Effect of dialysis flux and membrane material on dyslipidaemia and inflammation in haemodialysis patients.

BACKGROUND: Dyslipidaemia, inflammation and oxidative stress are prominent risk factors that potentially cause vascular disease in haemodialysis patients. Dialysis modalities affect uraemic dyslipidaemia, possibly by modifying oxidative stress, but the effects of dialyser flux and membrane material on atherogenic remnant particles and oxidized low-density lipoproteins (LDL) are unknown. METHODS: We performed a randomized crossover study in 36 patients on haemodialysis to analyse the effect of dialyser flux and membrane material on plasma lipids, apolipoproteins and markers of inflammation and oxidative stress. Stable patients on low-flux dialysis with polysulphone for >/=6 weeks were assigned to high-flux polysulphone or high-flux modified cellulose with similar dialyser surface area and permeability characteristics and crossed over twice every 6 weeks. RESULTS: Thirty patients completed the study per protocol. Treatments with high-flux polysulphone and modified cellulose lowered serum triglyceride (by 20% and 10%, respectively; P<0.05) and remnant-like particle cholesterol by 32% (P<0.001) and 11% (NS) after the first 6 weeks of treatment. Oxidized LDL decreased significantly with high-flux polysulphone, but not with modified cellulose. Apolipoproteins CII and CIII were reduced, whereas the ratio CII/CIII was increased (all P<0.05). Acute-phase proteins and LDL and high-density lipoprotein cholesterol remained unaffected. CONCLUSIONS: This randomized crossover study demonstrates a potent effect of high-flux haemodialysis on uraemic dyslipidaemia. Polysulphone membrane material showed superiority on oxidatively modified LDL, an indicator of oxidative stress in haemodialysis patients.     

Role transition for patient care vice presidents: from a single entity to a system focus

The authors describe the process used and outcomes achieved by five patient care vice presidents who became a cohesive working group after the system integration of their separate organizations. Overcoming the hurdles that face any emerging group, these nurse executives developed a common patient-centered care delivery system and common leadership structure. They committed to four major leadership roles with common obligations and expectations for patient care vice presidents and hospital presidents, and role changes in terms of time spent as coach, interventionist, and crisis manager.     

Portable ultrasound in disaster triage: a focused review

Ultrasound technology has become ubiquitous in modern medicine. Its applications span the assessment of life-threatening trauma or hemodynamic conditions, to elective procedures such as image-guided peripheral nerve blocks. Sonographers have utilized ultrasound techniques in the pre-hospital setting, emergency departments, operating rooms, intensive care units, outpatient clinics, as well as during mass casualty and disaster management. Currently available ultrasound devices are more affordable, portable, and feature user-friendly interfaces, making them well suited for use in the demanding situation of a mass casualty incident (MCI) or disaster triage. We have reviewed the existing literature regarding the application of sonology in MCI and disaster scenarios, focusing on the most promising and practical ultrasound-based paradigms applicable in these settings.     

Legal Rights or Simply Wishes? The Struggle for Sexual Recognition of People with Physical Disabilities Using Personal Assistance in Sweden

The purpose of this study is to explore the lived experience of sexuality for people with physical disabilities using formal personal assistance services in Sweden, from their own perspective. This is analyzed in relation to the aims of personal assistance services according to Swedish law, which states that they should be framed in terms of autonomy, integrity and self-determination making it possible to live a good life, on the same terms as non-disabled people. Data were collected through face-to-face interviews with ten assistance users and through observations on an online discussion forum for people with disabilities. The main findings of the study concern participants?? struggle to be recognized as sexual beings in order to be able to live as desired, as well as the different strategies needed to overcome obstacles in sexual expression. Results indicate the need to train personal assistants about handling assistance users?? sexuality and sexual situations.     

Using GI-specific patient outcome measures in renal transplant patients: Validation of the GSRS and GIQLI

Introduction: Gastrointestinal (GI) side-effects occur frequently as a result of immunosuppressant regimens used in renal transplant patients. Little effort has been made to quantify the impact of these side-effects on patients’ health-related quality of life and symptom severity. Objective: To assess the psychometric characteristics of two GI-specific outcome instruments (the Gastrointestinal Rating Scale (GSRS) and the Gastrointestinal Quality of Life Index (GIQLI)) for use in post-renal transplant patients. Methods: Cross-sectional study conducted at 5 clinical centers in 4 countries. Patients were required to be on mycophenolate mofetil and a calcineurin inhibitor. Patients completed the GSRS, GIQLI and two generic instruments (the Psychological General Well-Being Index and the EQ-5D) at one timepoint. Reliability, construct and known groups validity were assessed. Results: In general the GSRS and the GIQLI demonstrated Cronbach’s alphas higher than 0.70. The GIQLI was moderately to highly correlated with the PGWB and EQ-5D. Correlations among the GSRS and generic instruments were slightly lower. The GSRS and GIQLI both distinguished between patients with and without GI complaints (all p<0.05). Conclusions: The GSRS and the GIQLI are appropriate for use in a post-renal transplant population. Scores on both instruments demonstrated significant differences between renal transplant patients with GI complications and without GI complications.     

Gastrointestinal-specific patient-reported outcome instruments differentiate between renal transplant patients with or without GI complications

BACKGROUND: Gastrointestinal (GI) complications are frequently reported postrenal transplant and are often associated with immunosuppressant regimens including mycophenolate mofetil (MMF). This study evaluated the ability of two GI-specific patient-reported outcome (PRO) instruments to differentiate between patients with and without GI complaints. METHODS: Discriminant validity of the Gastrointestinal Symptom Rating Scale (GSRS) and Gastrointestinal Quality of Life Index (GIQLI), as well as two generic instruments (Psychological General Well-Being Index (PGWB) and EQ-5D, was assessed in a multinational study of renal transplant recipients. Patients received therapy that included a calcineurin inhibitor and MMF. Both t-tests and ANOVAs were used to examine differences between patients with and without GI complaints, among levels of severity, and between patients reporting presence/absence of specific GI side effects. RESULTS: Of 96 patients recruited (56% male), 43% had none, 39% mild, 13% moderate, and 6% severe GI symptoms. All GSRS subscales and the GIQLI total and four of the five subscale scores significantly differentiated between patients with/without GI complications (P < .05). The PGWB total score and three subscales, the EQ-5D significantly differentiated between the two groups (P < .05). Only GI-specific instruments discriminated between some severity levels; for example, the GSRS abdominal pain subscale discriminated between patients at all levels of severity (P < .05). The GIQLI total score and symptoms subscale differentiated between patients with no symptoms and those with mild or moderate or severe symptoms (P < .05). CONCLUSIONS: The GSRS and GIQLI differentiated between patients with/without GI side effects and by symptom severity better than did generic instruments, demonstrating excellent discriminant ability in this population.     

The vascular patient--diagnosis and minimally invasive therapy. Which technique for what illness?

The non-invasive imaging modalities, color coded duplex sonography (CCDS), magnetic resonance tomography (MRT), and computed tomography (CT), have pushed conventional angiography out of most diagnostic fields. The experienced user will achieve fast, reliable answers with CCDS in dedicated clinical settings. MRT as well as CT are concurring imaging modalities for the most appropriate diagnostic answer. Not only pure image quality, but also patient management, and availability play a major role. Catheter based angiography will in the future still play a role in mesenteric ischemia (non occlusive disease) and for imaging of very small vessel pathology, e.g. on panarteritis nodosa. At the moment, peripheral leg run-offs are still best performed with conventional angiography, nevertheless, MR as well as CT seem to have the ability to perform diagnostic procedures. Ongoing studies will allow a solid judgement in the near future. The true value of catheter angiography is in the direct assessment, planning, and performance of interventional procedures, e.g. catheter based obliteration or revascularization. Implantation of stent devices and a whole range of different mechanical and pharmacological revascularization procedures have improved the interventional management of vascular stenoses and occlusions. The interventional radiologist is treating physician in the classical sense in this setting. Acute bleeding episodes, e.g. in the brain, thorax, abdomen, or pelvis, are best imaged with computed tomography. Conventional angiography still plays a major diagnostic and therapeutic role in bleeding into preformed cavities, such as the bile ducts or the intestine. In this setting, all available information including CT scans should be valued. For complex therapeutic regimens in oncology or in pure palliative situations, angiographic diagnosis followed by embolization and/or ablation therapy is established.