Physical inactivity plays an important role in the development of kidney disease and its complications; however, the validity of standard tools for measuring physical activity (PA) is not well ...understood.
We investigated the performance of several readily available and widely used PA and physical function questionnaires, individually and in combination, against accelerometry among a cohort of chronic kidney disease (CKD) participants.
Forty-six participants from the Seattle Kidney Study, an observational cohort study of persons with CKD, completed the Physical Activity Scale for the Elderly, Human Activity Profile (HAP), Medical Outcomes Study SF-36 questionnaire, and the Four-week Physical Activity History questionnaires. We simultaneously measured PA using an Actigraph GT3X accelerometer during a 14-day period. We estimated the validity of each instrument by testing its associations with log-transformed accelerometry counts. We used the Akaike information criterion to investigate the performance of combinations of questionnaires.
All questionnaire scores were significantly associated with log-transformed accelerometry counts. The HAP correlated best with accelerometry counts (r(2) = 0.32) followed by SF-36 (r(2) = 0.23). Forty-three percent of the variability in accelerometry counts data was explained by a model that combined the HAP, SF-36, and Four-week Physical Activity History questionnaires.
A combination of measurement tools can account for a modest component of PA in patients with CKD; however, a substantial proportion of PA is not captured by standard assessments.
Invasive melanoma, a lethal form of skin cancer, is the seventh most common cancer in women. Factors such as a history of indoor tanning or sunburn and a personal or family history of skin cancer ...increase a woman’s risk of developing a melanoma.
Because the majority of melanomas occur in patients age 40 years or older, which is the age that is recommended for women to begin screening mammograms, the mammogram experience could be used to promote early detection of melanoma by introducing skin self-examinations (SSE) to a population of women who are already invested in preventive health.
This was a pilot and feasibility study that was designed to promote the early detection of melanoma among women who undergo a mammogram at the Lynn Sage Breast Center at the Northwestern Medicine/Prentice Women’s Hospital in Chicago, Illinois. The study was conducted in three phases: development of the materials, delivery of the program, and assessment of the program effectiveness.
Eighty six percent of women with scheduled mammogram appointments participated in the study (n = 560). Among these women, 68% noticed the SSE information in the changing rooms, 78% thought the information applied to them, and 68% identified with at least one of the risk factors for melanoma. Twenty percent of the patients checked their skin in the changing room, 13% noticed a concerning mole, and 60% of those women who noted a concerning lesion stated their intent to see a dermatologist for further evaluation.
A large proportion of the women in our study had risk factors for developing a melanoma and noticed the SSE information in the screening center. Placing an intervention to encourage methods for the early detection of melanoma in an outpatient mammography environment is an effective strategy to increase awareness in a large proportion of at-risk women.
This study reports the development and predictive value of the 60-foot walk test (60ftWT), a brief functional status measure for patients with heart failure (HF). The goal was to develop a test ...suitable for clinical settings and appropriate for patients with walking impairments.
The 6-min walk test (6MWT) has considerable predictive value, but requires a long walking course and has limited utility in patients with mobility-related comorbidities. A shorter, more clinically practical test is therefore needed.
A total of 144 patients (age 57.4 ± 11.4 years; 111 males) with symptomatic HF received baseline assessments using the 60ftWT, 6MWT, and self-reported symptom and health status. Patients were tested 3 months later to determine stability of assessments. HF hospitalizations or death from any cause were recorded for 3.5 years following baseline.
Median 60ftWT completion time was 26 s (interquartile range: 22 to 31 s). Longer 60ftWT time was associated with shorter 6MWT distance (r = −0.75; p < 0.001), and with higher symptom severity at baseline (r = −0.40; p < 0.001). Longer 60ftWT times also predicted increases in 6MWT and symptoms from baseline to 3 months (p < 0.01). Both WTs predicted long-term clinical outcomes, with patients taking longer than 31 s to complete the 60ftWT at greatest risk for HF hospitalization or death (hazard ratio: 2.13; 95% confidence interval: 1.18 to 3.84; p = 0.01).
The 60ftWT is an easily administered functional status measure that predicts adverse events, symptoms, and health status. It has the potential for considerable clinical utility to help identify patients at risk for future events and to calibrate treatments designed to improve functional status and quality of life.
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The parasite Fasciola hepatica infects a broad range of mammals with impunity. Following ingestion of parasites (metacercariae) by the host, newly excysted juveniles (NEJ) emerge from their cysts, ...rapidly penetrate the duodenal wall and migrate to the liver. Successful infection takes just a few hours and involves negotiating hurdles presented by host macromolecules, tissues and micro-environments, as well as the immune system. Here, transcriptome and proteome analysis of ex vivo F. hepatica metacercariae and NEJ reveal the rapidity and multitude of metabolic and developmental alterations that take place in order for the parasite to establish infection. We found that metacercariae despite being encased in a cyst are metabolically active, and primed for infection. Following excystment, NEJ expend vital energy stores and rapidly adjust their metabolic pathways to cope with their new and increasingly anaerobic environment. Temperature increases induce neoblast proliferation and the remarkable up-regulation of genes associated with growth and development. Cysteine proteases synthesized by gastrodermal cells are secreted to facilitate invasion and tissue degradation, and tegumental transporters, such as aquaporins, are varied to deal with osmotic/salinity changes. Major proteins of the total NEJ secretome include proteases, protease inhibitors and anti-oxidants, and an array of immunomodulators that likely disarm host innate immune effector cells. Thus, the challenges of infection by F. hepatica parasites are met by rapid metabolic and physiological adjustments that expedite tissue invasion and immune evasion; these changes facilitate parasite growth, development and maturation. Our molecular analysis of the critical processes involved in host invasion has identified key targets for future drug and vaccine strategies directed at preventing parasite infection.
This article accentuates the human experiences at the heart of social justice work in counseling. The history, counselor attributes, skills, costs, pitfalls, rewards, and ethical issues associated ...with advocacy counseling are highlighted. This article concludes with a discussion of the personal moral imperatives that inspire social activism and the challenge of discovering a personal advocacy style.
OBJECTIVES: Poor appetite is commonly reported by older people but is rarely measured. The Simplified Nutritional Appetite Questionnaire (SNAQ) was validated to predict weight loss in community ...dwelling older adults but has been little used in hospitals. We evaluated it in older women on admission to hospital and examined associations with healthcare outcomes. DESIGN: Longitudinal observational with followup at six months. SETTING: Female acute Medicine for Older People wards at a University hospital in England. PARTICIPANTS: 179 female inpatients. MEASUREMENTS: Age, weight, Body Mass Index (BMI), grip strength, SNAQ, Barthel Index Score, Mini Mental State Examination (MMSE), Geriatric Depression Scale: Short Form (GDSSF), Malnutrition Universal Screening Tool (MUST), category of domicile and receipt of care were measured soon after admission and repeated at six month follow-up. The length of hospital stay (LOS), hospital acquired infection, readmissions and deaths by follow-up were recorded. RESULTS: 179 female participants mean age 87 (SD 4.7) years were recruited. 42% of participants had a low SNAQ score (<14, indicating poor appetite). A low SNAQ score was associated with an increased risk of hospital acquired infection (OR 3.53; 95% CI: 1.48, 8.41; p=0.004) and with risk of death (HR 2.29; 95% CI: 1.12, 4.68; p = 0.023) by follow-up. CONCLUSION: Poor appetite was common among the older hospitalised women studied, and was associated with higher risk of poor healthcare outcomes.
Background Management options for symptomatic and infected walled-off pancreatic necrosis (WOPN) have evolved over the past decade from open surgical necrosectomy to more minimally invasive ...approaches. We reported the use of a combined percutaneous and endoscopic approach (dual modality drainage DMD) for the treatment of symptomatic and infected WOPN, with good short-term outcomes in a small cohort of patients. Objective To describe the long-term outcomes of 117 patients with symptomatic and infected WOPN treated by DMD. Design Review of a prospective, internal review board–approved database. Setting Single, North American, tertiary-care center. Patients All patients with symptomatic and infected WOPN treated by DMD at our institution between 2007 and 2012. Intervention DMD of symptomatic and infected WOPN. Main Outcome Measurements Disease-related mortality, pancreaticocutaneous fistula formation, need for early and late surgical intervention, procedure-related adverse events. Results A total of 117 patients underwent DMD for symptomatic and infected WOPN. A total of 103 have completed treatment, with all percutaneous drains removed. Ten patients are still undergoing treatment, and 4 patients died with percutaneous drains in place (3.4% disease-related mortality). For the patients completing therapy, the median duration of follow-up was 749.5 days. No patients required surgical necrosectomy or surgical treatment of DMD-related adverse events; 3 patients required late surgery for pain (n = 2) and gastric outlet obstruction (n = 1). There were no procedure-related deaths. In patients who have completed treatment, percutaneous drains have been removed in 100%; no patients have developed pancreaticocutaneous fistulas. Limitations Single-center design, lack of a comparison group. Conclusion DMD for symptomatic and infected WOPN results in favorable clinical outcomes; complete avoidance of pancreaticocutaneous fistulae, surgical necrosectomy, and major procedure-related adverse events, while maintaining single-digit disease-related mortality.
Objective: To assess levels of occupational stress in UK accident and emergency (A&E) consultants. Method: Postal survey of complete enumeration of UK consultants. Main outcome measures: GHQ-12 and ...SCL-D, and respondents' reported perceptions of stressors. Results: Of 371 valid respondents (78%), 21 declined to participate. Of the remaining 350, 154 (44.4%) had GHQ-12 scores over the threshold for distress, which is much higher than found in other studies of doctors. Levels of depression as measured by the SCL-D at 18% (n=63) were slightly higher than other groups. Thirty four (10%) reported suicidal ideation. Women had significantly higher SCL-D scores than men (U=6604, p<0.01). Respondents were highly satisfied with A&E as a specialty. Protective factors found in other occupational groups did not apply. Only one demographic or work related factor; number of hours reportedly worked during previous week by respondents in full time posts (median=57, interquartile range=57), significantly correlated with either stress outcome measure (GHQ-12 scores) (ρ=0.126, p<0.03). Logistic regression modelling revealed “being overstretched” (OR=1.18), “effect of hours (OR=0.82) and stress (OR=1.58) on family life”, and “lack of recognition” (OR=1.32) were significant predictors of GHQ identified caseness, while “the effect of stress on family life” (OR=1.53), low prestige of specialty (OR=1.20), and “dealing with management” (OR=1.28) predicted SCL-D scores. Conclusion: There are high levels of psychological distress among doctors working in A&E compared with other groups of doctors. There is likely to be an effect on staff morale and career longevity. Interventions to improve the working lives of A&E consultants are required, in particular a reduction in hours worked.
In response to the US opioid epidemic, the Centers for Disease Control and Prevention issued a guideline (CDCG) for prescribing opioids for chronic pain. Successful implementation of the CDCG ...requires identification of the information, skills, and support physicians need to carry out its recommendations. However, such data are currently lacking.
The authors performed one-on-one interviews with nine practicing physicians regarding their needs and perspectives for successful CDCG implementation, including the perceived barriers, focusing on communication strategies. Interviews were audio recorded, transcribed, and a thematic qualitative analysis was performed.
Three major themes were identified: communication, knowledge, and information technology (IT). Physicians reported that open communication with patients about opioids was difficult and burdensome, but essential; they shared their communication strategies. Knowledge gaps included patient-specific topics (eg, availability of/insurance coverage for non-opioid treatments) and more general areas (eg, opioid dosing/equivalencies, prescribing naloxone). Finally, physicians discussed the importance of innovation in IT, focusing on the electronic medical record for decision support and to allow safer opioid prescribing within the time constraints of clinical practice.
These qualitative data document practical issues that should be considered in the development of implementation plans for safer opioid prescribing practices. Specifically, healthcare systems may need to provide opioid-relevant communication strategies and training, education on key topics such as naloxone prescribing, resources for referrals to appropriate nonpharmacologic treatments, and innovative IT solutions. Future research is needed to establish that such measures will be effective in producing better outcomes for patients on opioids for chronic pain.
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