Audit and feedback using the brief Decision Support Analysis Tool (DSAT-10) to evaluate nurse–standardized patient encounters

ObjectiveTo evaluate the brief Decision Support Analysis Tool (DSAT-10) for auditing the quality of nurse–standardized patient encounters, structuring feedback for nurses, and testing instrument reliability.MethodsA systematic process was used to develop standardized patient scenarios, pilot-test scenarios, calibrate DSAT-10 coders, analyze taped telephone encounters using DSAT-10, and provide feedback. Inter-rater reliability was calculated using coder agreement, kappa, and intra-class correlation coefficients.ResultsSix scenarios portrayed patients’ decisional uncertainty from either: pressure from others (n = 2), unclear values (n = 2), or inadequate information (n = 2). Scenarios were easy to use over the telephone, produced realistic role performance, and were practical for audio-recording interactions. DSAT-10 analysis of 76 nurse–standardized patient encounters revealed nurses’ strengths (e.g., information provision) and their limitations (e.g., lack of discussion of values and/or support needs). Scores discriminated between trained and untrained nurses. The kappa coefficient over all items was 0.55 (95% CI: 0.49, 0.61) with higher agreement for encounters involving trained nurses (0.62; 95% CI: 0.43, 0.80).ConclusionAuditing nurse–standardized patient encounters using DSAT-10 and providing feedback to nurses was feasible. Although DSAT-10 items had adequate inter-rater reliability and discriminated between trained/untrained nurses, some items were problematic.Practice implicationsProviding feedback on nurse encounters with standardized patients experiencing uncertainty has the potential to enhance nurses’ decision support skills.     

Providing prenatal care to pregnant women with overweight or obesity: Differences in provider communication and ratings of the patient-provider relationship by patient body weight

ObjectiveTo examine the association of women’s body weight with provider communication during prenatal care.MethodsWe coded audio recordings of prenatal visits between 22 providers and 117 of their patients using the Roter Interaction Analysis System. Multivariate, multilevel Poisson models were used to examine the relationship between patient pre-pregnancy body mass index and provider communication.ResultsCompared to women with normal weight, providers asked fewer lifestyle questions (IRR 0.66, 95% CI 0.44–0.99, p = 0.04) and gave less lifestyle information (IRR 0.51, 95% CI 0.32–0.82, p = 0.01) to women with overweight and obesity, respectively. Providers used fewer approval (IRR 0.68, 95% CI 0.51–0.91, p = 0.01) and concern statements (IRR 0.68, 95% CI 0.53–0.86, p = 0.002) when caring for women with overweight and fewer self-disclosure statements caring for women with obesity (IRR 0.40, 95% CI 0.19–0.84 p = 0.02).ConclusionLess lifestyle and rapport building communication for women with obesity may weaken patient-provider relationship during routine prenatal care.Practice implicationsInterventions to increase use of patient-centered communication – especially for women with overweight and obesity – may improve prenatal care quality.     

Performance of a new rapid test for detecting anti-hepatitis E virus immunoglobulin M in immunocompetent and immunocompromised patients

BackgroundHepatitis E virus (HEV) infections are widespread in both developing and developed countries. It is, therefore, important to assess the performance of systems for rapidly detecting anti-HEV immunoglobulin M antibodies in human sera.ObjectivesTo evaluate the diagnostic value of a new immunochromatographic assay, the HEV IgM rapid test (Wantai).Study designBlood samples were taken from 30 acutely infected immunocompetent and 30 acutely infected immunocompromised patients, all with HEV RNA in their blood. Specificity and cross reactivity was assessed using samples from 30 HEV RNA negative immunocompetent patients who had acute Epstein–Barr virus (EBV) or cytomegalovirus (CMV) infections and 30 HEV RNA negative immunocompromised patients. The performance of the HEV IgM Rapid Test was compared to that of a conventional microplate enzyme immunoassay.ResultsThe sensitivity of the rapid test in immunocompetent patients was 90% (95% CI: 72.1–100%), similar to that of the Wantai microplate assay (sensitivity: 96.6%, 95% CI: 78.77–100%; p = 0.61). The sensitivity of the rapid test in immunocompromised patients was 73.3% (95% CI: 55.4–91.2%) and that of the microplate assay was 83.3% (95% CI: 65.44–100%; p = 0.53). The rapid test produced no false positive reactions with samples from HEV RNA negative patients; while the microplate assay gave two false positive results (3.3%).ConclusionThe new Wantai HEV IgM rapid test is easy to use and suitable for rapidly detecting acute hepatitis E infections in both immunocompetent and immunocompromised patients. However, HEV RNA must be detected using a molecular assay for diagnosing an HEV infection in anti-HEV IgM negative patients.     

With whom did you have sex? Evaluation of a partner notification training for STI professionals using motivational interviewing

ObjectiveTo enhance partner notification (PN) practices in Dutch STI clinics, a PN training using motivational interviewing as core strategy was offered to STI professionals and evaluated.MethodsThe effectiveness of PN training on professionals’ attitude, self-efficacy, skills and behavior toward PN, was examined using within-subject and between-subject comparison. Before the training and at three months follow-up, a questionnaire was completed by the intervention group (n = 54) and a non-random control group (n = 37).ResultsIn the within-subject comparison, positive changes were observed in self-efficacy, skills, and PN behaviors (all p < .05), but not in attitudes toward PN. When we examined differences in change-scores between the intervention and control group, self-efficacy was no longer significant.ConclusionThe PN training significantly improved PN skills and -behavior, but had no effect on professionals’ attitudes or self-efficacy toward PN. The selection of a convenience control sample seems to offer a more rigorous test of hypotheses than pre–post evaluation only.Practice implicationsThe beneficial effect of PN training of STI professionals seems to support a wider roll-out of the training to all STI clinics in the Netherlands, although effects on the number of partners notified and transmissions prevented need to be examined in future research.     

Nerve-sparing radical hysterectomy versus conventional radical hysterectomy in early-stage cervical cancer. A systematic review and meta-analysis of survival and quality of life

Background and aimsSurvival after radical hysterectomy (RH) for early-stage cervical cancer is good. Hence quality of life (QOL) after treatment is an important issue. Nerve-sparing radical hysterectomy (NSRH) improves QOL by selectively sparing innervation of bladder, bowel and vagina, reducing therapy-induced morbidity. However, the oncological outcome and the functional outcome after NSRH are subjects of debate. We aim to present the best possible evidence available regarding both QOL and survival after NSRH in early-stage cervical cancer.MethodsSystematic review and meta-analysis on studies comparing NSRH and RH.ResultsForty-one studies were included, and 27 were used for the meta-analysis. There was no difference in 2-, 3- and 5-year overall survival: the risk ratios (RRs) were respectively 1.02 (95% CI 0.99–1.05, n = 879), 1.01 (95% CI 0.95–1.08, n = 1324) and 1.03 (95% CI 0.99–1.08, n = 638). No difference was found in 2-, 3- and 5-year disease-free survival: RR 1.01 (95% CI 0.95–1.05, n = 1175), 0.99 (95% CI 0.94–1.03, n = 1130) and 1.00 (95% CI 0.95–1.06, n = 933) respectively. Post-operative time to micturition was significantly shorter in the NSRH group: standardized mean difference (SMD) −0.84 (CI 95% −1.07 to −0.60).ConclusionsNSRH can be considered safe and effective for early-stage cervical cancer since short- and long-term survival do not differ from those of conventional RH, while bladder function after NSRH is significantly less impaired.     

Comparison the effect of lateral wedge insole and acupuncture in medial compartment knee osteoarthritis: A randomized controlled trial

BackgroundThere is lack of well-designed trials evaluating structural benefits of non-pharmacologic therapies in knee osteoarthritis (OA). In this parallel-group randomized controlled trial, we aim to compare the possible advantages of lateral wedge insole and acupuncture in patients with medial knee OA.MethodPatients with grade two or three of medial knee OA were randomly allocated to group one who received an in shoe lateral wedge and group two who underwent acupuncture. We assessed patients' pain, function and knee joint cartilage thickness before and after intervention. Paired t-test and independent samples t-test were used for in group and between group analyses. (Level of evidence: 2.)ResultsTwenty patients in each group were recruited in the study. Pain significantly decreased after therapy in both groups one and two (paired t test, P < 0.001, 95% CI: 1.62–3.25 and 1.58–3.20 respectively). Function improved in each group (paired t test, P = 0.001, 95% CI of 0.94–2.38 in group one and 0.97–2.43 in group two). A non-clinically statistically significant difference regarding the femoral and tibial cartilage thickness was obtained in both groups one (P = 0.005, CI: − 0.43–0.82 and P = 0.037, CI: − 0.44–0.80 respectively) and two (P = 0.025, CI: − 0.45–0.79 and P = 0.035, CI: − 0.29–0.96 respectively). Between groups analysis showed no significant difference regarding abovementioned measures.ConclusionBoth lateral wedge insole and acupuncture can be effective in the treatment of medial knee osteoarthritis without any superiority of one over the other.Iranian Registry of Clinical Trials: IRCT201201108235N1.URL: http://irct.ir/searchen.php     

Examiner characteristics and interrater reliability in a communication OSCE

ObjectiveTo identify inter-individual examiner factors associated with interrater reliability in a summative communication OSCE in the 4th study year.MethodsThe OSCE consists of 4 stations assessed with a 4-item 5-point global rating instrument. A bivariate secondary analysis of interrater reliability in relation to 4 examiner factors (gender, profession, OSCE experience, examiner training) was conducted. Intraclass correlation coefficients (ICC) were calculated and compared between examiner dyads of different similarity.Results169 pairwise ratings from 19 different examiners in 16 dyads were analysed. Interrater reliability is significantly higher in examiner dyads of same vs. different gender (ICC = 0.76 (95%CI = 0.65-0.83) vs. ICC = 0.41 (95%CI = 0.21-0.57)), in dyads of two clinicians vs. non-clinical/mixed professions (ICC = 0.72 (95%CI = 0.56-0.83) vs. ICC = 0.57 (95%CI = 0.41-0.69)), and in dyads with high vs. low/mixed OSCE experience (ICC = 0.73 (95%CI 0.50-0.87) vs. ICC = 0.56 (95%CI = 0.41-0.69)). Participation in recent examiner training had no influence on ICCs.ConclusionBetter concordance of ratings between clinically active examiners might be a hint for context specificity of good communication. Higher interrater reliability between examiners with same gender may indicate gender-specific communication concepts.Practice implicationsMedical faculties introducing summative assessment of communication competence should focus the influence of examiner characteristics on interrater reliability.     

The diagnostic and prognostic significance of soluble urokinase plasminogen activator receptor in Crimean-Congo hemorrhagic fever

BackgroundCrimean-Congo hemorrhagic fever (CCHF) is a potentially fatal disease caused by a tick-borne virus from the Bunyaviridae family. It has recently been reported that soluble urokinase-type plasminogen activator receptor (suPAR), secreted from endothelial cells and the mononuclear phagocyte system, one of the main targets of the CCHF virus, is a potential biomarker for several bacterial and viral infection diseases.ObjectivesThis study was intended to determine the diagnostic and prognostic significance of suPAR levels in CCHF.Study designThis retrospective study was conducted between June 2006 and August 2009 using plasma from patients monitored with a diagnosis of CCHF and from healthy blood donors. Levels of plasma suPAR were determined using an enzyme-linked immunosorbent assay (ELISA) kit according to the manufacturer's instructions.ResultsOne hundred CCHF patients were enrolled in the study. The control group was made up of 53 healthy blood donors. suPAR values of 6.2 ± 4.2 were determined in the CCHF patients and of 2.3 ± 0.6 in the control group (p < 0.0001). A suPAR level optimum diagnostic cut-off point of 3.06 ng/mL was determined, with an area underneath the ROC (AUROC) curve of 0.94 (95% CI: 0.89–0.97), sensitivity of 87% (95% CI: 79–93%), specificity of 92% (95% CI: 82–98%), PPV of 95% and NPV of 79%. Five of the patients died. suPAR was 18.4 ± 9.1 in the patients that died and 5.6 ± 2.6 in the survivors (p = 0.034). In terms of mortality, suPAR level had an optimum diagnostic cut-off point of 10.6 ng/mL, AUROC of 0.97 (95% CI: 0.94–0.99), sensitivity of 100% (95% CI: 48–100%), specificity of 96% (95% CI: 90–99%), PPV of 50% and NPV of 100%.ConclusionsPlasma suPAR level, a new biomarker, is a test that can be used in the differential diagnosis and monitoring of CCHF in patients admitted to hospital with suspected infection. The test is at the same time important in being a possible predictor of mortality.     

Type and frequency of healthcare encounters can predict poor surgical outcomes in anterior cruciate ligament reconstruction patients

BackgroundSeveral challenges are associated with collecting clinically meaningful post-operative outcomes. The widespread implementation of electronic medical records (EMR) offers a new opportunity to evaluate surgical outcomes using routinely collected data in these systems. This study evaluated whether surgical outcomes can be ascertained from EMR’s hospital and outpatient encounters. Specifically, we evaluated anterior cruciate ligament reconstructions (ACLR) outcomes.MethodsA retrospective cohort study of 6985 ACLRs performed between 2/2005-9/2012 was conducted. Patient encounters during days 1–90 and days 91–180 after ACLR surgery were the exposures of interest. Nine hospital and eight outpatient encounter types were evaluated. The main endpoint of the study was revision surgery six months after ACLR.ResultsThe cohort was 66.7% male, the mean age was 28 (standard deviation = 11) years-old, and the incidence of revision was 1.5% (n = 105). After adjustments, in days 1–90 post-ACLR, compared to patients with 0–4 orthopedic office visits, patients with 5–9 (hazard ratio (HR) = 9.9, 95% confidence interval(CI), 4.3–23.2) and those with 10 or more (HR = 13.8, 95%CI, 5.6–33.8) visits had a higher risk of revision. In days 91–180, patients with any outpatient hospital encounters (HR = 2.5, 95%CI 1.4–4.5) had a higher risk of revision than patients without visits. Additionally, patients with 4–5 regular office visits (HR = 3.8 times, 95%CI, 2.0–7.0) had a higher risk of revision surgery than those with 0–1 visits.DiscussionThe number of post-operative outpatient visits was associated with ACLR revision surgery. Using EMR encounters to assess surgical outcomes is a viable option for monitoring ACLR patients. The simple assessment of visit types and number of encounters alone can provide valuable information regarding the normal course of rehabilitation of a surgical patient and possible deviation from this normal course. In large cohorts of patients, this type of patient surveillance can assist surgeons with monitoring their patients.     

SP600125 promotes resolution of allergic airway inflammation via TLR9 in an OVA-induced murine acute asthma model

Backgroundc-Jun N-terminal kinase (JNK) relays extracellular stimuli through phosphorylation cascades that lead to various cell responses. In the present study, we aimed to investigate the effect of the JNK inhibitor SP600125 on the resolution of airway inflammation, and the underlying mechanism using a murine acute asthma model.MethodsFemale C57BL/6 mice were sensitized with saline or ovalbumin (OVA) on day 0, and challenged with OVA on day 14–20. Meanwhile, some of the mice were treated with SP600125 (30 mg/kg) intraperitoneally 2 h before each challenge. The airway inflammation was evaluated by counting the numbers of various types of inflammatory cells in bronchoalveolar lavage fluid (BALF), histopathology, cytokines production and mucus secretion in individual mouse. In addition, we analyzed the protein levels of phosphorylated JNK and TLR9 in the lung tissues.ResultsSP600125 markedly reduced the invasion of inflammatory cells into the peribronchial regions, and decreased the numbers of eosinophils, monocytes, neutrophils and lymphocytes in BALF. SP600125 also reduced the level of plasma OVA-specific IgE, lowered the production of pro-inflammatory cytokines in BALF and alleviated mucus secretion. Meanwhile, SP600125 inhibited OVA-induced, increased expression of p-JNK and TLR9 in the lung tissues.ConclusionsCollectively, our data demonstrated that SP600125 promoted resolution of allergic airway inflammation via TLR9 in an OVA-induced murine acute asthma model. The JNK-TLR9 pathway may be a new therapeutic target in the treatment for the allergic asthma.     

The Relapsing Polychondritis Disease Activity Index: Development of a disease activity score for relapsing polychondritis

ObjectiveThe rarity of relapsing polychondritis (RP) has hindered the development of standardized tools for clinical assessment. Here, we describe the development of a preliminary score for disease assessing activity in RP, the Relapsing Polychondritis Disease Activity Index (RPDAI).MethodsTwenty-seven RP experts participated in an international collaboration. Selection and definition of items for disease activity were established by consensus during a 4-round internet-based Delphi survey. Twenty-six experts assessed the Physician's Global Assessment (PGA) of disease activity on 43 test cases on a 0–100 scale, yielding a total of 1118 PGA ratings. The weight of each item was estimated by multivariate regression models with generalized estimating equation, using PGA as the dependent variable.ResultsExperts decided in consensus that the RPDAI should consider the 28-day period before each RPDAI assessment. Inter-rater reliability assessed by the intra-class correlation coefficient for the 1118 PGA ratings was 0.51 (CI95%: 0.41–0.64). The final RPDAI score comprised 27 items with individual weights ranging from 1 to 24 and a maximum theoretical RPDAI score of 265. Correlation between the RPDAI scores calculated based on the weights derived from the final multivariate model, and the 1118 PGA ratings was good (r = 0.56, p < 0.0001).ConclusionWe have developed the first consensus scoring system to measure disease activity in relapsing polychondritis (see www.RPDAI.org for online scoring). This tool will be valuable for improving the care of patients with this rare disease.     

Circuit resistance training is an effective means to enhance muscle strength in older and middle aged adults: A systematic review and meta-analysis

BackgroundPhysical exercise, particularly resistance training (RT), is proven treatment to reduce the accelerated decline in muscle strength exhibited by older adults, but its effect is hindered by low adherence rate, even under well-structured programs.Objective and data sourcesWe investigated the efficacy of circuit resistance training (CRT) on muscle strength, lean mass and aerobic capacity in older adults based on report in MEDLINE, EMBASE, ClinicalTrials.gov and Cochrane electronic (through 8/2016). Study eligibility criteria: middle and older aged men and/or women who followed a structured program, assigned to CRT. Study appraisal and synthesis methods: Out of 237 originally identified articles, 10 articles were included with a total of 362 patients with mean: age −64.5 ± 7.4 years; 3 ± 1.15 sessions/week; session duration 41.8 ± 15.9 min.ResultsUpper body strength modestly increased, by 1.14 kg (95% CI; 0.28–2.00), whereas larger increment was seen in lower body strength (11.99; 2.92–21.06). Higher program volume (>24 sessions) positively influenced upper body strength and aerobic capacity.Limitations(1) variability in the studies’ validity; (2) relatively low number of studies.ConclusionCRT is a valid alternative to conventional RT. Its shorter duration and lower intensity relative to traditional RT, may increase adherence to training in older adults.     

Long-term anti-TNF therapy and the risk of serious infections in a cohort of patients with rheumatoid arthritis: Comparison of adalimumab,etanercept and infliximab in the GISEA registry

ObjectiveTo evaluate the risk of serious infections (SIs) in RA patients receiving anti-TNF therapy on the basis of the data included in the GISEA register.MethodsThe study involved 2769 adult patients with long-standing RA (mean age 53.2 ± 13.4 years; mean disease duration 9.0 ± 8.3 years) enrolled in the GISEA register, who had been treated for at least 6 months with TNF inhibitors or had discontinued therapy due to SI: 837 (30%) treated with infliximab (IFN), 802 (29%) with adalimumab (ADA), and 1130 (41%) with etanercept (ETN).Results176 patients had experienced at least one of the 226 Sis during the 9 years of treatment with an anti-TNF agent, an overall incidence of 31.8/1000 patient-years (95% CI 25.2–38.3): 23.7/1000 patient-years (95% CI 13.1–34.2) on ADA; 12.8/1000 patient-years (95% CI 6.3–19.4) on ETN and 65.1/1000 patient-years (95% CI 48.4–81.8) on IFN. The risk was higher in the first than in the second year of treatment, but this difference was not statistically significant (p = 0.08) (38.9% of the SIs were recorded in the first 12 months of treatment). The risk of SI was significantly different among the three treatment groups (p < 0.0001). Multivariate models confirmed that the use of steroids (p < 0.046), concomitant DMARD treatment during anti-TNF therapy (p = 0.004), advanced age at the start of anti-TNF treatment (p < 0.0001), and the use of IFN or ADA rather than ETN (respectively p < 0.0001 and p = 0.023) were strong and statistically significant predictors of infection.ConclusionsAnti-TNF therapy is associated with a small but significant risk of SI that is associated with the concomitant use of steroids, advanced age at the start of anti-TNF treatment, and the type of anti-TNF agent.     

Respiratory virus detection in nasopharyngeal aspirate versus bronchoalveolar lavage is dependent on virus type in children with chronic respiratory symptoms

BackgroundThe comparative yield of respiratory virus detection from nasopharyngeal aspirate (NPA) versus bronchoalveolar lavage (BAL) is uncertain. Furthermore, the significance of virus detection and its relationship to lower airway neutrophilic inflammation is poorly studied.ObjectivesTo evaluate the sensitivity, specificity and predictive values of NPA for detecting respiratory viruses in BAL; and to determine the relationship between viruses and lower airway neutrophilia in children with non-acute respiratory illness.Study design150 paired NPA and BAL samples were obtained from 75 children aged <18 years undergoing flexible bronchoscopy for investigation of chronic respiratory symptoms. Viral studies were performed using polymerase chain reaction (PCR). Cellularity studies were performed on BALs. Diagnostic parameters of NPA compared to BAL and associations between viruses and lower airway %neutrophils were evaluated.ResultsNPA had a higher yield than BAL for detection of any respiratory virus (52 versus 38, respectively). NPA had a high sensitivity (92%) and low specificity (57%) for detecting HRV in BAL with poor kappa agreement value of 0.398 (95% CI 0.218–0.578, p < 0.001). NPA had a fair sensitivity (69%) and good specificity (90.3%) for detecting HAdV on BAL, kappa agreement was 0.561 (95% CI 0.321–0.801, p < 0.001). HAdV positivity on NPA, compared to negativity, was independently associated with heightened airway neutrophilia [mean difference (95% CI): 18 (1,35); p = 0.042].ConclusionsNPA has a higher yield for respiratory virus detection than BAL, however its diagnostic accuracy is dependent on viral species. Adenovirus positivity is associated with significantly heightened lower airway neutrophilia in children with chronic respiratory symptoms.     

Pulmonary hypertension in systemic lupus erythematosus: prevalence,predictors and diagnostic strategy

ObjectivesTo investigate the prevalence and predictors of pulmonary hypertension (PH) in patients with systemic lupus erythematosus (SLE) and to validate a diagnostic strategy.Methods245 patients with SLE entered a screening program. Possible PH was defined as two consecutive systolic pulmonary arterial pressure (PAP) values ≥ 40 mm Hg by echocardiography. The subsequent diagnostic procedure, including right heart catheterization if needed, confirmed or excluded the diagnosis of PH secondary to cardiopulmonary disease or SLE-related pulmonary arterial hypertension (PAH). Independent predictors of PH were identified by multivariant multiple linear or logistic regression models. The sensitivity (S), specificity (SP), positive (PPV) and negative predictive values (NPV) were calculated for different screening cutoff values.Results88% patients were women. The mean (SD) age at the time of enrolment was 45 (16) years. 12 cases of PH were detected, all secondary, with a resulting prevalence of 5%. Two consecutive echocardiographic PAP measurements ≥ 40 mm Hg performed best as the cutoff point for screening (S 100%, SP 97%, PPV 70, NPV 100), as compared with single PAP measurements ≥ 30 mm Hg or ≥ 40 mm Hg The age at the time of enrolment was the only variable independently associated with PAP values (p = 0.0001), with the SLICC damage index score showing a borderline association (p = 0.08). Only the age at the time of enrolment showed an independent association with PH (OR 1.10, 95% CI 1.06–1.17).ConclusionWe found a low prevalence of PH. Screening echocardiograms in asymptomatic lupus patients are thus not recommended. Two consecutive PAP values ≥ 40 mm Hg by echocardiogram is the best screening cutoff for starting investigations in SLE patients with suspected PH.     

Current outcomes of chronic active antibody mediated rejection – A large single center retrospective review using the updated BANFF 2013 criteria

BackgroundThe updated BANFF 2013 criteria has enabled a more standardized and complete serologic and histopathologic diagnosis of chronic active antibody mediated rejection (cAMR). Little data exists on the outcomes of cAMR since the initiation of this updated criteria.Methods123 consecutive patients with biopsy proven cAMR (BANFF 2013) between 2006 and 2012 were identified.ResultsPatients identified with cAMR were followed for a median of 9.5 (2.7–20.3) years after transplant and 4.3 (0–8.8) years after cAMR. Ninety-four (76%) recipients lost their grafts with a median survival of 1.9 years after diagnosis with cAMR. Mean C4d and allograft glomerulopathy scores were 2.6 ± 0.7 and 2.2 ± 0.8, respectively. 53.2% had class II DSA, 32.2% had both class I and II, and 14.5% had class I DSA only. Chronicity score >8 (HR 2.9, 95% CI 1–8.4, p = 0.05), DSA >2500 MFI (HR 2.8, 95% CI 1.1–6.8, p = 0.03), Scr >3 mg/dL (HR 3.2, 95% CI 1.6–6.3, p = 0.001) and UPC >1 g/g (HR 2.5, 95% CI 1.4–4.5, p = 0.003) were associated with a higher risk of graft loss.ConclusionscAMR was associated with poor graft survival after diagnosis. Improved therapies and earlier detection strategies are likely needed to improve outcomes of cAMR in kidney transplant recipients.     

Early versus late treatment of spinal cord compression with long-term intrathecal enzyme replacement therapy in canine mucopolysaccharidosis type I

Enzyme replacement therapy (ERT) with intravenous recombinant human alpha-l-iduronidase (IV rhIDU) is a treatment for patients with mucopolysaccharidosis I (MPS I). Spinal cord compression develops in MPS I patients due in part to dural and leptomeningeal thickening from accumulated glycosaminoglycans (GAG). We tested long-term and every 3-month intrathecal (IT) and weekly IV rhIDU in MPS I dogs age 12–15 months (Adult) and MPS I pups age 2–23 days (Early) to determine whether spinal cord compression could be reversed, stabilized, or prevented. Five treatment groups of MPS I dogs were evaluated (n = 4 per group): IT + IV Adult, IV Adult, IT + IV Early, 0.58 mg/kg IV Early and 1.57 mg/kg IV Early. IT + IV rhIDU (Adult and Early) led to very high iduronidase levels in cervical, thoracic, and lumber spinal meninges (3600–29,000% of normal), while IV rhIDU alone (Adult and Early) led to levels that were 8.2–176% of normal. GAG storage was significantly reduced from untreated levels in spinal meninges of IT + IV Early (p < .001), IT + IV Adult (p = .001), 0.58 mg/kg IV Early (p = .002) and 1.57 mg/kg IV Early (p < .001) treatment groups. Treatment of dogs shortly after birth with IT + IV rhIDU (IT + IV Early) led to normal to near-normal GAG levels in the meninges and histologic absence of storage vacuoles. Lysosomal storage was reduced in spinal anterior horn cells in 1.57 mg/kg IV Early and IT + IV Early animals. All dogs in IT + IV Adult and IV Adult groups had compression of their spinal cord at 12–15 months of age determined by magnetic resonance imaging and was due to protrusion of spinal disks into the canal. Cord compression developed in 3 of 4 dogs in the 0.58 mg/kg IV Early group; 2 of 3 dogs in the IT + IV Early group; and 0 of 4 dogs in the 1.57 mg/kg IV Early group by 12–18 months of age. IT + IV rhIDU was more effective than IV rhIDU alone for treatment of meningeal storage, and it prevented meningeal GAG accumulation when begun early. High-dose IV rhIDU from birth (1.57 mg/kg weekly) appeared to prevent cord compression due to protrusion of spinal disks.     

Effectiveness of training final-year undergraduate nutritionists in motivational interviewing

ObjectivesTo assess the efficacy of a motivational interviewing (MI) training programme on trainee nutritionists.MethodsA repeated measures design was applied to assess clinician behaviours in a ‘helping’ conversation. Participants were 32 nutrition students, assessed at baseline and one-month follow-up.ResultsThe training significantly reduced the use of closed questions and MI non-adherent behaviours (MINA) (P for both = <0.001). Trainees significantly increased reflections, affirmations, summaries (P for all = <0.001) and the use of open questions (P = <0.013) which are all key indicators of MI beginner-competence. The talk-time ratio of the nutritionists also changed significantly, in favour of the client which serves as an indication of MI being used effectively. There were also significant increases in ‘global' scores for empathy, direction, autonomy/support, collaboration and evocation.ConclusionsNewly trained nutritionists 1 month post-training have a consultation style which suggested positive outcomes for clients. The trainees' scores at the one month post-training assessment were verifiable as ‘beginning proficiency'.Practice implicationsBehaviour change counselling skills for nutritionists were enhanced, at one month post-training. MI training workshops with video feedback enhances communication skills which are likely to lead to positive consultation-behaviour changes in the trainee nutritionists.     

Dengue virus infection during pregnancy increased the risk of adverse fetal outcomes? An updated meta-analysis

ObjectiveTo evaluate the effect of maternal dengue virus (DENV) infection during pregnancy in premature birth, low birth weight, miscarriage and stillbirth.MethodsSystematic electronic literature searches were conducted including PubMed, Medline, Embase, Web of science, Scopus and the Cochrane Library database, up until July 5, 2017. Effect sizes were estimated by using the relative risk (RR) or odds ratio (OR) with theirs corresponding 95% confidence interval (CI). Subgroup analyses were conducted for study design (prospective or retrospective) and clinical symptom of participants (symptomatic or asymptomatic). Statistical analysis was conducted by STATA 12.0.ResultsThe initial systematic literature searches identified 1048 studies. After screening, fourteen studies were included. The pooled results did not suggest maternal DENV infection might increase the risk of adverse fetal outcomes with a pooled RR of 0.96 (95% CI: 0.85–1.09, I² = 49.6%) for premature birth, RR of 0.99 (95%CI: 0.87–1.12, I² = 35.1%) for low birth weight, OR of 1.77 (95% CI: 0.99–3.15, I² = 17.5%) for miscarriage and RR of 3.42 (95% CI: 0.76–15.49, I² = 54.8%) for stillbirth. Subgroup analysis of studies in symptomatic participants still did not indicate DENV infection appeared to be a risk factor for premature birth, low birth weight and miscarriage with pooled effect size of 0.99 (95% CI: 0.87–1.13, I² = 49.3%), 1.22 (95% CI: 0.827–1.80, I² = 55.1%) and 1.19 (95% CI: 0.56–2.55, I² = 4.7%), respectively.ConclusionsCurrent evidence did not suggest that maternal DENV infection during pregnancy might increase the risk of premature birth, low birth weight, miscarriage and stillbirth.