Educating renal nurses - inferior vena caval ultrasound for intravascular volume assessment

Aim: Volume status of haemodialysis patients can be evaluated by trained doctors using ultrasound (US) of the inferior vena cava (IVC). To date, renal nurses have not been taught this skill. As part of a larger study exploring the use of US by renal nurses we developed an educational program to ensure that renal nurses received adequate US training to attain competence in IVC ultrasound (IVC-US). Methods: The educational program was divided into four parts. Initially a clinical US expert delivered the necessary theoretical and then practical components of the program. After this the nurse undertook a period of self-directed US practice (100 scans). During this period three formative reviews of the recorded scan clips with feedback occurred. Specific feedback covered US technique, image optimisation and acquisition and image interpretation. Finally, as a summative assessment the nurse performed and interpreted 60 scans on 10 dialysis patients. These scans were independently assessed for quality and the nurse interpretations reviewed for accuracy, prior to deeming the candidate competent to independently perform IVC-US. Findings: Ultrasound education involves knowledge and skill acquisition. Initial theoretical and practical education must be translated into competence through task repetition and targeted feedback. A staged educational program that involves these components is likely to be successful. The rate for US skill acquisition varies and a summative assessment ensuring competence prior to independent scanning is important. Conclusions: This four-step program demonstrated that it is feasible to educate a renal nurse in IVC-US for intravascular volume assessment

A Population-based Study on Lymph Node Retrieval in Patients with Esophageal Cancer: Results from the Dutch Upper Gastrointestinal Cancer Audit

Background: For esophageal cancer, the number of retrieved lymph nodes (LNs) is often used as a quality indicator. The aim of this study is to analyze the number of retrieved LNs in The Netherlands, assess factors associated with LN yield, and explore the association with short-term outcomes. This is a population-based study on lymph node retrieval in patients with esophageal cancer, presenting results from the Dutch Upper Gastrointestinal Cancer Audit. Study Design: For this retrospective national cohort study, patients with esophageal carcinoma who underwent esophagectomy between 2011 and 2016 were included. The primary outcome was the number of retrieved LNs. Univariable and multivariable regression analyses were used to test for association with ≥ 15 LNs. Patients and Results: 3970 patients were included. Between 2011 and 2016, the median number of LNs increased from 15 to 20. Factors independently associated with ≥ 15 LNs were: 0–10 kg preoperative weight loss (versus: unknown weight loss, odds ratio [95% confidence interval]: 0.71 [0.57–0.88]), Charlson score 0 (versus: Charlson score 2: 0.76 [0.63–0.92]), cN2 category (reference: cN0, 1.32 [1.05–1.65]), no neoadjuvant therapy and neoadjuvant chemotherapy (reference: neoadjuvant chemoradiotherapy, 1.73 [1.29–2.32] and 2.15 [1.54–3.01]), minimally invasive transthoracic (reference: open transthoracic, 1.46 [1.15–1.85]), open transthoracic (versus open and minimally invasive transhiatal, 0.29 [0.23–0.36] and 0.43 [0.32–0.59]), hospital volume of 26–50 or > 50 resections/year (reference: 0–25, 1.94 [1.55–2.42] and 3.01 [2.36–3.83]), and year of surgery [reference: 2011, odds ratios (ORs) 1.48, 1.53, 2.28, 2.44, 2.54]. There was no association of ≥ 15 LNs with short-term outcomes. Conclusions: The number of LNs retrieved increased between 2011 and 2016. Weight loss, Charlson score, cN category, neoadjuvant therapy, surgical approach, year of resection, and hospital volume were all associated with increased LN yield. Retrieval of ≥ 15 LNs was not associated with increased postoperative morbidity/mortality

Streptococcal peritonitis in Australian peritoneal dialysis patients: predictors, treatment and outcomes in 287 cases

Background There has not been a comprehensive, multi-centre study of streptococcal peritonitis in patients on peritoneal dialysis (PD) to date. Methods The predictors, treatment and clinical outcomes of streptococcal peritonitis were examined by binary logistic regression and multilevel, multivariate poisson regression in all Australian PD patients involving 66 centres between 2003 and 2006. Results Two hundred and eighty-seven episodes of streptococcal peritonitis (4.6% of all peritonitis episodes) occurred in 256 individuals. Its occurrence was independently predicted by Aboriginal or Torres Strait Islander racial origin. Compared with other organisms, streptococcal peritonitis was associated with significantly lower risks of relapse (3% vs 15%), catheter removal (10% vs 23%) and permanent haemodialysis transfer (9% vs 18%), as well as a shorter duration of hospitalisation (5 vs 6 days). Overall, 249 (87%) patients were successfully treated with antibiotics without experiencing relapse, catheter removal or death. The majority of streptococcal peritonitis episodes were treated with either intraperitoneal vancomycin (most common) or first-generation cephalosporins for a median period of 13 days (interquartile range 8–18 days). Initial empiric antibiotic choice did not influence outcomes. Conclusion Streptococcal peritonitis is a not infrequent complication of PD, which is more common in indigenous patients. When treated with either first-generation cephalosporins or vancomycin for a period of 2 weeks, streptococcal peritonitis is associated with lower risks of relapse, catheter removal and permanent haemodialysis transfer than other forms of PD-associated peritonitis.Stacey O'Shea, Carmel M Hawley, Stephen P McDonald, Fiona G Brown, Johan B Rosman, Kathryn J Wiggins, Kym M Bannister and David W Johnso

Preventing AVF thrombosis: the rationale and design of the Omega-3 fatty acids (Fish Oils) and Aspirin in Vascular access OUtcomes in REnal Disease (FAVOURED) study

Background: Haemodialysis (HD) is critically dependent on the availability of adequate access to the systemic circulation, ideally via a native arteriovenous fistula (AVF). The Primary failure rate of an AVF ranges between 20-54%, due to thrombosis or failure of maturation. There remains limited evidence for the use of anti-platelet agents and uncertainty as to choice of agent(s) for the prevention of AVF thrombosis. We present the study protocol for a randomised, double-blind, placebo-controlled, clinical trial examining whether the use of the anti-platelet agents, aspirin and omega-3 fatty acids, either alone or in combination, will effectively reduce the risk of early thrombosis in de novo AVF

High spatial resolution analysis of ferromanganese concretions by LA-ICP-MS†

A procedure was developed for the determination of element distributions in cross-sections of ferromanganese concretions using laser ablation inductively coupled plasma mass spectrometry (LA-ICP-MS). The effects of carrier flow rates, rf forward power, ablation energy, ablation spot size, repetition rate and number of shots per point on analyte intensity were studied. It is shown that different carrier gas flow rates are required in order to obtain maximum sensitivities for different groups of elements, thus complicating the optimisation of ICP parameters. On the contrary, LA parameters have very similar effects on almost all elements studied, thus providing a common optimum parameter set for the entire mass range. However, for selected LA parameters, the use of compromise conditions was necessary in order to compensate for relatively slow data acquisition by ICP-MS and maintain high spatial resolution without sacrificing the multielemental capabilities of the technique. Possible variations in ablation efficiency were corrected for mathematically using the sum of Fe and Mn intensities. Quantification by external calibration against matrix-matched standards was successfully used for more than 50 elements. These standards, in the form of pressed pellets (no binder), were prepared in-house using ferromanganese concentrates from a deep-sea nodule reference material as well as from shallow-marine concretions varying in size and having different proportions of three major phases: aluminosilicates, Fe- and Mn-oxyhydroxides. Element concentrations in each standard were determined by means of conventional solution nebulisation ICP-MS following acid digestion. Examples of selected inter-element correlations in distribution patterns along the cross-section of a concretion are given

Completion strategy or emphasis manipulation? Task support for teaching information problem solving

While most students seem to solve information problems effortlessly, research shows that the cognitive skills for effective information problem solving are often underdeveloped. Students manage to find information and formulate solutions, but the quality of their process and product is questionable. It is therefore important to develop instruction for fostering these skills. In this research, a 2-h online intervention was presented to first-year university students with the goal to improve their information problem solving skills while investigating effects of different types of built-in task support. A training design containing completion tasks was compared to a design using emphasis manipulation. A third variant of the training combined both approaches. In two experiments, these conditions were compared to a control condition receiving conventional tasks without built-in task support. Results of both experiments show that students' information problem solving skills are underdeveloped, which underlines the necessity for formal training. While the intervention improved students’ skills, no differences were found between conditions. The authors hypothesize that the effective presentation of supportive information in the form of a modeling example at the start of the training caused a strong learning effect, which masked effects of task support. Limitations and directions for future research are presented

Dialyse péritonéale chez les aborigènes australiens.

Indigenous people in wealthy countries have outcomes of chronic disease that are comparable to those of patients in low socio-economic developing countries. This is not different for renal disease and outcomes of renal replacement therapy. This chapter addresses the dilemmas of using Peritoneal Dialysis in aboriginal patients in Australia. The focus is on aboriginal people in very remote areas and some personal views are presented as to the causes of the gap between outcomes for aboriginal and non-aboriginal patients and how the many failed attempts to close the gap could be addressed.Les populations aborigènes des pays riches ont des évolutions de maladies chroniques comparables à celles des patients des pays en développement à faible niveau socio-économique. Ce n’est pas différent pour la maladie rénale et les résultats des thérapeutiques de remplacement rénal. Ce chapitre aborde les dilemmes liés à l’utilisation de la dialyse péritonéale chez les patients aborigènes en Australie. L’accent est mis sur les aborigènes vivants dans des régions très éloignées. Nous exprimons nos opinions personnelles quant aux causes de l’écart entre les résultats obtenues chez les patients aborigènes et non aborigènes ; nous suggérons comment les nombreuses tentatives qui se sont avérées infructueuses pour combler l’écart pourraient être traitées