Disease severity adversely affects delivery of dialysis in acute renal failure

Background/Aims: Methods of intermittent hemodialysis (IHD) dose quantification in acute renal failure (ARF) are not well defined. This observational study was designed to evaluate the impact of disease activity on delivered single pool Kt/V-urea in ARF patients. Methods: 100 patients with severe ARF (acute intrinsic renal disease in 18 patients, nephrotoxic acute tubular necrosis in 38 patients, and septic ARF in 44 patients) were analyzed during four consecutive sessions of IHD, performed for 3.5-5 h every other day or daily. Target IHD dose was a single pool Kt/V-urea of 1.2 or more per dialysis session for all patients. Prescribed Kt/V-urea was calculated from desired dialyzer clearance (K), desired treatment time (t) and anthropometric estimates for urea distribution volume (V). The desired clearance (K) was estimated from prescribed blood flow rate and manufacturer's charts of in vivo data obtained in maintenance dialysis patients. Delivered single pool Kt/V-urea was calculated using the Daugirdas equation. Results: None of the patients had prescription failure of the target dose. The delivered IHD doses were substantially lower than the prescribed Kt/V values, particularly in ARF patients with sepsis/septic shock. Stratification according to disease severity revealed that all patients with isolated ARF, but none with 3 or more organ failures and none who needed vasopressive support received the target dose. Conclusion: Prescription of target IHD dose by single pool Kt/V-urea resulted in suboptimal dialysis dose delivery in critically ill patients. Numerous patient-related and treatment-immanent factors acting in concert reduced the delivered dose. Copyright (C) 2007 S. Karger AG, Basel

Meridional Overturning Circulation in a multi-basin model. Part II: Sensitivity to diffusivity and wind in warm and cool climates

This is the final version. Available from the American Meteorological Society via the DOI in this record. The response of the meridional overturning circulation (MOC) to changes in Southern Ocean (SO) zonal wind forcing and Pacific basin vertical diffusivity is investigated under varying buoyancy forcings, corresponding to ‘warm’, ‘present-day’ and ‘cold’ states, in a two-basin general circulation model connected by a southern circumpolar channel. We find that the Atlantic MOC (AMOC) strengthens with increased SO wind stress or diffusivity in the model Pacific, under all buoyancy forcings. The sensitivity of the AMOC to wind stress increases as the buoyancy forcing is varied from a warm to a present-day or cold state, whereas it is most sensitive to the Pacific diffusivity in a present-day or warm state. Similarly, the AMOC is more sensitive to buoyancy forcing over the Southern Ocean under reduced wind stress or enhanced Pacific diffusivity. These results arise because of the increased importance of the Pacific pathway in the warmer climates, giving an increased linkage between the basins and so the opportunity for the diffusivity in the Pacific to affect the overturning in the Atlantic. In cooler states, such as in glacial climates, the two basins are largely decoupled and the wind strength over the SO is the primary determinant of the AMOC strength. Both wind- and diffusively-driven upwelling sustain the AMOC in the warmer (present-day) state. Changes in SO wind stress alone do not shoal the AMOC to resemble that observed at the last glacial maximum; changes in the buoyancy forcing are also needed to decouple the two basins.Natural Environment Research Council (NERC)Royal Societ

Fit for the future? The place of global health in the UK's postgraduate medical training: a review.

OBJECTIVES: That health is now global is increasingly accepted. However, a 'mismatch between present professional competencies and the requirements of an increasingly interdependent world' has been identified. Postgraduate training should take account of the increasingly global nature of health; this paper examines the extent to which they currently do. DESIGN: Trainees across 11 medical specialties reviewed the content of their postgraduate curriculum. SETTING: Not relevant. PARTCIPANTS: None. MAIN OUTCOME MEASURES: Competencies were coded as 'UK' (statement only relevant to UK work), 'global' (statement with an explicit reference to aspects of health outside the UK) or generic (relevant both to the UK and international settings). RESULTS: Six of the 11 curricula reviewed contained global health competencies. These covered the global burden or determinants of disease and appropriate policy responses. Only one College required trainees to 'be aware of the World Health Organization', or 'know the local, national and international structures for health care'. These cross-cutting competencies have applicability to all specialties. All 11 curricula contained generic competencies where a global health perspective and/or experience could be advantageous, e.g. caring for migrant or culturally different patients. CONCLUSION: Trainees in all specialties should achieve a minimum requirement of global health awareness. This can be achieved through a small number of common competencies that are consistent across core curricula. These should lead on from equivalent undergraduate competencies. Addressing the current gap in the global health content of postgraduate medical curricula will ensure that the UK has health professionals that are trained to meet the health challenges of the future