Community acquired acute kidney injury: findings from a large population cohort

Background: The extent of patient contact with medical services prior to development of community acquired-acute kidney injury (CA-AKI)is unknown. Aim: We examined the relationship between incident CA-AKI alerts, previous contact with hospital or primary care and clinical outcomes. Design: A prospective national cohort study of all electronic AKIalerts representing adult CA-AKI. Methods: Data were collected for all cases of adult (≥18 years of age) CA-AKI in Wales between 1 November 2013 and 31 January 2017. Results: There were a total of 50 560 incident CA-AKI alerts. In 46.8% there was a measurement of renal function in the 30 days prior to the AKI alert. In this group, in 63.8% this was in a hospital setting, of which 37.6% were as an inpatient and 37.5% in Accident and Emergency. Progression of AKI to a higher AKI stage (13.1 vs. 9.8%, P  50% from the creatinine value generating the alert), the proportion of patients admitted to Intensive Care (5.5 vs. 4.9%, P = 0.001) and 90-day mortality (27.2 vs. 18.5%, P < 0.001) was significantly higher for patients with a recent test. 90-day mortality was highest for patients with a recent test taken in an inpatient setting prior to CA-AKI (30.9%). Conclusion: Almost half of all patients presenting with CA-AKI are already known to medical services, the majority of which have had recent measurement of renal function in a hospital setting, suggesting that AKI for at least some of these may potentially be predictable and/or avoidable

Understanding Global Systems Today—A Calibration of the World3-03 Model between 1995 and 2012

In 1972 the Limits to Growth report was published. It used the World3 model to better understand the dynamics of global systems and their relationship to finite resource availability, land use, and persistent pollution accumulation. The trends of resource depletion and degradation of physical systems which were identified by Limits to Growth have continued. Although World3 forecast scenarios are based on key measures and assumptions that cannot be easily assessed using available data (i.e., non-renewable resources, persistent pollution), the dynamics of growth components of the model can be compared with publicly available global data trends. Based on Scenario 2 of the Limits to Growth study, we present a calibration of the updated World3-03 model using historical data from 1995 to 2012 to better understand the dynamics of today’s economic and resource system. Given that accurate data on physical limits does not currently exist, the dynamics of overshoot to global limits are not assessed. In this paper we offer a new interpretation of the parametrisation of World3-03 using these data to explore how its assumptions on global dynamics, environmental footprints and responses have changed over the past 40 years. The results show that human society has invested more to abate persistent pollution, to increase food productivity and have a more productive service sector

How good are we at managing acute kidney injury in hospital?

Introduction. Acute kidney injury (AKI) is a common clinical problem associated with adverse outcomes. This study identifies the incidence of AKI in two UK district general hospitals’ without on-site renal services and assesses AKI management and level of nephrologist input. Methods. The AKIN classification was used to identify 1020 AKI patients over 6 months. Data were collated on patient demographics, AKI management and referral to nephrology and intensive care services. Short/long-term renal outcomes were investigated. Patients were followed up for 14 months post-discharge. Results. Incidence of hospital-based AKI was 6.4%. Mean patient age was 73 years. There was 28.1% acute in-hospital mortality with a further 21.6% 14-month mortality. Only 8.3% of patients were referred to nephrology services for in-hospital review, and only 8.1% had outpatient nephrology follow-up. Compliance with the AKI National Confidential Enquiry into Patient Outcomes and Deaths (NCEPOD) recommendations was poor with 32.8% of patients having renal imaging and 15% of patients having acid–base status assessed. NCEPOD compliance improved with nephrology input. Patients referred to nephrology were likely to be younger with pre-existing CKD and severe AKI. 10.5% of AKI episodes were unrecognized. Forty percent of those with unrecognized AKI, (compared with 15% of recognized AKI) developed de novo or progression of pre-existing CKD. Conclusion. AKI in DGHs is mostly managed without nephrology input. There are significant shortcomings in AKI recognition and management in this setting. This is associated with poor mortality and long-term CKD. This study supports a need to improve the teaching and training of front-line medical staff in identifying AKI. Additionally, implementation of AKI e-alert systems may encourage early recognition and provide a prompt for renal referral

The effect of work-based mentoring on patient outcome in musculoskeletal physiotherapy:study protocol for a randomised controlled trial

BACKGROUND: Despite persistent calls to measure the effectiveness of educational interventions on patient outcomes, few studies have been conducted. Within musculoskeletal physiotherapy, the effects of postgraduate clinical mentoring on physiotherapist performance have been assessed, but the impact of this mentoring on patient outcomes remains unknown. The objective of this trial is to assess the effectiveness of a work-based mentoring programme to facilitate physiotherapist clinical reasoning on patient outcomes in musculoskeletal physiotherapy. METHODS/DESIGN: A stepped wedge cluster randomised controlled trial (CRCT) has been designed to recruit a minimum of 12 senior physiotherapists who work in musculoskeletal outpatient departments of a large National Health Service (NHS) organization. Participating physiotherapists will be randomised by cluster to receive the intervention at three time periods. Patients will be blinded to whether their physiotherapist has received the intervention. The primary outcome measure will be the Patient-Specific Functional Scale; secondary outcome measures will include the EQ-5D, patient activation, patient satisfaction and physiotherapist performance. Sample size considerations used published methods describing stepped wedge designs, conventional values of 0.80 for statistical power and 0.05 for statistical significance, and pragmatic groupings of 12 participating physiotherapists in three clusters. Based on an intergroup difference of 1.0 on the PSFS with a standard deviation of 2.0, 10 patients are required to complete outcome measures per physiotherapist, at time period 1 (prior to intervention roll-out) and at each of time periods 2, 3 and 4, giving a sample size of 480 patients. To account for the potential loss to follow-up of 33%, 720 sets of patient outcomes will be collected. All physiotherapist participants will receive 150 hours of mentored clinical practice as the intervention and usual in-service training as control. Consecutive, consenting patients attending treatment by the participating physiotherapists during data collection periods will complete outcome measures at baseline, discharge and 12 months post-baseline. The lead researcher will be blinded to the allocation of the physiotherapist when analyzing outcome data; statistical analysis will involve classical linear models incorporating both an intervention effect and a random intercept term to reflect systematic differences among clusters. TRIAL REGISTRATION: Assigned 31 July 2012: ISRCTN79599220. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (doi:10.1186/1745-6215-15-409) contains supplementary material, which is available to authorized users

17β‐estradiol ameliorates age‐associated loss of fibroblast function by attenuating IFN‐γ/STAT1‐dependent miR‐7 upregulation

Age-related defects in fibroblast differentiation and functionality were previously shown to be associated with impaired hyaluronan (HA) synthase 2 (HAS2) and epidermal growth factor receptor (EGFR) function, as a result of upregulated microRNA-7 (miR-7) expression. In aging fibroblasts, inhibiting miR-7 prevented the dysregulation of the HA-mediated CD44/EGFR signaling pathway. Here, we investigated transcriptional upregulation of miR-7 and implicated the age-associated over-activation of JAK/STAT1 as a primary candidate. STAT1 binding sites were identified on the putative miR-7 promoter and stimulation of fibroblasts with the inflammatory cytokine, interferon-{gamma} (IFN-{gamma}), significantly increased miR-7 transcriptional activity and resulted in upregulated miR-7 and loss of EGFR. Additionally, we demonstrated arole for the anti-inflammatory steroid, 17b-estradiol (E2), in the attenuation of miR-7 expression. E2 stimulation promoted estrogen receptor (ER) interactions with the miR-7 putative promoter and suppressed miR-7 expression. E2 also attenuated STAT1expression and activity. Furthermore, treatments with E2 restored fibroblast functionality, including proliferation, migration and differentiation, key events in effective wound healing. In light of our findings, we propose that the regulation of miR-7 by pro- and anti-inflammatory mediators plays a wider role than previously thought. The modulation of fibroblast functions and ultimately wound healing by miR-7 activators or inhibitors could provide realistic targets for the restoration of chronic wound healing capabilities in the elderly

Severe hyperkalaemia: demographics and outcome

Background. Few studies have evaluated the prevalence of severe hyperkalaemia in unselected patient populations.We identified all episodes of severe hyperkalaemia occurring in 1 year, and described patient demographics, clinical response and outcome. We also assessed junior doctor knowledge of its causes and significance. Materials and methods. A retrospective interrogation of the database of the regional biochemical laboratory identified all episodes of severe hyperkalaemia (K ≥ 6.5 mmol/L) occurring in 2011. The understanding of trainee doctors of the importance, causes and treatment of severe hyperkalaemia was assessed by structured questionnaire. Results. Severe hyperkalaemia was recorded in 433 samples (365 patients) giving a prevalence of 0.11%. Thirty-six per cent of episodes occurred in patients under the care of a nephrologist, who were significantly younger than those not under the care of a nephrologist. In the nephrology cohort, 86% occurred in patients with chronic kidney disease (CKD), the majority of which had CKD Stage 5. In the non-nephrology cohort, only 65% occurred in the context of CKD, which was equally distributed between Stages 3 and 5 CKD. In both patient groups, roughly 50% of episodes occurred in association with acute kidney injury (AKI). Acute mortality (death within 48 h of documented severe hyperkalaemia) was higher in the non-nephrology compared with the nephrology cohort. Time to repeat serum potassium was influenced by the clinical setting with shorter time to repeat for acute care compared with ward settings. Assessment of trainee doctor’s knowledge suggested significant deficiencies in relation to severe hyperkalaemia. Conclusions. The prevalence of severe hyperkalaemia was low and occurred predominantly in the context of CKD and/or AKI. The majority of episodes occurred in patients not under the care of a nephrologist. Variability in time to repeat serum potassium levels suggested deficiencies in care, and assessment of trainee doctor’s knowledge suggests the need for further educational initiatives to highlight its importance

Historic Food Production Shocks: Quantifying the Extremes

Understanding global food production trends is vital for ensuring food security and to allow the world to develop appropriate policies to manage the food system. Over the past few years, there has been an increasing attention on the global food system, particularly after the extreme shocks seen in food prices after 2007. Several papers and working groups have explored the links between food production and various societal impacts however they often categorise production shocks in different ways even to the extent of identifying different levels, countries and timings for shocks. In this paper we present a simple method to quantify and categorise cereal production shocks at a country level. This method can be used as a baseline for other studies that examine the impact of these production shocks on the global food system

Exploration of mentor and mentee perspectives of a mentored clinical practice programme to improve patient outcomes in musculoskeletal physiotherapy

Background: A recent randomised controlled trial has demonstrated the impact on practice of an educational programme for clinicians. Mentored clinical practice in musculoskeletal physiotherapy resulted in clinically significant improvements in both physiotherapist performance and patient outcomes. The objectives of this study were to explore mentor and mentee perceptions of a mentored clinical practice programme, in order to identify key factors in the process to improve patient outcomes. Methods: Employing a case study design of a mentoring programme that led to improved patient outcomes, mentored clinical practice was explored from multiple perspectives using a grounded theory strategy of enquiry to derive a theory of mentored clinical practice grounded in the views of the participants. Semi-structured interviews with a purposive sample of mentors and mentees were employed along with qualitative observations of mentored clinical practice. Data analysis and collection were concurrent, with analysis an iterative process deriving inductive analytical categories from the data through constant comparison. Findings: Highly informative themes of how the complex interaction between mentor, mentee, patient and environment worked successfully were identified from the data. The mentors’ knowledge, additional perspectives, critical analysis and facilitatory style were enabling factors, as were mentees’ motivation, openness to criticism and commitment to reflect on practice. Themes around potential threats to the mentees’ development were also identified. Overloading or contradictory feedback and lack of relationship with mentees were barriers that mentors could bring; fear, defensiveness, routine working, people-pleasing and lack of experience were potential mentee barriers. A model emerges from the data demonstrating how these themes interact, providing guidance to mentors and mentees to optimise the effectiveness of mentored clinical practice. Conclusion: This study provides a sound basis for future mentored clinical practice, producing a model from key themes from a case study where impact on clinician performance and patient outcomes are established

Structural characterization of an α-1, 6-linked galactomannan from natural Cordyceps 2 sinensis

An α-1, 6-linked galactomannan was isolated and purified from natural Cordyceps sinensis. The fine structure analysis of this polysaccharide was elucidated based on partial acid hydrolysis, monosaccharide composition, methylation and 1D/2D nuclear magnetic resonance (NMR) spectroscopy. Monosaccharide composition analysis revealed that this polysaccharide was mainly composed of galactose (68.65%), glucose (6.65%) and mannose (24.02%). However, after partial acid hydrolysis the percentages of galactose, glucose and mannose were changed to 3.96%, 13.82% and 82.22%, respectively. The molecular weight of this polysaccharide was 7207. Methylation and NMR analysis revealed that this galactomannan had a highly branched structure, mainly consisted of a mannan skeleton and galactofuranosyl chains. The structure of galactofuranosyl part was formed by alternating (1 → 5)-lined β-Galf and (1 → 6)-liked β-Galf or a single (1 → 6)-liked β-Galf, attaching to the O-2 and O-4 of the mannose chain, and terminated at β-T-Galf. The mannan core was revealed by analyzing the partial acid hydrolysate of the galactomannan and the structure was composed of (1 → 6)-linked α-Manp backbone, with substituted at C-2 by short chains of 2-substituted Manp or Galf branches