Anti-coagulation, anti-platelets or no therapy in haemodialysis patients with atrial fibrillation: a decision analysis

BACKGROUND: Optimal treatment of atrial fibrillation (AF) in the haemodialysis population is uncertain due to the exclusion of this group from randomized trials. The risk-benefit profile for anticoagulation and anti-platelet therapy in haemodialysis differs from the general population due to platelet dysfunction from uraemia, altered pharmacokinetics and increased falls risk. METHODS: This decision analysis used a Markov-state transition model that took a patient perspective over a 5 year timeframe. The Markov model compared life-years gained and quality-adjusted life-years gained (QALY) for three AF treatment strategies: warfarin, aspirin and no treatment. The base case was a 70-year-old man on haemodialysis with non-valvular AF. RESULTS: In the base case, the total health outcomes in life-years and QALY were 2.37 and 1.47 respectively for warfarin, 2.38 and 1.61 respectively for aspirin, and 2.39 and 1.61 respectively for no treatment. Thus, warfarin led to 0.14 fewer QALY or 1.7 fewer months of life lived in full health, compared with either aspirin or no therapy. The finding that warfarin generated the lowest expected QALY was robust to one-way, two-way and probabilistic sensitivity analyses. CONCLUSIONS: Our results suggest that warfarin should not be the default choice for older haemodialysis patients with non-valvular AF as it provides the fewest QALY compared with aspirin or no therapy

Sociomateriality Implications of Software As a Service Adoption on IT-workers’ Roles and Changes in Organizational Routines of IT Systems Support

This paper aims to deepen our understanding on how sociomateriality practices influence IT workers’ roles and skill set requirements and changes to the organizational routines of IT systems support, when an organization migrates an on-premise IT system to a software as a service (SaaS) model. This conceptual paper is part of an ongoing study investigating organizations that migrated on-premise IT email systems to SaaS business models, such as Google Apps for Education (GAE) and Microsoft Office 365 systems, in New Zealand tertiary institutions. We present initial findings from interpretive case studies. The findings are, firstly, technological artifacts are entangled in sociomaterial practices, which change the way humans respond to the performative aspects of the organizational routines. Human and material agencies are interwoven in ways that reinforce or change existing routines. Secondly, materiality, virtual realm and spirit of the technology provide elementary levels at which human and material agencies entangle. Lastly, the elementary levels at which human and material entangle depends on the capabilities or skills set of an individual

Pregnancy outcomes for kidney transplant recipients with transplantation as a child

IMPORTANCE: Pregnancy outcomes for women who received a kidney transplant in childhood are uncertain. OBJECTIVES: To report pregnancy outcomes for women with kidney transplantation in childhood (aged <18 years; child-tx mothers) and to compare them with those for women who received a kidney transplant in adulthood (aged≥18 years; adult-tx mothers). DESIGN, SETTING, AND PARTICIPANTS: Observational cohort study in Australia and New Zealand of all women with a functioning kidney transplant included in the Australia and New Zealand Dialysis and Transplant Registry for whom at least 1 pregnancy was reported between January 1, 1963, and December 31, 2012. MAIN OUTCOMES AND MEASURES: Pregnancy outcomes including live birth rates, gestational age, and proportion of babies who are small for gestational age. RESULTS: A total of 101 pregnancies in 66 child-tx mothers and 626 pregnancies in 401 adult-tx mothers were reported. At the time of pregnancy, child-tx mothers had a mean age of 25 (95%CI, 24-26) years with a functioning transplant for 10 (95%CI, 9-11) years, while adult-tx mothers had a mean age of 31 (95%CI, 31-31) years with a functioning transplant for 6 (95%CI, 5-6) years (both P <.001). Live births occurred in 76%of pregnancies in child-tx mothers and 77%of pregnancies in adult-tx mothers. The mean gestational ages were similar between child-tx and adult-tx mothers (35 [95%CI, 33-37] vs 36 [95%CI, 35-36] weeks, respectively; P =.68). The incidence of prematurity (<37 weeks' gestation) was also similar (child-tx mothers, 45%; adult-tx mothers, 53%). A similar proportion of preterm babies born to child-tx and adult-tx mothers were small for gestational age (22%vs 10%, respectively; odds ratio [OR] = 2.53 [95%CI, 1.13-5.69]). Term babies born to child-tx and adult-tx mothers were frequently small for gestational age (57%vs 38%, respectively; OR = 2.16 [95%CI, 1.23-3.81]), both significantly more frequently than babies born at term in the general population (child-tx mothers, OR = 11.93 [95%CI, 5.56-25.61]; adult-tx mothers, OR = 5.52 [95%CI, 2.56-11.89]). CONCLUSIONS AND RELEVANCE: Pregnancy outcomes for child-tx mothers are similar to those for adult-tx mothers, with no difference in the rate of live births, gestational age, or small for gestational age. Regardless of when women received their kidney transplant, their pregnancies are likely to result in a live, albeit preterm, birth. This work should provide comfort to child-tx mothers and their physicians that their early onset of kidney failure and longer period of transplantation and immunosuppression do not adversely affect their pregnancy outcomes compared with adult-tx mothers