Differences between physicians in the likelihood of referral and acceptance of elderly patients for dialysis-influence of age and comorbidity

BACKGROUND: Incidence of dialysis in elderly patients in the Netherlands is low compared to other countries. This study aims to assess the impact of patients' age and comorbidity on the likelihood of referral and acceptance of patients for dialysis and whether this is affected by physician characteristics. METHODS: A vignette study was performed among 209 primary care physicians, 162 non-nephrology specialists and 20 nephrologists working in the north of the Netherlands. Physicians were offered six vignettes concerning case-reports of patients with end-stage renal disease (ESRD) and varying comorbidities or circumstances and asked about the likelihood of referral/acceptance of the patient in the given circumstances. RESULTS: The likelihood of referral within groups of physicians varied widely, especially within the group of primary care physicians and non-nephrology specialists, but was not affected by characteristics of physicians. The likelihood of referral or acceptance of patients for dialysis depended on the patient's age, and type and severity of comorbidity. In general, primary care physicians and non-nephrology specialists were less likely to refer than nephrologists were to accept. Differences within and between groups of physicians were larger for 80- than for 65-year-old patients, and for patients with less severe shortness of breath and cognitive impairments and more severe diabetes and social impairments. Hardly any differences were found for patients with cancer. CONCLUSION: Patients' age and comorbidities affect the likelihood of referral. Differences between groups of physicians suggest that there is insufficient agreement on the extent to which these factors should affect the referral/acceptance of patients for dialysis. These findings underline the need for more research into circumstances under which patients might benefit from dialysis. Guidelines should be developed to improve the referral of elderly and less healthy patients

Resource partitioning among African savanna herbivores in North Cameroon: the importance of diet composition, food quality and body mass

The relationship between herbivore diet quality, and diet composition (the range of food plants consumed) and body mass on resource partitioning of herbivores remains the subject of an ongoing scientific debate. In this study we investigated the importance of diet composition and diet quality on resource partitioning among eight species of savanna herbivore in north Cameroon, with different body mass. Dung samples of four to seven wild herbivore and one domesticated species were collected in the field during the dry and wet period. Diet composition was based on microhistological examination of herbivore droppings, epidermis fragments were identified to genus or family level. In addition, the quality of the faecal droppings was determined in terms of phosphorus, nitrogen and fibre concentrations. The results showed that there was no significant correlation between body mass and (differences in) diet composition for wet and dry season. When all species are considered, only significant relationships are found by the Spearman rank correlation analyses during the wet season between body mass and phosphorus and nitrogen, but this relationship did not exist during the dry season. When the analyses focuses on ruminants only (thus leaving out hippo), none of the relationships between body mass and diet quality was significant in either season. During the dry season the proportion of graminoids ranged between 10% (small unidentified herbivore species) to 90% (hippopotamus), during the wet season this proportion ranged from 60% (zebu) to 90% (hippopotamus). All species but zebu had more graminoids in their dung during wet season compared with dry season. However all species but hartebeest had more graminoids old stems in their dung during the dry season, compared with the wet season. The niche breadth for food categories consumed by kob (0.300), hippo (0.090), hartebeest (0.350), roan (0.510) and zebu (0.300) was much greater in the dry season than in the wet season for kob (0.120), hippo (0.020), hartebeest (0.190), roan (0.090) and zebu (0.200). When looking at grass taxa consumed, the niche breadth of kob (0.220), hartebeest (0.140), and roan (0.250) was also greater in the dry season when compared with the wet season for kob (0.050), hartebeest (0.120) and roan (0.120). The opposite was found for zebu and hippo. Comparison of the species’ diet compositions with randomized data showed that dietary overlap between different herbivore species was much higher than what would be expected on the basis of chance, demonstrating surprisingly limited niche separation between species. This offers potential for competition, but it is more likely that the high niche overlap indicates absence of competition, due to low herbivore densities and abundant food resources, permitting species to share non-limiting resources. With increasing herbivore densities and subsequent increasing scarcity of resources, the relationship between diet quality and body mass in combination with increased niche separation is expected to become more visibl

Accepting or declining dialysis: considerations taken into account by elderly patients with end-stage renal disease

BACKGROUND: Elderly patients with end-stage renal disease have to make a difficult decision whether or not to start dialysis. This study explores the considerations taken into account by these patients in decision-making regarding renal replacement therapy. METHOD: In-depth interviews were conducted to gain an enhanced understanding of the considerations in treatment decision-making. Fourteen patients aged 65 years or older participated in the interviews, of whom 8 patients had made the decision to start, and 6 patients the decision to decline, dialysis. RESULTS: All participating patients had a variety of health problems, but appeared to have normal cognitive functions. Patients who declined dialysis were older and more often men and widow(er)s compared with patients who accepted dialysis. Patients chose to start dialysis because they enjoyed life, were not prepared to face the end of life, felt they had no other choice or had care-giving responsibilities for family members. Patients declined dialysis because of the speculated loss of autonomy, their age-associated decrease in vitality, distance from dialysis center and reluctance to think about the future. CONCLUSION: Results suggest that patients' decisions to decline or accept dialysis are not based on the effectiveness of the treatment, but rather on personal values, beliefs and feelings toward life, suffering and death, and the expected difficulties in fitting the treatment into their life

Балканська криза (1990–2005 рр.) в контексті геополітичних трансформацій

Досліджено трансформаційні процеси, на тлі яких розгорталася Балканська криза. Розглянуто зовнішньополітичний контекст Балканської кризи та показано як глобалізація, розпад Радянського Союзу, а отже, трансформація, а також інтеграція Західної Європи вплинули на розгортання подій в регіоні.In this article, there is analyzed the frameworks of the transformation processes of the Balkan Crisis. It revives international background of the Balkan Crisis and demonstrates the influence of globalization, Soviet Union disintegration, and therefore the NATO transformation, as well as Western European integration on the events in the Region

Seasonality and the persistence and invasion of measles

The critical community size (CCS) for measles, which separates persistent from extinction-prone populations, is arguably the best understood stochastic threshold in ecology. Using simple models, we explore a relatively neglected relationship of how the CCS scales with birth rate. A predominantly positive relationship of persistence with birth rate is complicated by the accompanying dynamical transitions of the underlying deterministic process. We show that these transitions imply a lower CCS for high birth rate less developed countries and contrary to the experience in lower birth rate, industrial countries, the CCS may increase after vaccination. We also consider the evolutionary implications of the CCS for the origin of measles; this analysis explores how the deterministic and stochastic thresholds for invasion and persistence set limits on the mechanism by which this highly infectious pathogen could have successfully colonized its human host

Vasopressin release is enhanced by the Hemocontrol biofeedback system and could contribute to better haemodynamic stability during haemodialysis

Haemodialysis with the Hemocontrol biofeedback system (HHD) is associated with improved haemodynamic stability compared with standard haemodialysis (HD) (SHD). Although the beneficial effect of HHD on haemodynamic stability is generally explained by its effect on blood volume, we questioned whether additional factors could play a role. Since HHD is associated with higher initial dialysate sodium concentrations and ultrafiltration (UF) rate, we studied whether the beneficial effect of HHD on haemodynamic stability may be explained by an increased release of the vasoconstrictor arginine vasopressin (AVP). Fifteen chronic dialysis patients underwent SHD and HHD in random order. All other treatment factors were identical and patients served as their own control. Plasma levels of AVP were measured pre-dialysis, at 30 and 60 min intra-dialysis and, next, hourly until completion of the dialysis session. Plasma AVP levels did not change significantly during SHD, whereas AVP levels rose significantly within 30 min after the start of HHD (P 0.01). AVP levels were significantly higher at 30 and 60 min of HHD in comparison with SHD (P 0.05). Dialysis hypotension occurred significantly less frequent during HHD than during SHD (P 0.05). HHD is associated with higher initial AVP levels compared with SHD. The enhanced release of the vasoconstrictor AVP with HHD could contribute to the lower frequency of dialysis hypotension by facilitating fluid removal during the first part of the dialysis session, permitting lower UF rates during the second half of the dialysis session