Education Before Kidney Transplantation: What Do Patients Need to Know?

Astellas Pharma Canada Inc.Peer ReviewedCONTEXT: Poor knowledge about immunosuppressive (IS) medications remains a major problem for patients in the posttransplant setting. Therefore, more effective educational strategies in the pretransplant setting are being considered as a possible method to improve knowledge and readiness for the challenges of posttransplant care. However, the most effective/relevant content of a pretransplant educational program is yet to be determined. OBJECTIVE: To identify pretransplant education topics from the posttransplant patient perspective. DESIGN: A focus group meeting was conducted among 7 high-functioning, stable adult kidney transplant recipients recruited from the Saskatchewan Transplant Program. Demographic information including age, gender, occupation, background/ethnicity, and time since transplant were recorded. A moderator, assistant moderator, and research assistant facilitated the 90-minute focus group meeting using a predetermined semistructured interview guide. The session was audio recorded and transcribed verbatim. Nvivo software was used to code the data and identify emerging themes exploring views of participants relating to the educational information required for pretransplant patients. RESULTS: Patients were satisfied with the education they had received. Ideas were classified into the following major themes-patient satisfaction, transplant waitlist, surgery, medications, posttransplant complications, lifestyle and monitoring, knowledge acquisition, illusion of control, and life changes posttransplant. Knowledge gaps were identified in all areas of the transplantation process and were not exclusive to IS medications. CONCLUSION: Misconceptions regarding transplantation were identified by a group of high-functioning, stable adult recipients who were satisfied with their clinical care. Future educational strategies should aim to address the entire transplantation process and not be limited to medications

Outcomes of cinacalcet withdrawal in Australian dialysis patients

Background: Secondary hyperparathyroidism (SHPT) in chronic kidney disease is associated with cardiovascular and bone pathology. Measures to achieve parathyroid hormone (PTH) target values and control biochemical abnormalities associated with SHPT require complex therapies, and severe SHPT often requires parathyroidectomy or the calcimimetic cinacalcet. In Australia, cinacalcet was publicly funded for dialysis patients from 2009 to 2015 when funding was withdrawn following publication of the EVOLVE study, which resulted in most patients on cinacalcet ceasing therapy. We examined the clinical and biochemical outcomes associated with this change at Australian renal centres. Methods: We conducted a retrospective study of dialysis patients who ceased cinacalcet after August 2015 in 11 Australian units. Clinical outcomes and changes in biochemical parameters were assessed over a 24‐ and 12‐month period respectively from cessation of cinacalcet. Results: 228 patients were included (17.7% of all dialysis patients from the units). Patients were aged 63±15 years with 182 patients on haemodialysis and 46 on peritoneal dialysis. Over 24 months following cessation of cinacalcet, we observed 26 parathyroidectomies, 3 episodes of calciphylaxis, 8 fractures and 50 deaths. Seven patients recommenced cinacalcet, meeting criteria under a special access scheme. Biochemical changes from baseline to 12 months after cessation included increased levels of serum PTH from 54 (IQR 27‐90) pmol/L to 85 (IQR 41‐139) pmol/L (

Hepatic safety of antibiotics used in primary care

Antibiotics used by general practitioners frequently appear in adverse-event reports of drug-induced hepatotoxicity. Most cases are idiosyncratic (the adverse reaction cannot be predicted from the drug's pharmacological profile or from pre-clinical toxicology tests) and occur via an immunological reaction or in response to the presence of hepatotoxic metabolites. With the exception of trovafloxacin and telithromycin (now severely restricted), hepatotoxicity crude incidence remains globally low but variable. Thus, amoxicillin/clavulanate and co-trimoxazole, as well as flucloxacillin, cause hepatotoxic reactions at rates that make them visible in general practice (cases are often isolated, may have a delayed onset, sometimes appear only after cessation of therapy and can produce an array of hepatic lesions that mirror hepatobiliary disease, making causality often difficult to establish). Conversely, hepatotoxic reactions related to macrolides, tetracyclines and fluoroquinolones (in that order, from high to low) are much rarer, and are identifiable only through large-scale studies or worldwide pharmacovigilance reporting. For antibiotics specifically used for tuberculosis, adverse effects range from asymptomatic increases in liver enzymes to acute hepatitis and fulminant hepatic failure. Yet, it is difficult to single out individual drugs, as treatment always entails associations. Patients at risk are mainly those with previous experience of hepatotoxic reaction to antibiotics, the aged or those with impaired hepatic function in the absence of close monitoring, making it important to carefully balance potential risks with expected benefits in primary care. Pharmacogenetic testing using the new genome-wide association studies approach holds promise for better understanding the mechanism(s) underlying hepatotoxicity

Relief of exertional breathlessness following bariatric surgery for severe obesity: Physiological mechanisms

Purpose: Obese adults are two-to-four times more likely to experience physical activity-limiting breathlessness than their normal weight counterparts. Despite the high prevalence of breathlessness in obesity, researchers and healthcare providers have a limited understanding of the physiological mechanisms of breathlessness on exertion in obesity. Therefore, the aim of this study was to advance the understanding of the physiological mechanisms of exertional breathlessness in obesity by examining the effects of extreme weight loss through bariatric surgery for class III obesity (BMI>40 kg/m2) on physiological and breathlessness responses during cardiopulmonary cycle exercise testing. We hypothesized that relief of exertional breathlessness following bariatric surgery would be primarily related to the reduced metabolic and ventilatory requirements of exercise, while changes in static and dynamic respiratory mechanics would be less important.Methods: We compared cardiac, metabolic, ventilatory, breathing pattern, operating lung volume and breathlessness responses to symptom-limited incremental CPET (25-watts/2-min) in 6 obese adults (3 women) aged 43.7±2.8 years (mean±SEM) before (PRE) and 3-months after bariatric surgery (POST). Pulmonary function test and body composition parameters were also compared PRE and POST.Results: Compared with PRE, body mass, BMI, fat mass and lean body mass decreased by an average of 23.8 kg (129.4±6.2 vs.105.6±5.8 kg), 8.7 kg/m2 (47.1±1.6 vs. 38.4±1.6 kg/m2), 18.5 kg (61.6±4.6 vs. 43.1±4.8 kg) and 4.4 kg (62.2±4.1 vs. 57.8±4.6 kg) in POST, respectively (all p<0.05). Peak power output was not significantly different in POST vs. PRE: 154±21 vs. 133±11 watts (p=0.185). With few exceptions, heart rate, the rate of oxygen uptake, the rate of carbon dioxide production and minute ventilation (V̇E) were lower during exercise in POST vs. PRE. The reduced V̇E response to exercise in POST vs. PRE reflected adoption of a relatively slower (less tachypneic) breathing pattern. Inspiratory capacity (IC) decreased by 0.13 L from rest-to-peak exercise in PRE, reflecting dynamic lung hyperinflation. In contrast, IC increased by 0.21 L from rest-to-peak exercise in POST (p=0.034 vs. PRE). Inspiratory reserve volume (expressed as a percentage of forced vital capacity [IRV%FVC]) was lower at any given V̇E during exercise in POST vs. PRE. Clinically-meaningful decreases in intensity ratings of breathlessness were observed during exercise at standardized submaximal power outputs ≥75 watts in POST vs. PRE; for example, by 1.0 and 1.4 Borg 0-10 scale units at 75-watts (p<0.05) and at the highest equivalent power output of 117-watts (p<0.08). However, these differences did not persist when breathlessness was examined in relation to V̇E. Breathlessness-IRV%FVC curves were rightward shifted during exercise in POST vs. PRE, such that breathlessness intensity ratings were lower at any given IRV%FVC during exercise in POST vs. PRE.Conclusion: Relief of exertional breathlessness following extreme weight loss via bariatric surgery for class III obesity could not be explained by improved breathing mechanics but was mechanistically linked to the reduced metabolic and ventilatory requirements of exercise.Objectifs: Les adultes obèses sont deux à quatre fois plus susceptibles de subir de l'essoufflement qui pourrait limiter leur activité physique comparé à des individus de poids normal. La compréhension des mécanismes physiologiques sur cet essoufflement parmi les chercheurs et professionnels de santé demeurent toutefois limitées. Donc, le but de cette étude était de mieux comprendre les mécanismes physiologiques de l'essoufflement chez les individus obèses en examinant les effets de la perte de poids extrême à la suite d'une intervention de chirurgie bariatrique pour l'obésité de classe III (IMC ≥ 40 kg/m2). À cet effet, nous avons évalué les responses physiologiques et l'essoufflement lors d'un test d'exercice cardio-pulmonaire à base de cycloergomètre. Nous postulons que le soulagement de l'essoufflement à l'effort à la suite d'une chirurgie bariatrique serait principalement lié à la réduction des besoins métabolique et ventilatoires durant l'exercice, tandis que les changements de mécanismes respiratoires statique et dynamique seraient moins important. Méthodologie: Nous avons comparé les paramètres cardiaques, métaboliques, le schéma respiratoire, les volumes pulmonaires ainsi que le taux d'essoufflement atteint à la limite symptomatique lors d'un test d'exercice à intensité progressive sur une bicyclette ergométrique (25 watts/2 min) avec 6 adultes obèses (3 femmes) âgés de 43,7±2,8 ans (moyenne ± SEM) avant (PRÉ) et 3 mois après la chirurgie bariatrique (POST). Les tests de fonction pulmonaire et les paramètres de composition corporelle ont également été évalués PRÉ-POST.Résultats: Par rapport au PRÉ, la masse corporelle, l'IMC, la masse grasse et la masse maigre ont diminué en moyenne de 23,8 kg (129,4 ± 6,2 vs 105,6 ± 5,8 kg), 8,7 kg / m2 (47,1 ± 1,6 vs 38,4 ± 1,6 kg / m2), 18,5 kg (61,6 ± 4,6 vs 43,1 ± 4,8 kg) et 4,4 kg (62,2 ± 4,1 vs 57,8 ± 4,6 kg) dans le POST, respectivement (tous p <0,05). La puissance de sortie maximale n'était pas significativement différente entre le POST et PRÉ: 154 ± 21 vs 133 ± 11 watts (p = 0,185). En dehors de quelques exceptions, la fréquence cardiaque, le taux d'absorption d'oxygène, le taux de production de dioxyde de carbone et la ventilation (V̇E) étaient plus faibles pendant l'exercice durant le POST comparativement au PRÉ. La réduction de la réponse V̇E durant l'exercice dans le POST par rapport au PRÉ reflète l'utilisation d'un schéma respiratoire relativement plus lent (moins de tachypnée). Le fait que la capacité inspiratoire (CI) entre les exercices de repos et les exercices de pointe a diminué de 0,13 L révèle une hyperinflation pulmonaire dynamique. En revanche, la CI a augmenté de 0,21 litre lors de l'exercice de repos à l'exercice maximale dans le POST (p = 0,034 vs PRÉ). Le volume de réserve inspiratoire (exprimé en pourcentage de la capacité vitale forcée [% CVF]) était plus faible à toute mesure de V̇E durant l'exercice dans le POST vs PRÉ. Des diminutions cliniquement significatives sur l'intensité de l'essoufflement ont été observées pendant l'exercice à des puissances de sortie sous-maximales normalisées ≥75 watts en POST vs PRÉ; par exemple, par 1,0 et 1,4 unités d'échelle Borg 0-10 à 75 watts (p <0,05) et à la puissance de sortie équivalente la plus élevée de 117 watts (p <0,08). Cependant, ces différences n'ont pas persisté lorsque l'essoufflement a été examiné par rapport à la V̇E. Les courbes associées à l'essoufflement et IRV%CVF ont été décalées vers la droite pendant l'exercice dans POST vs. PRÉ, de telle sorte que les taux d'intensité d'essoufflement étaient plus faibles à tout IRV% de CVF pendant l'exercice du POST comparativement au PRÉ.Conclusion: Le soulagement de l'essoufflement à l'effort après une perte de poids extrême par chirurgie bariatrique pour l'obésité de classe III ne pouvait être expliquer par une amélioration des mécanismes pulmonaires, mais était plutôt lié à une réduction d'exigences métaboliques et ventilatoires durant l'exercice

Possible Doxazosin-Induced Leukopenia

INTRODUCTION Doxazosin is a selective long-acting a1-adrenergic antagonist. It is indicated for the treatment of benign prostatic hyperplasia and stage I and II (mild to moderate) essential hypertension.1 A MEDLINE search revealed no previous reports of leukopenia associated with the use of doxazosin

Individualized Therapy to Prevent Bone Mineral Density Loss after Kidney and Kidney-Pancreas Transplantation

Background and objectives: Most patients who undergo kidney or kidney-pancreas transplantation have renal osteodystrophy, and immediately after transplantation bone mineral density (BMD) commonly falls. Together, these abnormalities predispose to an increased fracture incidence. Bisphosphonate or calcitriol therapy can preserve BMD after transplantation, but although bisphosphonates may be more effective, they pose potential risks for adynamic bone

Optimization of TriboelectricNanogenerator for Small Power Electronics

TriboelectricNanogenerators (TENGs) is a new era energy source to power portable small electronic devices. This paper presents the fabrication of vertical contact separation mode TENGs. Three different TENGs device prototypes are fabricated: (1) Kapton-Aluminium; (2) Teflon-Aluminium and (3) Room Temperature Vulcanizing (RTV)-Aluminium. To optimize the performance of TENGs the effect of various parameters such as thickness of dielectric layer, contact time between two layers and contact separation movement of layers have been observed. Experimental result demonstrates that the output voltage increases initially and then decreases with the increase in thickness of dielectric layer. It is also reported that output voltage of TENGs decreases and increases with the increase in contact time and contact separation movement respectively. In this work, an output voltage obtained from TENGs is suitable to drive applications based on small power electronics

Effects of a Preprinted Order on Management of Community-Acquired Pneumonia

ABSTRACTBackground: A preprinted order was implemented in an effort to improve management of community-acquired pneumonia at an acute care hospital in an urban setting.Objective: To evaluate use of the preprinted order and to compare management of community-acquired pneumonia before and after implementation of this tool.Methods: A chart review was conducted for 3 groups of patients who had been admitted with community-acquired pneumonia: patients admitted after implementation of the preprinted order, divided into group A (preprinted order used in treatment plan) and group B (preprinted order not used), and historical controls (admitted before implementation of the preprinted order).Results: Of the 103 patients with community-acquired pneumonia who were admitted after introduction of the preprinted order, 43 (42%) had preprinted orders in their charts. The rates of inappropriate admission, based on pneumonia severity index (either documented in the chart or determined on a post hoc basis for this study), were 8% (1/12) for group A patients with a documented pneumonia severity index, 35% (11/31) for group A patients without a documented pneumonia severity index, 33% (20/60) for group B patients, and 16% (8/51) for the historical controls. Both blood and sputum were cultured for 63% (27/43) of the patients in group A, 25% (15/60) of those in group B, and 47% (24/51) of the controls. Empiric antibiotic therapy was consistent with guidelines for 74% (32/43) of the patients in group A, 65% (39/60) of those in group B, and 53% (27/51) of the controls. Step-down therapy was initiated for 43% (13/30) of eligible patients in group A, for 27% (10/37) of those in group B, and for 62% (20/32) of controls. The mean length of stay was 6.9 days for group A patients, 7.4 days for group B patients, and 9.9 days for controls.Conclusions: After introduction of a preprinted order for community- acquired pneumonia, the appropriateness of admission, rates of culture, and selection of empiric antibiotics consistent with guidelines increased, and length of stay decreased. The occurrence and timeliness of step-down was unaffected. As such, the introduction of the preprinted order increased compliance with published guidelines. More consistent use of the preprinted order and the pneumonia severity index might result in further improvements.ABSTRACTHistorique : Un système d’ordonnances préimprimées a été mis en place dans le but d’améliorer le traitement des pneumonies extrahospitalières dans un centre hospitalier de soins de courte durée en milieu urbain.Objectif : Évaluer l’emploi des ordonnances préimprimées et comparer le traitement des pneumonies extrahospitalières avant à après la mise en oeuvre de ce système.Méthodes : Une analyse des dossiers médicaux de 3 groupes de patients hospitalisés pour une pneumonie extrahospitalière a été effectuée : deux groupes formés des patients hospitalisés après la mise en oeuvre des ordonnances préimprimées, le Groupe A chez qui les ordonnances préimprimées ont été utilisées dans leur plan de soins et le Groupe B chez qui les ordonnances préimprimées n’ont pas été utilisées; et un troisième, le groupe témoin historique, formé des patients hospitalisés avant la mise en oeuvre des ordonnances préimprimées.Résultats : Des 103 patients atteints de pneumonie extrahospitalière hospitalisés après la mise en oeuvre des ordonnances préimprimées, 43 (42 %) avaient une telle ordonnance dans leur dossier. Les taux d’hospitalisation inappropriée, basée sur l’indice de gravité de la pneumonie (soit consigné au dossier médical, soit déterminé a posteriori pour cette étude), étaient de 8 % (1/12) pour les patients du Groupe A dont l’indice de gravité de la pneumonie était consigné, de 35 % (11/31) pour les patients du Groupe A sans indice de gravité de la pneumonie consigné, de 33 % (20/60) pour les patients du Groupe B, et de 16 % (8/51) pour les patients du groupe témoin. Une culture du sang et des crachats a été réalisée chez 63 % (27/43) des patients du Groupe A, chez 25 % (15/60) de ceux du Groupe B, et chez 47 % (24/51) des témoins. L’antibiothérapie empirique était conforme aux lignes directrices chez 74 % (32/43) des patients du Groupe A, chez 65 % (39/60) de ceux du Groupe B, et chez 53 % (27/51) des témoins. Un traitement dégressif a été amorcé chez 43 % (13/30) des patients admissibles du Groupe A, chez 27 % (10/37) des patients du Groupe B, et chez 62 % (20/32) des témoins. La durée moyenne des hospitalisations était de 6,9 jours chez les patients du Groupe A, de 7,4 jours chez ceux du Groupe B, et de 9,9 jours chez les témoins.Conclusions : Après la mise en oeuvre du système d’ordonnances préimprimées pour la prise en charge des pneumonies extrahospitalières, on a observé une augmentation de la pertinence des hospitalisations, des taux de culture et du choix de l’antibiothérapie empirique conformément aux lignes directrices, et une diminution de la durée des hospitalisations. Le recours et l’opportunité du traitement dégressif n’ont pas été modifiés. Ainsi la mise en oeuvre du système d’ordonnances préimprimées a amélioré le respect des lignes directrices publiées. Un emploi plus cohérent des ordonnances préimprimées et de l’indice de gravité de la pneumonie améliorerait peut-être davantage les résultats

Characterizing and Developing Strategies for the Treatment of Community-Acquired Pneumonia at a Community Hospital

BACKGROUND: Patients admitted to Lions Gate Hospital, North Vancouver, British Columbia, with a primary diagnosis of community-acquired pneumonia (CAP) have a mean length of stay (LOS) of 9.1 days compared with 7.9 days for peer group hospitals. This difference of 1.2 days results in an annual potential savings of 406 bed days and warranted an investigation into the management of CAP