Adaptive responses to very low protein diets: The first comparison of ketoacids to essential amino acids

Adaptive responses to very low protein diets: The first comparison of ketoacids to essential amino acids. Eight patients with chronic renal failure (GFR 18.8 ± 2.7 ml/min) were randomized to a crossover comparison of a very low protein diet (VLPD) containing 0.28g protein and 35kcal per kg per day, plus an isomolar mixture of either ketoacids (KA) or essential amino acids (EAA). Subjects initiated the diets 14 days before hospital admission and following a four-day equilibration, a five-day nitrogen balance (BN) was performed. Whole-body protein turnover (WBPT) was measured during fasting and feeding using intravenous [1-13C]leucine and intragastric [5,5,5-2H3]leucine. Even though the VLPD/KA regimen contained 15% less nitrogen, BN was neutral and did not differ between the regimens. Nitrogen conservation with KA was due to a reduction in urea nitrogen appearance. Rates of WBPT measured during fasting and feeding did not differ between the KA or EAA regimens. During both regimens, feeding decreased protein degradation, whereas protein synthesis was unchanged. Although feeding stimulated leucine oxidation, rates were 50 to 100% lower than reported in CRF patients consuming 0.6 or 1.0g protein/kg/day. Thus, neutral BN with the VLPD regimen is achieved by a marked reduction in amino acid oxidation and a postprandial inhibition of protein degradation

Rapid assessment of tetanus vaccine-induced immunity in Bangladesh and the Gambia.

We have developed recombinant fragment C based rapid point of care dipstick devices to assess tetanus immunization status using plasma or whole blood. The devices demonstrated specificity of 0.90 and sensitivity of 0.90 (whole blood)/0.94 (plasma) at field sites in Bangladesh and The Gambia when compared to a commercial ELISA with the immune cut-off titer set as ≥0.1IU/mL

3MPower Evidence Café 1: Report

3MPower will generate evidence on technology use for Teacher Professional Development (TPD) in low- and middle-income countries, with a particular focus on children’s foundation numeracy skills in schools serving marginalised, low-income, rural communities. 3Mpower will study the use of numeracy TPD courses on Muktopaath - a government-led e-Learning platform used by over 400,000 teachers in Bangladesh - to answer the question “How are primary numeracy teachers using mobile learning for teacher development in rural schools and in what ways does this change learning and teaching?” 3MPower will generate evidence about the validity of every step linking teachers’ use of mobile learning to improved student learning outcomes, through at-scale mixed methods research. 3MPower includes four process evaluation studies and two quasi-experimental impact evaluation studies with 240 teachers and 3,600 learners. Qualitative methods include Participatory Ethnographic Evaluation Research (PEER) exploring rural teachers’ experiences of accessing CPD with technology and the practical application CPD to teaching and learning. Throughout the research, 3MPower will engage a broad range of national stakeholders including government policymakers, policy implementers, teacher educators, rural education officers, and rural teachers. Stakeholders will participate in an iterative series of knowledge exchange activities, beginning with co-design and continuing throughout, through a series of Evidence Cafes. to make sense of the emerging evidence, refine the research approach, and identify implications and recommendations for policy and practice. 3MPower findings will address significant gaps in global evidence on the use of technology for teacher development in marginalised schools, the role of communities of practice, and the impacts at-scale on teaching quality and learning outcomes

Systemic Levamisole-Induced Vasculitis in a Cocaine User without Cutaneous Findings: A Consideration in Diagnosis

Levamisole is a known immunomodulating agent frequently used as a cutting agent in cocaine consumed in the United States today. Numerous cases of anti-neutrophil cytoplasmic antibody (ANCA) vasculitis connected with the use of levamisole-adulterated cocaine have previously been reported in the literature, classically characterized by a retiform purpuric rash. We report a case of a crack-cocaine user without cutaneous abnormalities who developed ANCA-associated glomerulonephritis that progressed to renal failure. This case demonstrates the difficulties in solidifying the diagnosis of levamisole-induced vasculitis in the absence of cutaneous findings and the need to pursue more testing to establish causality in ANCA-associated vasculitis that has potential for severe end-organ damage in patients who continue to use cocaine

Long-term outcomes among Medicare patients readmitted in the first year of hemodialysis: a retrospective cohort study.

BACKGROUND: Readmission within 30 days of hospital discharge is common and costly among end-stage renal disease (ESRD) patients. Little is known about long-term outcomes after readmission. We estimated the association between hospital admissions and readmissions in the first year of dialysis and outcomes in the second year. METHODS: Data on incident dialysis patients with Medicare coverage were obtained from the United States Renal Data System (USRDS). Readmission patterns were summarized as no admissions in the first year of dialysis (Admit-), at least one admission but no readmissions within 30 days (Admit+/Readmit-), and admissions with at least one readmission within 30 days (Admit+/Readmit+).We used Cox proportional hazards models to estimate the association between readmission pattern and mortality, hospitalization, and kidney transplantation, accounting for demographic and clinical covariates. RESULTS: Among the 128,593 Medicare ESRD patients included in the study, 18.5% were Admit+/Readmit+, 30.5% were Admit+/Readmit-, and 51.0% were Admit-. Readmit+/Admit+ patients had substantially higher long-term risk of mortality (HR = 3.32 (95% CI, 3.21-3.44)), hospitalization (HR = 4.46 (95% CI, 4.36-4.56)), and lower likelihood of kidney transplantation (HR = 0.52 (95% CI, 0.44-0.62)) compared to Admit- patients; these associations were stronger than those among Admit+/Readmit- patients. CONCLUSIONS: Patients with readmissions in the first year of dialysis were at substantially higher risk of poor outcomes than either patients who had no admissions or patients who had hospital admissions but no readmissions. Identifying strategies to both prevent readmission and mitigate risk among patients who had a readmission may improve outcomes among this substantial, high-risk group of ESRD patients

Making sense of DialysisConnect: a qualitative analysis of stakeholder viewpoints on a web-based information exchange platform to improve care transitions between dialysis clinics and hospitals.

BACKGROUND: U.S. hospitals and dialysis centers are penalized for 30-day hospital readmissions of dialysis patients, despite little infrastructure to facilitate care transitions between these settings. We are developing a third-party web-based information exchange platform, DialysisConnect, to enable clinicians to view and exchange information about dialysis patients during admission, hospitalization, and discharge. This health information technology solution could serve as a flexible and relatively affordable solution for dialysis facilities and hospitals across the nation who are seeking to serve as true partners in the improved care of dialysis patients. The purpose of this study was to evaluate the perceived coherence of DialysisConnect to key clinical stakeholders, to prepare messaging for implementation. METHODS: As part of a hybrid effectiveness-implementation study guided by Normalization Process Theory, we collected data on stakeholder perceptions of continuity of care for patients receiving maintenance dialysis and a DialysisConnect prototype before completing development and piloting the system. We conducted four focus groups with stakeholders from one academic hospital and associated dialysis centers [hospitalists (n = 5), hospital staff (social workers, nurses, pharmacists; n = 9), nephrologists (n = 7), and dialysis clinic staff (social workers, nurses; n = 10)]. Transcriptions were analyzed thematically within each component of the construct of coherence (differentiation, communal specification, individual specification, and internalization). RESULTS: Participants differentiated DialysisConnect from usual care variously as an information dashboard, a quick-exchange communication channel, and improved discharge information delivery; some could not differentiate it in terms of workflow. The purpose of DialysisConnect (communal specification) was viewed as fully coherent only for communicating outside of the same healthcare system. Current system workarounds were acknowledged as deterrents for practice change. All groups delegated DialysisConnect tasks (individual specification) to personnel besides themselves. Partial internalization of DialysisConnect was achieved only by dialysis clinic staff, based on experience with similar technology. CONCLUSIONS: Implementing DialysisConnect for clinical users in both settings will require presenting a composite picture of current communication processes from all stakeholder groups to correct single-group misunderstandings, as well as providing data about care transitions communication beyond the local context to ease resistance to practice change

Post-hospitalization dialysis facility processes of care and hospital readmissions among hemodialysis patients: a retrospective cohort study

Abstract Background Both dialysis facilities and hospitals are accountable for 30-day hospital readmissions among U.S. hemodialysis patients. We examined the association of post-hospitalization processes of care at hemodialysis facilities with pulmonary edema-related and other readmissions. Methods In a retrospective cohort comprised of electronic medical record (EMR) data linked with national registry data, we identified unique patient index admissions (n = 1056; 2/1/10–7/31/15) that were followed by ≥3 in-center hemodialysis sessions within 10 days, among patients treated at 19 Southeastern dialysis facilities. Indicators of processes of care were defined as present vs. absent in the dialysis facility EMR. Readmissions were defined as admissions within 30 days of the index discharge; pulmonary edema-related vs. other readmissions defined by discharge codes for pulmonary edema, fluid overload, and/or congestive heart failure. Multinomial logistic regression to estimate odds ratios (ORs) for pulmonary edema-related and other vs. no readmissions. Results Overall, 17.7% of patients were readmitted, and 8.0% had pulmonary edema-related readmissions (44.9% of all readmissions). Documentation of the index admission (OR = 2.03, 95% CI 1.07–3.85), congestive heart failure (OR = 1.87, 95% CI 1.07–3.27), and home medications stopped (OR = 1.81, 95% CI 1.08–3.05) or changed (OR = 1.69, 95% CI 1.06–2.70) in the EMR post-hospitalization were all associated with higher risk of pulmonary edema-related vs. no readmission; lower post-dialysis weight (by ≥0.5 kg) after vs. before hospitalization was associated with 40% lower risk (OR = 0.60, 95% CI 0.37–0.96). Conclusions Our results suggest that some interventions performed at the dialysis facility in the post-hospitalization period may be associated with reduced readmission risk, while others may provide a potential existing means of identifying patients at higher risk for readmissions, to whom such interventions could be efficiently targeted

Association of social worker-assessed psychosocial factors with 30-day hospital readmissions among hemodialysis patients

Abstract Background Evidence regarding the effect of psychosocial factors on hospital readmission in the setting of hemodialysis is limited. We examined whether social worker-assessed factors were associated with 30-day readmission among prevalent hemodialysis patients. Methods Data on 14 factors were extracted from the first available psychosocial assessment performed by social workers at three metropolitan Atlanta dialysis centers. Index admissions (first admission preceded by ≥30 days without a previous hospital discharge) were identified in the period 2/1/10–12/31/14, using linked national administrative hospitalization data. Readmission was defined as any admission within 30 days after index discharge. Associations of each of the psychosocial factors with readmission were assessed using multivariable logistic regression with adjustment for patient and index admission characteristics. Results Among 719 patients with index admissions, 22.1% were readmitted within 30 days. No psychosocial factors were statistically significantly associated with readmission risk. However, history of substance abuse vs. none was associated with a 29% higher risk of 30-day readmission [OR: 1.29, 95% CI: 0.75–2.23], whereas depression/anxiety was associated with 20% lower risk [OR: 0.80, 95% CI: 0.47–1.36]. Patients who were never married and those who were divorced, or widowed had 38 and 17% higher risk of 30-day readmission, respectively, than those who were married [OR: 1.38, 95% CI: 0.84–2.72; OR: 1.17, 95% CI: 0.73–1.90]. Conclusions Results suggest that psychosocial issues may be associated with risk of 30-day readmission among dialysis patients. Despite the limitations of lack of generalizability and potential misclassification due to patient self-report of psychosocial factors to social workers, further study is warranted to determine whether addressing these factors through targeted interventions could potentially reduce readmissions among hemodialysis patients

Evidence Café 2: Report

This report describes an evidence café held with key stakeholders in Bangladesh as part of the 3MPower project, a collaboration between the Open University and the University of Dhaka. 3MPower is generating evidence on technology use for Teacher Professional Development (TPD) in low- and middle-income countries, with a particular focus on children’s foundation numeracy skills in schools serving marginalised, low-income, rural communities

Additional file 1 of Post-hospitalization dialysis facility processes of care and hospital readmissions among hemodialysis patients: a retrospective cohort study

: Table S1 Index admission and patient characteristics of a cohort of prevalent hemodialysis patients admitted at least once while on hemodialysis treatment at Emory or Wake Forest between February 2010 and July 2015, by 30-day readmission of any type and by 30-day pulmonary edema-related readmission. (DOCX 17 kb