competent than their past selves (i.e. social improvement illusion), although this was moderated by self-esteem. Despite her lifelong episodic memory impairment, HC also showed these biases of temporal self-appraisal. Together, these findings do not support the theory that the temporal extension of the self-concept requires the ability to recollect richly detailed memories of the self in the past and future.     

Effects of social subordination and oestradiol on resting‐state amygdala functional connectivity in adult female rhesus monkeys

Preclinical studies demonstrate that chronic stress modulates the effects of oestradiol (E2) on behaviour through the modification of the amygdala and the medial prefrontal cortex (mPFC) neuronal structure. Clinical studies suggest that alterations in amygdala functional connectivity (FC) with the mPFC may be associated with stress‐related phenotypes, including mood and anxiety disorders. Thus, identifying the effects of stress and E2 on amygdala‐mPFC circuits is critical for understanding the neurobiology underpinning the vulnerability to stress‐related disorders in women. In the present study, we used a well‐validated rhesus monkey model of chronic psychosocial stress (subordinate social rank) to examine effects of E2 on subordinate (SUB) (i.e. high stress) and dominant (DOM) (i.e. low stress) female resting‐state amygdala FC with the mPFC and with the whole‐brain. In the non‐E2 treatment control condition, SUB was associated with stronger left amygdala FC to subgenual cingulate (Brodmann area [BA] 25: BA25), a region implicated in several psychopathologies in people. In SUB females, E2 treatment strengthened right amygdala‐BA25 FC, induced a net positive amygdala‐visual cortex FC that was positively associated with frequency of submissive behaviours, and weakened positive amygdala‐para/hippocampus FC. Our findings show that subordinate social rank alters amygdala FC and the impact of E2 on amygdala FC with BA25 and with regions involved in visual processing and memory encoding.