Interdisciplinary care clinics in chronic kidney disease

The burden of chronic kidney disease (CKD) is substantial, and is associated with high hospitalization rates, premature deaths, and considerable health care costs. These factors provide strong rationale for quality improvement initiatives in CKD care. The interdisciplinary care clinic (IDC) has emerged as one solution to improving CKD care. The IDC team may include other physicians, advanced practice providers, nurses, dietitians, pharmacists, and social workers--all working together to provide effective care to patients with chronic kidney disease. Studies suggest that IDCs may improve patient education and preparedness prior to kidney failure, both of which have been associated with improved health outcomes. Interdisciplinary care may also delay the progression to end-stage renal disease and reduce mortality. While most studies suggest that IDC services are likely cost-effective, financing IDCs is challenging and many insurance providers do not pay for all of the services. There are also no robust long-term studies demonstrating the cost-effectiveness of IDCs. This review discusses IDC models and its potential impact on CKD care as well as some of the challenges that may be associated with implementing these clinics

Simplified citrate anticoagulation for continuous renal replacement therapy

Simplified citrate anticoagulation for continuous renal replacement therapy.BackgroundRegional anticoagulation with trisodium citrate is an effective form of anticoagulation for continuous renal replacement therapy (CRRT) for patients with contraindications to heparin. However, because of the metabolic complications of trisodium citrate, it is a complicated technique requiring specialized dialysis solutions. We have designed a simplified protocol for citrate regional anticoagulation for CRRT.MethodsTwo percent trisodium citrate was delivered at 250 mL/h via the prefilter port of a COBE PRISMA device, with the rate adjusted to maintain a postfilter ionized calcium (iCa++) <0.5mmol/L. A central calcium gluconate infusion was used to maintain a systemic iCa++ at 1.1mmol/L. A standard dialysate solution consisting of 0.9% saline, KCl 3mmol/L, and MgSO4 1mmol/L was delivered at 1000 mL/h. We retrospectively reviewed the outcomes and complications associated with this protoco1 in 29 patients treated from July 1999 to October 1999, evaluating the frequency of clotting of the dialyzer, bleeding complications, citrate toxicity, and patient mortality.ResultsThe Kaplan–Meier curve for dialyzer survival demonstrated a 61% survival rate at 48 hours. There were no episodes of significant bleeding or citrate toxicity. Seventy-two percent of patients died for reasons unrelated to CRRT.ConclusionsA CRRT protocol using regional 2% trisodium citrate anticoagulation is not associated with significant bleeding complications or citrate toxicity, and represents a simplified approach compared with previous applications using 4% trisodium citrate

Effect of environmental complexity and stocking density on fear and anxiety in broiler chickens

Barren housing and high stocking densities may contribute to negative affective states in broiler chickens, reducing their welfare. We investigated the effects of environmental complexity and stocking density on broilers’ attention bias (measure of anxiety) and tonic immobility (measure of fear). In Experiment 1, individual birds were tested for attention bias (n = 60) and in Experiment 2, groups of three birds were tested (n = 144). Tonic immobility testing was performed on days 12 and 26 (n = 36) in Experiment 1, and on day 19 (n = 72) in Experiment 2. In Experiment 1, no differences were observed in the attention bias test. In Experiment 2, birds from high-complexity pens began feeding faster and more birds resumed feeding than from low-complexity pens following playback of an alarm call, suggesting that birds housed in the complex environment were less anx-ious. Furthermore, birds housed in high-density or high-complexity pens had shorter tonic immobility durations on day 12 compared to day 26 in Experiment 1. In Experiment 2, birds from high-density pens had shorter tonic immobility durations than birds housed in low-density pens, which is contrary to expectations. Our results suggest that birds at 3 weeks of age were less fearful under high stocking density conditions than low density conditions. In addition, results indicated that the complex environment improved welfare of broilers through reduced anxiety

Experiential aspects of tourism gift consumption

This article addresses how consumers make use of fantasy, feelings, and fun when deciding, giving, and consuming gifts of tourism and leisure. Despite little industry awareness, consumers are engaging with such behaviour because tourism gifts offer considerable scope for the creative expression of donor–recipient relationships. This UK-based interpretive qualitative study captured data from donors, recipients, and tourism and leisure providers. The feelings (emotions), fantasies (imagination and dreaming), and fun (playfulness) were interrogated through the behavioural phases of gift decision making, gift exchange, post-exchange, and gift consumption. A range of emotions were displayed by donors and recipients at different stages in the gift-giving process; donor decision making in groups for created gifts was particularly charged. Fantasies were evident both for donors planning gifts and for recipients. As an intangible gift, means of exchange allowed for creative mechanisms beyond the classic wrapping strategies associated with physical gifts. The ‘decoy’ strategy stimulated the recipient’s imagination to conjure fantastical scenarios. Fun or playfulness was built into many of the gifts and often related to an element of ‘surprise’, an attribute of the perfect gift (e.g. Belk, 1996) in Western societies

Childbearing practices in Kanadier Mennonite Women

© Canadian Nurses Association. Reproduced with permission. Further reproduction is prohibited.Cross-cultural nursing practices call for attention to be paid to the unique beliefs and practices of the groups with which nurses come in contact. The Kanadier Mennonites are a conservative religious group who live in Alberta, Manitoba and Ontario. An exploratory, descriptive study was conducted with this group in southern Alberta to generate information about their health and illness beliefs. This article focuses on their knowledge, beliefs and practices in relation to childbearing interviews were conducted with 45 women, the majority of whom were married and had been born in Mexico. Among the sample there had been a range of one to 16 pregnancies. The participants noted that childbearing Is not a topic openly discussed with others. Women learn about childbearing from their mothers and other women but also from physicians and books. During pregnancy there are particular activities to be avoided including the use of strong cleaning fluids and hand milking of cows. Foods such as milk need to be ingested to ensure a healthy pregnancy. Prenatal care was not emphasized in Mexico nor has it become a customary practice in Canada but deliveries in hospital are the norm in both these countries. During the postpartum the women receive support from their immediate and extended family in order to recuperate. Nurses need to explore individual Kanadier Mennonite beliefs regarding childbearing and work with this group in developing acceptable health promotion programs to help ensure healthy pregnancy outcomes. The blending of nursing practice knowledge in a non-intrusive manner with a group of people with differing belief systems is a necessary and achievable goal.Ye

Loop amplitudes in gauge theories: modern analytic approaches

This article reviews on-shell methods for analytic computation of loop amplitudes, emphasizing techniques based on unitarity cuts. Unitarity techniques are formulated generally but have been especially useful for calculating one-loop amplitudes in massless theories such as Yang-Mills theory, QCD, and QED.Comment: 34 pages. Invited review for a special issue of Journal of Physics A devoted to "Scattering Amplitudes in Gauge Theories." v2: typesetting macro error fixe

Altered Peripheral Sensitivity to Glucocorticoids in Primary Open-Angle Glaucoma

PURPOSE. Increased levels of glucocorticoids are associated with raised intraocular pressure (IOP). The activity of glucocorticoids is regulated at a prereceptor level by 11␤-hydroxysteroid dehydrogenases (11␤-HSD). This study was an investigation of the central and peripheral sensitivity to glucocorticoids in patients with POAG or ocular hypertension (OHT) and the differential metabolism of glucocorticoids by 11␤-HSDs. METHODS. Patients with POAG or OHT and normal control subjects were studied. Peripheral sensitivity to glucocorticoids was assessed as dermal blanching and central sensitivity by dexamethasone suppression testing. Daily production rates of glucocorticoids were determined by quantifying metabolites in 24-hour urine. Plasma cortisol levels were determined at baseline (9 AM) and after an overnight low-dose dexamethasone suppression test. In a separate study, plasma and aqueous humor cortisol levels were determined in patients with POAG and normal subjects. RESULTS. Patients with POAG exhibited a greater cutaneous vasoconstrictor response to glucocorticoids than patients with OHT and normal subjects (20.7 Ϯ 3.1 vs. 8.5 Ϯ 4.4 and 8.6 Ϯ 4.5 arbitrary units, respectively; P Ͻ 0.05 in each case). Total glucocorticoid production rates were not different between groups, nor were total circulating cortisol levels before or after suppression of the hypothalamic-pituitary-adrenal axis by dexamethasone or concentrations in aqueous humor. The ratio of urinary cortisol to cortisone metabolites was elevated in POAG versus normal control and OHT (1.74 Ϯ 0.13 vs. 1.34 Ϯ 0.11 and 1.32 Ϯ 0.14; P Ͻ 0.05 in each case), indicating a change in the balance of 11␤-HSDs, without a change in other metabolic pathways. CONCLUSIONS. Patients with POAG exhibit increased peripheral vascular sensitivity to glucocorticoids. Increased sensitivity of glucocorticoid receptors, may enhance local glucocorticoid action in the eye and exacerbate the adverse effects of glucocorticoids in this condition (Invest Ophthalmol Vis Sci

Citrullinated Inhibitor of DNA Binding 1 Is a Novel Autoantigen in Rheumatoid Arthritis

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/150530/1/art40886_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/150530/2/art40886.pd

Inflammatory properties of inhibitor of DNA binding 1 secreted by synovial fibroblasts in rheumatoid arthritis

Abstract Background Inhibitor of DNA binding 1 (Id1) is a nuclear protein containing a basic helix-loop-helix (bHLH) domain that regulates cell growth by selective binding and prevention of gene transcription. Sources of Id1 production in rheumatoid arthritis synovial tissue (RA ST) and its range of functional effects in RA remain to be clarified. Methods We analyzed Id1 produced from synovial fibroblasts and endothelial cells (ECs) with histology and real-time polymerase chain reaction (RT-PCR). Fibroblast supernatants subjected to differential centrifugation to isolate and purify exosomes were measured for Id1 by enzyme-linked immunosorbent assay (ELISA). Western blotting of Id1-stimulated ECs was performed to determine the kinetics of intracellular protein phosphorylation. EC intracellular signaling pathways induced by Id1 were subsequently targeted with silencing RNA (siRNA) for angiogenesis inhibition. Results By PCR and histologic analysis, we found that the primary source of Id1 in STs is from activated fibroblasts that correlate with inflammatory scores in human RA ST and in joints from K/BxN serum-induced mice. Normal (NL) and RA synovial fibroblasts increase Id1 production with stimulation by transforming growth factor beta (TGF-β). Most of the Id1 released by RA synovial fibroblasts is contained within exosomes. Endothelial progenitor cells (EPCs) and human dermal microvascular ECs (HMVECs) activate the Jnk signaling pathway in response to Id1, and Jnk siRNA reverses Id1-induced HMVEC vessel formation in Matrigel plugs in vivo. Conclusions Id1 is a pleotropic molecule affecting angiogenesis, vasculogenesis, and fibrosis. Our data shows that Id1 is not only an important nuclear protein, but also can be released from fibroblasts via exosomes. The ability of extracellular Id1 to activate signaling pathways expands the role of Id1 in the orchestration of tissue inflammation.http://deepblue.lib.umich.edu/bitstream/2027.42/134552/1/13075_2016_Article_984.pd

Mutation of the Diamond-Blackfan Anemia Gene Rps7 in Mouse Results in Morphological and Neuroanatomical Phenotypes

The ribosome is an evolutionarily conserved organelle essential for cellular function. Ribosome construction requires assembly of approximately 80 different ribosomal proteins (RPs) and four different species of rRNA. As RPs co-assemble into one multi-subunit complex, mutation of the genes that encode RPs might be expected to give rise to phenocopies, in which the same phenotype is associated with loss-of-function of each individual gene. However, a more complex picture is emerging in which, in addition to a group of shared phenotypes, diverse RP gene-specific phenotypes are observed. Here we report the first two mouse mutations (Rps7(Mtu) and Rps7(Zma)) of ribosomal protein S7 (Rps7), a gene that has been implicated in Diamond-Blackfan anemia. Rps7 disruption results in decreased body size, abnormal skeletal morphology, mid-ventral white spotting, and eye malformations. These phenotypes are reported in other murine RP mutants and, as demonstrated for some other RP mutations, are ameliorated by Trp53 deficiency. Interestingly, Rps7 mutants have additional overt malformations of the developing central nervous system and deficits in working memory, phenotypes that are not reported in murine or human RP gene mutants. Conversely, Rps7 mouse mutants show no anemia or hyperpigmentation, phenotypes associated with mutation of human RPS7 and other murine RPs, respectively. We provide two novel RP mouse models and expand the repertoire of potential phenotypes that should be examined in RP mutants to further explore the concept of RP gene-specific phenotypes.This research was supported in part by the Intramural Research Program of NHGRI, NIH, and the Wellcome Trust and by NHMRC Australia grant 366746. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript