Fragmentation of care as a barrier to optimal ESKD management

Caring for patients with end-stage kidney disease (ESKD) in the United States is challenging, due in part to the complex epidemiology of the disease's progression as well as the ways in which care is delivered. As CKD progresses toward ESKD, the number of comorbidities increases and care involves multiple healthcare providers from multiple subspecialties. This occurs in the context of a fragmented US healthcare delivery system that is traditionally siloed by provider specialty, organization, as well as systems of payment and administration. This article describes the role of care fragmentation in the delivery of optimal ESKD care and identifies research gaps in the evidence across the continuum of care. We then consider the impact of care fragmentation on ESKD care from the patient and health system perspectives and explore opportunities for system-level interventions aimed at improving care for patients with ESKD.     

Early gastric cancer: a report of 30 cases

Thirty patients with early gastric cancer have been reviewed. Endoscopy demonstrated gastric abnormality in 93% of patients examined and biopsy was accurate in 96% of cases. Twenty-nine patients were treated by partial gastrectomy, although three required further procedures. The commonest morphological type was type III (45%). Five patients with early gastric cancer had lymph node spread at the time of presentation. The relative 5-year survival rate was 68%. Four patients eventually died of gastric cancer. Three patients (10%) developed a second primary carcinoma. The significance of this diagnosis is emphasized and selective screening is considered.     

Cortical bone cyst following a greenstick radial fracture.

There are only a few reports of well defined cystic lesions of the peripheral skeleton following fracture. In children, these lesions are mostly small cortical defects affecting the distal radial metaphysis after a greenstick or torus fracture. A cyst is reported complicating a greenstick fracture, together with a brief review of published reports confirming that these are asymptomatic lesions which can be managed conservatively without further investigation.     

Implementing a simpler approach to mission-based planning in a medical school.

Changes in the education, research, and health care environments have had a major impact on the way in which medical schools fulfill their missions, and mission-based management approaches have been suggested to link the financial information of mission costs and revenues with measures of mission activity and productivity. The authors describe a simpler system, termed Mission-Aligned Planning (MAP), and its development and implementation, during fiscal years 2002 and 2003, at the School of Medicine at the University of Texas Health Science Center at San Antonio, Texas. The MAP system merges financial measures and activity measures to allow a broad understanding of the mission activities, to facilitate strategic planning at the school and departmental levels. During the two fiscal years mentioned above, faculty of the school of medicine reported their annual hours spent in the four missions of teaching, research, clinical care, and administration and service in a survey designed by the faculty. A financial profit or loss in each mission was determined for each department by allocation of all departmental expenses and revenues to each mission. Faculty expenses (and related expenses) were allocated to the missions based on the percentage of faculty effort in each mission. This information was correlated with objective measures of mission activities. The assessment of activity allowed a better understanding of the real costs of mission activities by linking salary costs, assumed to be related to faculty time, to the missions. This was a basis for strategic planning and for allocation of institutional resources.     

The information needs of women newly diagnosed with breast cancer

Nurses can play a key role in patient education, including providing patients with useful and approrate information Rather than focusing on the process of education or information giving by nurses, this study places emphasis on the content of that information by taking the patients'perspective and asking the patients themselves what particular types of information are perceived as important at a specific point in time The aim of the study was to explore what particular types of information were important to women newly diagnosed with breast cancer, to enable nurses and other health care professionals to utilize their time as effectively as possible and provide a high-quality service to individuals in their care Women with breast cancer (a mean of 2 5 weeks from diagnosis) were interviewed and asked to compare items of information The items of information were presented m pairs and the women stated a preference for one item in that pan- Thirty-six pairs were presented in total The analysis involved the use of a Thurstone scaling model, which allowed rank ordermgs, or profiles of information needs, to be developed, reflecting the perceived importance of each item Information about the likelihood of cure, the spread of the disease and treatment options were perceived as the most important items of information at the tune of diagnosis Other information needs, in order of descending priority, included information about the risk to family, side-effects     

Effect of asymmetric vocal fold stiffness on traveling wave velocity in the canine larynx.

The vocal fold (VF) traveling wave is essential to normal voice production. The present investigation describes a new method to determine traveling wave velocity (TWV) in the in vivo canine phonatory model. This method synchronizes photoglottographic and electroglottographic waveforms with videostroboscopic images to determine the duration of time the traveling wave moves between two tattoos placed a known distance apart between the upper and lower margins of each VF. Using this method, we compared the TWV of a paralyzed VF with the TWV of the contralateral, electrically stimulated VF during phonation in two canines. In addition, the presumed VF stiffness asymmetry in the simulated acute recurrent laryngeal nerve paralysis state was confirmed by measuring Young's modulus of each VF. The results indicated that the TWV of the paralyzed VF averaged 55% of the TWV of the normal, stiffer VF when the glottal gap was small and entrainment occurred. This study demonstrated the feasibility of quantifying traveling wave motion in asymmetric VF stiffness disorders. The potential use of TWV in human beings as a target to optimize the phonosurgical results in asymmetric VF stiffness disorders is discussed.     

Retention of "safe" blood donors. The Retrovirus Epidemiology Donor Study

BACKGROUND: There are obvious advantages to increasing donor retention. However, for reasons of blood safety, certain donors may, in fact, be more desirable to retain than others. “Safe” donors are defined as those who provided a blood donation that was negative on all laboratory screening tests and who subsequently reported no behavioral risks in response to an anonymous survey. This study identifies the most important factors affecting the intention of “safe” donors to provide another donation. STUDY DESIGN AND METHODS: An anonymous survey asking about donation history, sexual history, injecting drug use, and recent donation experience was mailed to 50,162 randomly selected allogeneic donors (including directed donors) who gave blood from April through July or from October through December 1993 at one of the five United States blood centers participating in the Retrovirus Epidemiology Donor Study. Before mailing, questionnaires were coded to designate donors with nonreactive laboratory screening tests at their most recent donation. RESULTS: A total of 34,726 donors (69%) responded, with substantially higher response among repeat donors. According to reported intentions only, the vast majority of “safe” donors indicated a high likelihood of donating again within the next 12 months. Only 3.4 percent reported a low likelihood of donating again. A comparison of those likely to return and those unlikely to return reveals significant differences in demographics and in ratings of the donation experience. A higher proportion of those unlikely to return were first-time donors, minority-group donors, and donors with less education. The highest projected loss among “safe” donors was seen for those who gave a fair to poor assessment of their treatment by blood center staff or of their physical well-being during or after donating. CONCLUSION: These data suggest that efforts to improve donors' perceptions of their donation experience, as well as attention to the physical effects of blood donation, may aid in the retention of both repeat and first-time donors.