Perspectives of healthcare providers on the nutritional management of patients on haemodialysis in Australia: An interview study

Objective To describe the perspectives of healthcare providers on the nutritional management of patients on haemodialysis, which may inform strategies for improving patient-centred nutritional care. Design Face-to-face semistructured interviews were conducted until data saturation, and thematic analysis based on principles of grounded theory. Setting 21 haemodialysis centres across Australia. Participants 42 haemodialysis clinicians (nephrologists and nephrology trainees (15), nurses (12) and dietitians (15)) were purposively sampled to obtain a range of demographic characteristics and clinical experiences. Results Six themes were identified: responding to changing clinical status (individualising strategies to patient needs, prioritising acute events, adapting guidelines), integrating patient circumstances (assimilating life priorities, access and affordability), delineating specialty roles in collaborative structures (shared and cohesive care, pivotal role of dietary expertise, facilitating access to nutritional care, perpetuating conflicting advice and patient confusion, devaluing nutritional specialty), empowerment for behaviour change (enabling comprehension of complexities, building autonomy and ownership, developing self-efficacy through engagement, tailoring self-management strategies), initiating and sustaining motivation (encountering motivational hurdles, empathy for confronting life changes, fostering non-judgemental relationships, emphasising symptomatic and tangible benefits, harnessing support networks), and organisational and staffing barriers (staffing shortfalls, readdressing system inefficiencies). Conclusions Organisational support with collaborative multidisciplinary teams and individualised patient care were seen as necessary for developing positive patient-clinician relationships, delivering consistent nutrition advice, and building and sustaining patient motivation to enable change in dietary behaviour. Improving service delivery and developing and delivering targeted, multifaceted self-management interventions may enhance current nutritional management of patients on haemodialysis

Chandra X-Ray Observations of Nineteen Millisecond Pulsars in the Globular Cluster 47 Tucanae

We present spectral and long-timescale variability analyses of \textit{Chandra} ACIS-S observations of the 19 millisecond pulsars (MSPs) with precisely known positions in the globular cluster 47 Tucanae. The X-ray emission of the majority of these MSPs is well described by a thermal (blackbody or neutron star hydrogen atmosphere) spectrum with a temperature $T_{\rm eff}\sim(1-3)\times10^6$ K, emission radius $R_{\rm eff}\sim0.1-3$ km, and luminosity $L_{X}\sim10^{30-31}$ ergs s$^{-1}$. For several MSPs, there is indication that a second thermal component is required, similar to what is seen in some nearby field MSPs. The radio-eclipsing binary MSPs 47 Tuc J, O, and W show a significant non-thermal component, with photon index $\Gamma\sim 1-1.5$, which may originate in an shock formed due to interaction between the relativistic pulsar wind and matter from the stellar companion. We re-examine the X-ray--spindown luminosity relation ($L_{X}-\dot{E}$) and find that due to the large uncertainties in both parameters the result is consistent with both the linear $L_{X}-\dot{E}$ relation and the flatter $L_X\propto\dot{E}^{0.5}$ predicted by polar cap heating models. In terms of X-ray properties, we find no clear systematic differences between MSPs in globular clusters and in the field of the Galaxy.Comment: 13 pages, 6 figures, accepted for publication in the Astrophysical Journa

Redistribution Of Air Within The Lungs May Potentiate "Fright" Bradycardia In Submerged Crocodiles (Crocodylus porosus)

1. Voluntary undisturbed dives by Crocodylus porosus were short in duration (3.08 + 1.87 min, mean + SD) and accompanied by a small but significant bradycardia (14.3 + 5.9% drop). 2. When crocodiles were disturbed underwater there was a rapid onset of "fright" bradycardia, to 65 + 6.0% of surface heart rates and dive durations were prolonged to 19.6 + 1.8 min. 3. The development of "fright" bradycardia was not accompanied by any increase in intratracheal pressure or expulsion of lung gas. However, sustained contraction of the abdomen and expansion of the thorax revealed a redistribution of air anteriorly within the lungs. 4. We propose that the redistribution of air within the lungs may generate an afferent signal which potentiates the initiation of a severe, dive-prolonging bradycardia

Cranberries for treating urinary tract infections

Background Cranberries (particularly in the form of cranberry juice) have been used widely for several decades for the prevention and treatment of urinary tract infections (UTIs). The aim of this review is to assess the effectiveness of cranberries in treating such infections. Objectives To assess the effectiveness of cranberries for the treatment of UTIs. Search strategy The search strategy developed by the Cochrane Renal Group was used. Also, companies involved with the promotion and distribution of cranberry preparations were contacted; electronic databases and the Internet were searched using English and non English language terms; reference lists of review articles and relevant studies were also searched. Date of last search: December 2007 Selection criteria All randomised controlled trials (RCTs) or quasi-RCTs of cranberry juice or cranberry products for the treatment of UTIs. Studies of men, women or children were included. Data collection and analysis Titles and abstracts of studies that were potentially relevant to the review were screened by one author, RJ, who discarded studies that were clearly ineligible but aimed to be overly inclusive rather than risk losing relevant studies. Authors RJ and LM independently assessed whether the studies met the inclusion criteria. Further information was sought from the authors where papers contained insufficient information to make a decision about eligibility. Main results No studies were found which fulfilled all of the inclusion criteria. Two studies were excluded because they did not have any relevant outcomes and two studies are currently being undertaken. Authors' conclusions After a thorough search, no RCTs which assessed the effectiveness of cranberry juice for the treatment of UTIs were found. Therefore, at the present time, there is no good quality evidence to suggest that it is effective for the treatment of UTIs. Well-designed parallel group, double blind studies comparing cranberry juice and other cranberry products versus placebo to assess the effectiveness of cranberry juice in treating UTIs are needed. Outcomes should include reduction in symptoms, sterilisation of the urine, side effects and adherence to therapy. Dosage (amount and concentration) and duration of therapy should also be assessed. Consumers and clinicians will welcome the evidence from these studies.Output Type: Revie

Towards a Real-Time Data Driven Wildland Fire Model

A wildland fire model based on semi-empirical relations for the spread rate of a surface fire and post-frontal heat release is coupled with the Weather Research and Forecasting atmospheric model (WRF). The propagation of the fire front is implemented by a level set method. Data is assimilated by a morphing ensemble Kalman filter, which provides amplitude as well as position corrections. Thermal images of a fire will provide the observations and will be compared to a synthetic image from the model state.Comment: 5 pages, 4 figure

2D cognitive optical data processing with phase change materials

We demonstrate high-density, multi-level crystallization of a Ge2Sb2Te5 thin film using tightly focused femtosecond laser pulses. The optical reflectivity in each distinct phase states level is characterized for applications in ultra-fast cognitive parallel data processing

Parenteral versus oral iron therapy for adults and children with chronic kidney disease

Background The anaemia seen in chronic kidney disease (CKD) may be exacerbated by iron deficiency. Iron can be provided through different routes, with advantages and drawbacks of each route. It remains unclear whether the potential harms and additional costs of intravenous (IV) compared with oral iron are justified. Objectives To determine the benefits and harms of IV iron supplementation compared with oral iron for anaemia in adults and children with CKD. Search methods In March 2010 we searched the Cochrane Renal Group's specialised register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE and EMBASE without language restriction. Selection criteria We included randomised controlled trials (RCTs) and quasi‐RCTs in which oral and IV routes of iron administration were compared in adults and children with CKD. Data collection and analysis Two authors independently assessed study eligibility, risk of bias, and extracted data. Results were reported as risk ratios (RR) or risk differences (RD) with 95% confidence intervals (CI) for dichotomous outcomes and for continuous outcomes the mean difference (MD) was used or standardised mean difference (SMD) if different scales had been used. Statistical analyses were performed using the random‐effects model. Subgroup analysis and univariate meta‐regression were performed to investigate between study differences. Main results Twenty eight studies (2098 participants) were included. Risk of bias attributes were poorly performed and/or reported with low risk of bias reported in 12 (43%) studies for sequence generation, incomplete outcome reporting and selective outcome reporting and in 6 (16%) studies for allocation concealment. No study was blinded for participants, investigators and outcome assessors but all were considered at low risk of bias because the primary outcome of haemoglobin was a laboratory outcome and unlikely to be influenced by lack of blinding. Haemoglobin (22 studies, 1862 patients: MD 0.90 g/dL, 95% CI 0.44 to 1.37); ferritin (24 studies, 1751 patients: MD 243.25 μg/L, 95% CI 188.74 to 297.75); and transferrin saturation (18 studies, 1457 patients: MD 10.20%, 95% CI 5.56 to 14.83) were significantly increased by IV iron compared with oral iron. There was a significant reduction in erythropoiesis‐stimulating agent (ESA) dose in patients receiving dialysis who were treated with IV iron (9 studies, 487 patients: SMD ‐0.76, 95% CI ‐1.22 to ‐0.30). There was a high level of heterogeneity in all analyses. Mortality and cardiovascular morbidity did not differ significantly, but were reported in few studies. Gastrointestinal side effects were more common with oral iron, but hypotensive and allergic reactions were more common with IV iron. Authors' conclusions The included studies provide strong evidence for increased ferritin and transferrin saturation levels, together with a small increase in haemoglobin, in patients with CKD who were treated with IV iron compared with oral iron. From a limited body of evidence, we identified a significant reduction in ESA requirements in patients treated with IV iron, and found no significant difference in mortality. Adverse effects were reported in only 50% of included studies. We therefore suggest that further studies that focus on patient‐centred outcomes are needed to determine if the use of IV iron is justified on the basis of reductions in ESA dose and cost, improvements in patient quality of life, and with few serious adverse effects

Medical Device Regulation in Australia: Safe and Effective?

Objective: To describe the frequency, characteristics and outcomes of reports of possible harms related to medical devices submitted to the Australian Therapeutic Goods Administration (TGA) using data made publicly available on the TGA website. Design and setting: A retrospective analysis, conducted in January 2012, of data made publicly available on the TGA website from January 2000 to December 2011. Main outcome measures: The number and nature of reports of medical device incidents, recalls and alerts. Results: Up to December 2011, 6812 incidents involving medical devices were reported to the TGA, although there were several periods where data were unavailable. Incidents were reported more frequently in later years, most often by device sponsors, and were often attributed to mechanical problems. 295 deaths and 2357 serious injuries have been related to incidents, with serious injury (597) highest in 2009. Most incidents involving medical devices were not investigated (47.5%), or, after investigation, no further action was taken (25.0%). During the same time period, there were 35 medical device recalls and 34 medical device alerts issued by the TGA, with no consistent increase over time. Conclusions: Despite TGA reform proposals, greater transparency is still needed. Issues that have not been addressed include patchy and conflicting data in the public domain and lack of explanations for the large proportion of uninvestigated reports. To maintain public confidence in the national regulatory system these problems need to be resolved

Systematic reviews of surgical procedures in children: Quantity, coverage and quality

Aim Systematic reviews have the potential to map those areas where children are under‐represented in surgical research. We aimed to describe and evaluate the quantity, coverage and the quality of conduct and reporting of systematic reviews of surgical procedures in children. Methods We searched four biomedical databases, a systematic review register, reference lists and conducted hand searching to identify relevant reviews. Two reviewers worked independently to critically appraise included studies and abstract data. We assessed reporting quality using the preferred reporting items for systematic reviews and meta‐analysis statement and methodological quality using the Assessment of Multiple SysTemAtic Reviews tool. Results Fifteen systematic reviews were identified, representing 0.01% of all paediatric surgical citations in MEDLINE and E mbase. Thirteen of the reviews were C ochrane reviews, and most reviews (12/15) addressed subspecialty interests such as otorhinolaryngology. The median number of included trials per systematic review was four (interquartile range 1 to 9.5), the median number of primary outcomes was 5.5 (interquartile range 3.5 to 7.5). In general, reporting and methodological quality was good although there were several omissions, particularly around completeness of reporting of statistical methods used, and utilisation of quality assessments in analyses. Outcomes were often not clearly defined and descriptions of procedures lacked sufficient detail to determine the similarities and differences among surgical procedures within the contributing trials. Conclusion Systematic reviews of surgical procedures in children are rarely published. To improve the evidence base and guide research agendas, more systematic reviews should be conducted, using standard guidelines for conduct and reporting

Dietary patterns for adults with chronic kidney disease

This is the protocol for a review and there is no abstract. The objectives are as follows: This review will evaluate the benefits and harms of dietary patterns among adults with CKD (any stage including people with end-stage kidney disease (ESKD) treated with dialysis, transplantation or supportive care)