The systemic microcirculation in dialysis populations

In a rapidly expanding population of patients with chronic kidney disease, including 2 million people requiring renal replacement therapy, cardiovascular mortality is 15 times greater than the general population. In addition to traditional cardiovascular risk factors, more poorly defined risks related to uremia and its treatments appear to contribute to this exaggerated risk. In this context, the microcirculation may play an important early role in cardiovascular disease associated with chronic kidney disease. Experimentally, the uremic environment and dialysis have been linked to multiple pathways causing microvascular dysfunction. Coronary microvascular dysfunction is reflected in remote and more easily studied vascular beds such as the skin. There is increasing evidence for a correlation between systemic microvascular dysfunction and adverse cardiovascular outcomes. Systemic microcirculatory changes have not been extensively investigated across the spectrum of chronic kidney disease. Recent advances in non-invasive techniques studying the microcirculation in vivo in man are increasing the data available particularly in patients on hemodialysis. Here, we review current knowledge of the systemic microcirculation in dialysis populations, explore whether non-invasive techniques to study its function could be used to detect early stage cardiovascular disease, address challenges faced in studying this patient cohort and identify potential future avenues for research.This article is freely available via Open Access. Click on the publisher URL to access it via the publisher's site.Jennifer Williams is funded by a Kidney Research UK Training Fellowship TF_013_20151127.pre-print, post-print (12 month embargo

Increasing compliance with low tidal volume ventilation in the ICU with two nudge-based interventions: evaluation through intervention time-series analyses

Objectives: Low tidal volume (TVe) ventilation improves outcomes for ventilated patients, and the majority of clinicians state they implement it. Unfortunately, most patients never receive low TVes. ‘Nudges’ influence decision-making with subtle cognitive mechanisms and are effective in many contexts. There have been few studies examining their impact on clinical decision-making. We investigated the impact of 2 interventions designed using principles from behavioural science on the deployment of low TVe ventilation in the intensive care unit (ICU). Setting: University Hospitals Bristol, a tertiary, mixed medical and surgical ICU with 20 beds, admitting over 1300 patients per year. Participants: Data were collected from 2144 consecutive patients receiving controlled mechanical ventilation for more than 1 hour between October 2010 and September 2014. Patients on controlled mechanical ventilation for more than 20 hours were included in the final analysis. Interventions: (1) Default ventilator settings were adjusted to comply with low TVe targets from the initiation of ventilation unless actively changed by a clinician. (2) A large dashboard was deployed displaying TVes in the format mL/kg ideal body weight (IBW) with alerts when TVes were excessive. Primary outcome measure: TVe in mL/kg IBW. Findings: TVe was significantly lower in the defaults group. In the dashboard intervention, TVe fell more quickly and by a greater amount after a TVe of 8 mL/kg IBW was breached when compared with controls. This effect improved in each subsequent year for 3 years. Conclusions: This study has demonstrated that adjustment of default ventilator settings and a dashboard with alerts for excessive TVe can significantly influence clinical decision-making. This offers a promising strategy to improve compliance with low TVe ventilation, and suggests that using insights from behavioural science has potential to improve the translation of evidence into practice

Redesigning the 'choice architecture' of hospital prescription charts: a mixed methods study incorporating in situ simulation testing.

Objectives: To incorporate behavioural insights into the user-centred design of an inpatient prescription chart (Imperial Drug Chart Evaluation and Adoption Study, IDEAS chart) and to determine whether changes in the content and design of prescription charts could influence prescribing behaviour and reduce prescribing errors. Design: A mixed-methods approach was taken in the development phase of the project; in situ simulation was used to evaluate the effectiveness of the newly developed IDEAS prescription chart. Setting: A London teaching hospital. Interventions/methods: A multimodal approach comprising (1) an exploratory phase consisting of chart reviews, focus groups and user insight gathering (2) the iterative design of the IDEAS prescription chart and finally (3) testing of final chart with prescribers using in situ simulation. Results: Substantial variation was seen between existing inpatient prescription charts used across 15 different UK hospitals. Review of 40 completed prescription charts from one hospital demonstrated a number of frequent prescribing errors including illegibility, and difficulty in identifying prescribers. Insights from focus groups and direct observations were translated into the design of IDEAS chart. In situ simulation testing revealed significant improvements in prescribing on the IDEAS chart compared with the prescription chart currently in use in the study hospital. Medication orders on the IDEAS chart were significantly more likely to include correct dose entries (164/164 vs 166/174; p=0.0046) as well as prescriber's printed name (163/164 vs 0/174; p<0.0001) and contact number (137/164 vs 55/174; p<0.0001). Antiinfective indication (28/28 vs 17/29; p<0.0001) and duration (26/28 vs 15/29; p<0.0001) were more likely to be completed using the IDEAS chart. Conclusions: In a simulated context, the IDEAS prescription chart significantly reduced a number of common prescribing errors including dosing errors and illegibility. Positive behavioural change was seen without prior education or support, suggesting that some common prescription writing errors are potentially rectifiable simply through changes in the content and design of prescription charts

Quantum cryptography with a predetermined key, using continuous variable Einstein-Podolsky-Rosen correlations

Correlations of the type discussed by EPR in their original 1935 paradox for continuous variables exist for the quadrature phase amplitudes of two spatially separated fields. These correlations were experimentally reported in 1992. We propose to use such EPR beams in quantum cryptography, to transmit with high efficiency messages in such a way that the receiver and sender may later determine whether eavesdropping has occurred. The merit of the new proposal is in the possibility of transmitting a reasonably secure yet predetermined key. This would allow relay of a cryptographic key over long distances in the presence of lossy channels.Comment: 11 pages,3 figures, changes are important,presented at QELS(May,2000) San Francisc

The ferroelectric Mott-Hubbard phase of organic (TMTTF)2X conductors

We present experimental evidences for a ferro-electric transition in the family of quasi one- dimensional conductors (TMTTF)2X. We interpret this new transition in the frame of the combined Mott-Hubbard state taking into account the double action of the spontaneous charge disproportionation on the TMTTF molecular stacks and of the X anionic potentials

Ample consumption period available until use-by dates: a potential, marketing position for store brands

Traditionally store brands in Australia are viewed with suspicion in regard to their quality and are usually purchased because of the "value for money" that they offer. Australian supermarket majors are considering introducing a new suite of store brands in the higher price brackets. The danger of moving upscale however is that these store brands are relinquishing their value for money appeal and will come head to head with the manufactured brands. Store brands will now require some quality dimension to compete. This paper after studying the attitudes and behavioural response of grocery shoppers to use by dates, is proposing that that the promise of "generous" use-by dates as a surrogate for quality, could be considered as a positioning plank to promote store brands as alternatives to manufactured brands. Logit analysis is employed to explain shoppers' perception and response to use-by dates, of products that they regularly buy, and of alternative products which they have never bought before if the use-by dates of their regular items are perceived to be too shor