Skills Included in Self-Management Interventions to Help People with Chronic Kidney Disease

Slowing the progression of chronic kidney disease (CKD) is a major goal of medical therapy and requires significant and complex self-management behaviors from patients. Similar to other chronic conditions, patients must have the knowledge, confidence, and skills to self-manage the disease in daily living. The core self-management skills of problem-solving, decision making, resource utilization, patient-provider partnerships, action planning, and self-tailoring will help patient perform key behaviors associated with slowed progression. These key behaviors include the avoidance of nonsteroidal anti-inflammatory drugs (NSAIDS), diet modifications, glycemic control, regular exercise, systolic blood pressure control, tobacco avoidance, and adherence to angiotensin-converting enzyme inhibitor (ACE-I) or angiotensin receptor blocker (ARB) medications. The purpose of this literature review was to review the components of tested CKD self-management interventions to identify the self-management skills that were included in the published studies and how the interventions were delivered. A search for literature was performed using multiple databases. Articles were selected for review if they were written in English, included adults 18 years of age who had Stage 1-4 CKD, and tested a self-management intervention using a quasiexperimental or experimental design. A total of eight research articles met the inclusion criteria. Action planning, problem-solving and enhancing patient-provider partnerships were included in some interventions; there was no evidence of decision-making, resource utilization, or self-tailoring. All of the interventions were delivered using face-to-face educational programs and none used information technology. Data from this review provides important information for designing future interventions that will improve CKD self-management programs. In addition, findings suggest additional methods are needed when delivering interventions so programs are readily available to underserved areas

Climate-driven changes in body condition

Although the lethal consequences of extreme heat are increasingly reported in the literature, the fitness costs of exposure to sub-lethal high air temperatures, typically identified in the 30- 40°C range, are poorly understood. We examine the effect of high (≥35°C) daily maxima on body condition of a semi-arid population of white-plumed honeyeaters Ptilotula penicillatus monitored between 1986 and 2012. During this 26 year period temperature has risen, on average, by 0.06°C each year at the site, the frequency of days with thermal maxima ≥35°C has increased and rainfall has declined. Exposure to high temperatures affected body condition of white-plumed honeyeaters, but only in low rainfall conditions. There was no effect of a single day of exposure to temperatures ≥35°C but repeated exposure was associated with reduced body condition: 3.0% reduction in body mass per day of exposure. Rainfall in the previous 30 days ameliorated these effects, with reduced condition evident only in dry conditions. Heat-exposed males with reduced body condition were less likely to be recaptured at the start of the following spring; they presumably died. Heat-exposed females, regardless of body condition, showed lower survival than exposed males, possibly due to their smaller body mass. The higher mortality of females and smaller males exposed to temperatures ≥35°C may have contributed to the increase in mean body size of this population over 23 years. Annual survival declined across time concomitant with increasing frequency of days ≥35°C and decreasing rainfall. Our study is one of few to identify a proximate cause of climate change related mortality, and associated long-term demographic consequence. Our results have broad implications for avian communities living in arid and semi-arid regions of Australia, and other mid-latitudes regions where daily maximum temperatures already approach physiological limits in regions affected by both decreased precipitation and warming.The work was conducted under permits SL100167 and SL100825 issued by the Office of Environment and Heritage, National Parks and Wildlife Service (NPWS), NSW and bands were supplied by the Australian Bird and Bat Banding Scheme. We thank the many volunteer banders and NPWS staff for support. Jim Thompson provided initial statistical advice and Loeske Kruuk, Peter Marsack and Katherine Selwood useful discussion or comments on the manuscript. The work received funding from the Norman Wettenhall Foundation and the Australian Research Council (ARC, Discovery grant DP120102651). Sutherland is funded by Arcadia, Peters by an ARC Future Fellowship (FT110100505) and Amano by a Marie Curie International Incoming Fellowship.This is the author accepted manuscript. The final version is available from Wiley via http://dx.doi.org/10.1890/15-064

Agreement between proxy and adolescent assessment of disability, pain, and well-being in juvenile idiopathic arthritis.

OBJECTIVES: Adolescents with juvenile idiopathic arthritis have demonstrated substantial disagreement with their proxy's assessment of their disability, pain, and well-being. Our objective was to describe the clinical and psychological factors associated with discordance. STUDY DESIGN: This analysis included 204 proxy-adolescent (median age, 13 years) dyads that completed a Childhood Health Assessment Questionnaire for disability with 100-mm visual analogue scales for pain and well-being. Depressive symptoms in adolescents were measured by the Mood and Feelings Questionnaire and in proxies the General Health Questionnaire. Disagreement was assessed using Bland-Altman plots. Associations with discordance were identified using logistic regression analyses. RESULTS: There was higher agreement for disability (84%) than for pain (71%) and well-being (66%). Regression analyses found no association between age, sex, or disease duration and disagreement. However, relationships between disease activity and disagreement in outcomes were identified. Independent associations were found between increasing Mood and Feelings Questionnaire scores and disagreement in pain and well-being. CONCLUSIONS: Proxy and adolescent reports of pain and well-being are more likely to disagree in those with severe disease. Adolescents who report depressive symptoms are also more likely to disagree with their proxy. The reasons for these are multifactorial, and considerations of both reports are important when assessing outcomes in juvenile idiopathic arthritis

Validity of a three-variable juvenile arthritis disease activity score in children with new-onset juvenile idiopathic arthritis

<p>Objectives To investigate the validity and feasibility of the Juvenile Arthritis Disease Activity Score (JADAS) in the routine clinical setting for all juvenile idiopathic arthritis (JIA) disease categories and explore whether exclusion of the erythrocyte sedimentation rate (ESR) from JADAS (the ‘JADAS3’) influences correlation with single markers of disease activity.</p> <p>Methods JADAS-71, JADAS-27 and JADAS-10 were determined at baseline for an inception cohort of children with JIA in the Childhood Arthritis Prospective Study. JADAS3-71, JADAS3-27 and JADAS3-10 were determined using an identical formula but with exclusion of ESR. Correlation of JADAS with JADAS3 and single measures of disease activity/severity were determined by category.</p> <p>Results Of 956 eligible children, sufficient data were available to calculate JADAS-71, JADAS-27 and JADAS-10 at baseline in 352 (37%) and JADAS3 in 551 (58%). The median (IQR) JADAS-71, JADAS-27 and JADAS-10 for all 352 children was 11 (5.9–18), 10.4 (5.7–17) and 11 (5.9–17.3), respectively. Median JADAS and JADAS3 varied significantly with the category (Kruskal–Wallis p=0.0001), with the highest values in children with polyarticular disease patterns. Correlation of JADAS and JADAS3 across all categories was excellent. Correlation of JADAS71 with single markers of disease activity/severity was good to moderate, with some variation across the categories. With the exception of ESR, correlation of JADAS3-71 was similar to correlation of JADAS-71 with the same indices.</p> <p>Conclusions This study is the first to apply JADAS to all categories of JIA in a routine clinical setting in the UK, adding further information about the feasibility and construct validity of JADAS. For the majority of categories, clinical applicability would be improved by exclusion of the ESR.</p&gt

Spatial variation in avian bill size is associated with humidity in summer among Australian passerines

Background: Climate imposes multiple selection pressures on animal morphology. Allen’s Rule proposes thatgeographic variation in the appendage size of endotherms, relative to body size, is linked to climatic variation,thereby facilitating heat exchange and body temperature regulation. Thus relatively larger appendages tend to befound in animals in warmer climates. Despite growing understanding of the role of the avian bill as an organ forheat exchange, few studies have tested the ecological significance of bill size for heat dissipation across speciesand environmental gradients. Amongst those that have, most have focused on the relationship with ambienttemperature, but there is growing evidence that humidity also has a strong influence on heat dissipation. Inparticular, increasing humidity reduces the potential for evaporative cooling, favouring radiative and convectiveheat loss via the bill, and hence potentially favouring larger bills in humid environments. Here, we usedphylogenetically-controlled analyses of the bill morphology of 36 species of Australian passerines to explore therelationship between bill size and multiple aspects of climate.Results: Humidity during the hot summer months (December-February) was positively associated with relative billsurface area across species. There was no overall association between bill size and summer temperatures per se, butthe association with humidity was mediated by temperature, with a significant interaction indicating strongerassociations with humidity at cooler summer temperatures. This is consistent with the idea that larger bills maybecome disadvantageous in humid conditions as ambient temperature approaches body temperature. Relative billsize was similar among closely related species, with phylogeny explaining 63.3% of the variance, and there wassignificant variation among species in their response to humidity. However, the relationship between relative billsize and humidity was not associated with phylogeny.Conclusions: Our results are consistent with the idea that body temperature regulation underlies continent-widepatterns of bill size variation in a broad range of Australian passerines, and suggests that Allen’s Rule may apply tohumidity gradients as well as temperature gradients. They add to growing evidence that a narrow focus ontemperature alone in studies of responses to climate change may limit our understanding of species’ sensitivities toclimatic variation, and of their capacity to adapt

An exploration of parents’ preferences for foot care in juvenile idiopathic arthritis: a possible role for the discrete choice experiment

Background: An increased awareness of patients’ and parents’ care preferences regarding foot care is desirable from a clinical perspective as such information may be utilised to optimise care delivery. The aim of this study was to examine parents’ preferences for, and valuations of foot care and foot-related outcomes in juvenile idiopathic arthritis (JIA).<p></p> Methods: A discrete choice experiment (DCE) incorporating willingness-to-pay (WTP) questions was conducted by surveying 42 parents of children with JIA who were enrolled in a randomised-controlled trial of multidisciplinary foot care at a single UK paediatric rheumatology outpatients department. Attributes explored were: levels of pain; mobility; ability to perform activities of daily living (ADL); waiting time; referral route; and footwear. The DCE was administered at trial baseline. DCE data were analysed using a multinomial-logit-regression model to estimate preferences and relative importance of attributes of foot care. A stated-preference WTP question was presented to estimate parents’ monetary valuation of health and service improvements.<p></p> Results: Every attribute in the DCE was statistically significant (p < 0.01) except that of cost (p = 0.118), suggesting that all attributes, except cost, have an impact on parents’ preferences for foot care for their child. The magnitudes of the coefficients indicate that the strength of preference for each attribute was (in descending order): improved ability to perform ADL, reductions in foot pain, improved mobility, improved ability to wear desired footwear, multidisciplinary foot care route, and reduced waiting time. Parents’ estimated mean annual WTP for a multidisciplinary foot care service was £1,119.05.<p></p> Conclusions: In terms of foot care service provision for children with JIA, parents appear to prefer improvements in health outcomes over non-health outcomes and service process attributes. Cost was relatively less important than other attributes suggesting that it does not appear to impact on parents’ preferences.<p></p&gt

Australian songbird body size tracks climate variation: 82 species over 50 years.

The observed variation in the body size responses of endotherms to climate change may be explained by two hypotheses: the size increases with climate variability (the starvation resistance hypothesis) and the size shrinks as mean temperatures rise (the heat exchange hypothesis). Across 82 Australian passerine species over 50 years, shrinking was associated with annual mean temperature rise exceeding 0.012°C driven by rising winter temperatures for arid and temperate zone species. We propose the warming winters hypothesis to explain this response. However, where average summer temperatures exceeded 34°C, species experiencing annual rise over 0.0116°C tended towards increasing size. Results suggest a broad-scale physiological response to changing climate, with size trends probably reflecting the relative strength of selection pressures across a climatic regime. Critically, a given amount of temperature change will have varying effects on phenotype depending on the season in which it occurs, masking the generality of size patterns associated with temperature change. Rather than phenotypic plasticity, and assuming body size is heritable, results suggest selective loss or gain of particular phenotypes could generate evolutionary change but may be difficult to detect with current warming rates.The work was partly supported by the Australian Research Council (DP120102651); JLG was partly supported by an Australian Research Council Future Fellowship (FT150100139); TA is funded by an Australian Research Council Future Fellowship (FT180100354); WJS is funded by Arcadia

Phosphoenolpyruvate carboxylase dentified as a key enzyme in erythrocytic Plasmodium falciparum carbon metabolism

Phospoenolpyruvate carboxylase (PEPC) is absent from humans but encoded in thePlasmodium falciparum genome, suggesting that PEPC has a parasite-specific function. To investigate its importance in P. falciparum, we generated a pepc null mutant (D10Δpepc), which was only achievable when malate, a reduction product of oxaloacetate, was added to the growth medium. D10Δpepc had a severe growth defect in vitro, which was partially reversed by addition of malate or fumarate, suggesting that pepc may be essential in vivo. Targeted metabolomics using 13C-U-D-glucose and 13C-bicarbonate showed that the conversion of glycolytically-derived PEP into malate, fumarate, aspartate and citrate was abolished in D10Δpepc and that pentose phosphate pathway metabolites and glycerol 3-phosphate were present at increased levels. In contrast, metabolism of the carbon skeleton of 13C,15N-U-glutamine was similar in both parasite lines, although the flux was lower in D10Δpepc; it also confirmed the operation of a complete forward TCA cycle in the wild type parasite. Overall, these data confirm the CO2 fixing activity of PEPC and suggest that it provides metabolites essential for TCA cycle anaplerosis and the maintenance of cytosolic and mitochondrial redox balance. Moreover, these findings imply that PEPC may be an exploitable target for future drug discovery

Protocol for the Foot in Juvenile Idiopathic Arthritis trial (FiJIA): a randomised controlled trial of an integrated foot care programme for foot problems in JIA

<b>Background</b>: Foot and ankle problems are a common but relatively neglected manifestation of juvenile idiopathic arthritis. Studies of medical and non-medical interventions have shown that clinical outcome measures can be improved. However existing data has been drawn from small non-randomised clinical studies of single interventions that appear to under-represent the adult population suffering from juvenile idiopathic arthritis. To date, no evidence of combined therapies or integrated care for juvenile idiopathic arthritis patients with foot and ankle problems exists. <b>Methods/design</b>: An exploratory phase II non-pharmacological randomised controlled trial where patients including young children, adolescents and adults with juvenile idiopathic arthritis and associated foot/ankle problems will be randomised to receive integrated podiatric care via a new foot care programme, or to receive standard podiatry care. Sixty patients (30 in each arm) including children, adolescents and adults diagnosed with juvenile idiopathic arthritis who satisfy the inclusion and exclusion criteria will be recruited from 2 outpatient centres of paediatric and adult rheumatology respectively. Participants will be randomised by process of minimisation using the Minim software package. The primary outcome measure is the foot related impairment measured by the Juvenile Arthritis Disability Index questionnaire's impairment domain at 6 and 12 months, with secondary outcomes including disease activity score, foot deformity score, active/limited foot joint counts, spatio-temporal and plantar-pressure gait parameters, health related quality of life and semi-quantitative ultrasonography score for inflammatory foot lesions. The new foot care programme will comprise rapid assessment and investigation, targeted treatment, with detailed outcome assessment and follow-up at minimum intervals of 3 months. Data will be collected at baseline, 6 months and 12 months from baseline. Intention to treat data analysis will be conducted. A full health economic evaluation will be conducted alongside the trial and will evaluate the cost effectiveness of the intervention. This will consider the cost per improvement in Juvenile Arthritis Disability Index, and cost per quality adjusted life year gained. In addition, a discrete choice experiment will elicit willingness to pay values and a cost benefit analysis will also be undertaken