Primary care physicians' perceptions of barriers and facilitators to management of chronic kidney disease: A mixed methods study.

BackgroundGiven the high prevalence of chronic kidney disease (CKD), primary care physicians (PCPs) frequently manage early stage CKD. Nonetheless, there are challenges in providing optimal CKD care in the primary care setting. This study sought to understand PCPs' perceptions of barriers and facilitators to the optimal management of CKD.Study designMixed methods study.Settings and participantsCommunity-based PCPs in four US cities: Baltimore, MD; St. Louis, MO; Raleigh, NC and San Francisco, CA.MethodologyWe used a self-administered questionnaire and conducted 4 focus groups of PCPs (n = 8 PCPs/focus group) in each city to identify key barriers and facilitators to management of patients with CKD in primary care.Analytic approachWe conducted descriptive analyses of the survey data. Major themes were identified from audio-recorded interviews that were transcribed and coded by the research team.ResultsOf 32 participating PCPs, 31 (97%) had been in practice for >10 years, and 29 (91%) practiced in a non-academic setting. PCPs identified multiple barriers to managing CKD in primary care including at the level of the patient (e.g., low awareness of CKD, poor adherence to treatment recommendations), the provider (e.g., staying current with CKD guidelines), and the health care system (e.g., inflexible electronic medical record, limited time and resources). PCPs desired electronic prompts and lab decision support, concise guidelines, and healthcare financing reform to improve CKD care.ConclusionsPCPs face substantial but modifiable barriers in providing care to patients with CKD. Interventions that address these barriers and promote facilitative tools may improve PCPs' effectiveness and capacity to care for patients with CKD

Constant-angle surfaces in liquid crystals

We discuss some properties of surfaces in R3 whose unit normal has constant angle with an assigned direction field. The constant angle condition can be rewritten as an Hamilton-Jacobi equation correlating the surface and the direction field. We focus on examples motivated by the physics of interfaces in liquid crystals and of layered fluids, and discuss the properties of the constant-angle surfaces when the direction field is singular along a line (disclination) or at a point (hedgehog defect

Chromogenic media for ESBL-positive Enterobacteriaceae

ChromID ESBL agar and Brilliance ESBL agar were compared for the isolation of extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae from 298 stools. These had comparable sensitivity and selectivity for the 116 positive samples. Pre-enrichment with cefpodoxime and extending incubation to 48 hours after direct plating both significantly increased sensitivity but reduced selectivity of both agars.This work was supported by a grant awarded to SP from the UK Department of Health, Wellcome Trust and the Health Innovation Challenge Fund (HICF-T5-342 and WT098600). TG is a Wellcome Trust Research Training Fellow. MET is a Clinician Scientist Fellow, supported by the Academy of Medical Sciences and the Health Foundation. The authors declare no conflicts of interest.This is the final version of the article. It first appeared from Elsevier via http://dx.doi.org/10.1016/j.diagmicrobio.2015.11.00

The lemur diversity of the Fiherenana-Manombo Complex, southwest Madagascar

We conducted the first comprehensive lemur survey of the Fiherenana - Manombo Complex (Atsimo-Andrefana Region), site of PK32-Ranobe, a new protected area within the Madagascar Protected Area System. Our cross-seasonal surveys of three sites revealed the presence of eight lemur species representing seven genera and four families, of which three are diurnal and five are nocturnal species. Six species were only recorded in the riparian and transitional forests of the Fiherenana and Manombo river valleys, while the spiny thicket at Ranobe contains only Microcebus (two species), all larger species having been extirpated by hunting in recent years. Two of our records (Mirza coquereli and Cheirogaleus sp.) represent new locality records or range extensions, but we failed to record one species (Phaner pallescens) expected to occur in the area, and question the literature supporting its presence south of the Manombo river. Our findings highlight the importance of the Fiherenana-Manombo Complex for the conservation of lemurs in southwest Madagascar, but also show that PK32 - Ranobe fails to protect the full lemur diversity of the Complex. The protected area does not include the riparian forests of the Manombo and Fiherenana rivers, and at least three lemur species are therefore unprotected. We strongly support the proposed extension of the protected area to include these riparian forests as well as other important habitats for locally endemic bird and reptile taxa.RÉSUMÉ La zone du Complexe Fiherenana - Manombo (Région d’Atsimo- Andrefana), site de PK32-Ranobe, une nouvelle aire protégée dans le Système des Aires Protégées de Madagascar (SAPM), a fait l’objet d’un premier inventaire de lémuriens. Nos prospections dans trois sites à différentes saisons ont révélé la présence de huit espèces de lémuriens représentés dans sept genres et trois familles, dont trois sont des espèces diurnes et cinq sont des espèces nocturnes. Nous n’avons pas pu identifier l’espèce du genre Lepilemur ni celle du genre Cheirogaleus à défaut de disposer de spécimens. Six espèces ne se trouvaient que dans les forêts riveraines et les forêts de transition des vallées des fleuves Fiherenana et Manombo. Le fourré épineux de Ranobe n’abrite que des Microcebus (deux espèces), toutes les espèces plus grandes ayant déjà été exterminées par la chasse au cours des dernières années. Nos estimations de densité indiquent que la population des Microcebus est deux fois plus importante dans le fourré épineux que dans la forêt riveraine (1,078 individus / km² vs. 546 individus / km²). Nous avons estimé la densité d’Eulemur rufus à 40 groupes / km² dans la vallée du Fiherenana, mais nos transects ne nous ont pas permis d’obtenir des estimations fiables pour les densités de Lemur catta et de Propithecus verreauxi. Deux des espèces répertoriées (Mirza coquereli et Cheirogaleus sp.) représentent de nouvelles observations pour la zone ou des extensions de leurs aires de répartition connues, mais nous n’avons pas pu trouver l’espèce Phaner pallescens qui devait être présente dans la zone et nous émettons des doutes portant sur les références publiées rapportant la présence de l’espèce au sud du fleuve Manombo. Nos résultats mettent en exergue l’importance du Complexe Fiherenana - Manombo pour la conservation des lémuriens dans le sud-ouest de Madagascar, mais ils indiquent que l’aire protégée de PK32 - Ranobe ne protège pas la diversité complète des lémuriens du Complexe. Les forêts riveraines des fleuves Fiherenana et Manombo ne sont pas incluses dans l’aire protégée de sorte qu’au moins trois espèces de lémuriens ne bénéficient alors d’aucune protection. Compte tenu des objectifs du SAPM et plus particulièrement de l’Objectif 1, à savoir ‘Conserver l’ensemble de la biodiversité unique de Madagascar’, nous estimons que la nouvelle aire protégée du PK32-Ranobe n’atteint pas ces objectifs et nous appuyons les efforts des promoteurs afin de re-délimiter l’aire protégée pour inclure les forêts riveraines ainsi que d’autres habitats importants pour la conservation des oiseaux et des reptiles localement endémiques

Common and Rare Variant Prediction and Penetrance of IBD in a Large, Multi-ethnic, Health System-based Biobank Cohort

BACKGROUND AND AIMS: Polygenic risk scores (PRS) may soon be used to predict inflammatory bowel disease (IBD) risk in prevention efforts. We leveraged exome-sequence and single nucleotide polymorphism (SNP) array data from 29,358 individuals in the multiethnic, randomly ascertained health system-based BioMe biobank to define effects of common and rare IBD variants on disease prediction and pathophysiology. METHODS: PRS were calculated from European, African American, and Ashkenazi Jewish (AJ) reference case-control studies, and a meta-GWAS run using all three association datasets. PRS were then combined using regression to assess which combination of scores best predicted IBD status in European, AJ, Hispanic, and African American cohorts in BioMe. Additionally, rare variants were assessed in genes associated with very early-onset IBD (VEO-IBD), by estimating genetic penetrance in each BioMe population. RESULTS: Combining risk scores based on association data from distinct ancestral populations improved IBD prediction for every population in BioMe and significantly improved prediction among European ancestry UK Biobank individuals. Lower predictive power for non-Europeans was observed, reflecting in part substantially lower African IBD case-control reference sizes. We replicated associations for two VEO-IBD genes, ADAM17 and LRBA, with high dominant model penetrance in BioMe. Autosomal recessive LRBA risk alleles are associated with severe, early-onset autoimmunity; we show that heterozygous carriage of an African-predominant LRBA protein-altering allele is associated with significantly decreased LRBA and CTLA-4 expression with T-cell activation. CONCLUSIONS: Greater genetic diversity in African populations improves prediction across populations, and generalizes some VEO-IBD genes. Increasing African American IBD case-collections should be prioritized to reduce health disparities and enhance pathophysiological insight.Peer reviewe