Patients' Perspectives on Health-Related Social Needs and Recommendations for Interventions: A Qualitative Study

RATIONALE & OBJECTIVE

People with low socioeconomic status are disproportionately affected by kidney failure, and their adverse outcomes may stem from unmet health-related social needs. This study explored hemodialysis patient perspectives on health-related social needs and recommendations for intervention.

STUDY DESIGN

Qualitative study using semistructured interviews.

SETTINGS & PARTICIPANTS

Thirty-two people with low socioeconomic status receiving hemodialysis at 3 hemodialysis facilities in Austin, Texas.

ANALYTICAL APPROACH

Interviews were analyzed for themes and subthemes using the constant comparative method.

RESULTS

Seven themes and 21 subthemes (in parentheses) were identified: (1) kidney failure was unexpected (never thought it would happen to me; do not understand dialysis); (2) providers fail patients (doctors did not act; doctors do not care); (3) dialysis is detrimental (life is not the same; dialysis is all you do; dialysis causes emotional distress; dialysis makes you feel sick); (4) powerlessness (dependent on others; cannot do anything about my situation); (5) financial resource strain (dialysis makes you poor and keeps you poor; disability checks are not enough; food programs exist but are inconsistent; eat whatever food is available; not enough affordable housing; unstable housing affects health and well-being); (6) motivation to keep going (faith, support system, will to live); and (7) interventions should promote self-efficacy (navigation of community resources, support groups).

LIMITATIONS

Limited quantitative data such as on dialysis vintage, and limited geographic representation.

CONCLUSIONS

Dialysis exacerbates financial resource strain, and health-related social needs exacerbate dialysis-related stress. The participants made recommendations to address social needs with an emphasis on increasing support and community resources for this population.

PLAIN-LANGUAGE SUMMARY

People receiving dialysis often experience health-related social needs, such as food and housing needs, but little is known about how these impact patients' health and well-being or how to best address them. We interviewed people receiving dialysis about how health-related social needs affect them and what they think dialysis facilities can do to help them address those needs. The participants reported that they often lose their independence after starting dialysis and health-related social needs are common, exacerbate their stress and emotional distress, and reduce their sense of well-being. Dialysis facilities may be able to enhance the experience of these patients by facilitating connections with local resources and providing opportunities for patients to support one another.

Facilitating Medical Care for Latinx Individuals at Risk for CKD: A Pilot Intervention

Rationale and Objective

Latinx individuals are at a higher risk for kidney failure than non-Latinx White individuals; however, they are less likely to receive pre-kidney failure medical care. The objective of this study was to determine the feasibility and acceptability of a community health worker (CHW) intervention that facilitated access to medical care for Latinx individuals.

Study Design

Single-arm prospective study.

Setting and Participants

Latinx adults were found to have albuminuria or risk factors for kidney disease at community screening events in Austin, Texas.

Intervention

A 6-month CHW intervention that facilitated the following: (1) obtaining medical insurance; (2) medical care coordination with primary and nephrology care; (3) kidney disease education; and (4) connection with local resources to address health-related social needs.

Outcomes

Recruitment, retention, medical care linkage, and participant and CHW-reported satisfaction with the intervention.

Results

Of the 173 individuals who attended the 2 community screening events, 49 agreed to participate in the study, of whom, 51% were men with a mean ± standard deviation (SD) age of 45 ± 14 years, and all self-identified as Mexican or Chicano. The mean ± SD estimated glomerular filtration rate (eGFR) was 110 ± 21 mL/min/1.73 m² and 41% of the participants reported a urine albumin-creatinine ratio of ≥30 mg/g. Among those enrolled, 28 of the 49 (57%) completed at least 1 CHW visit, and 20 of 49 (41%) completed the intervention. 7 individuals who needed assistance with insurance obtained insurance, and 15 of 20 (75%) scheduled an appointment with a primary care physician within 180 days. Participants reported that the US health care previously seemed inaccessible but gained insurance, the ability to navigate the system, and the ability to help others in their community to access medical care because of the program.

Limitations

Small sample size and a single community may limit generalizability.

Conclusions

We reported the acceptability of a CHW intervention. We encountered challenges with feasibility and identified strategies to overcome them. Studies are needed to test the effect of CHW interventions on outcomes and kidney health disparities.

Funding

National Kidney Foundation young investigator research grant to Dr Novick.

Plain Language Summary

Latinx individuals are at a higher risk for kidney failure than non-Latinx White individuals; however, they are less likely to receive pre-kidney failure medical care. We piloted a community health worker intervention that connected people with risk factors or showed evidence of kidney dysfunction at community screening events with medical care. Our findings indicate the acceptability of the intervention. We encountered challenges with feasibility and identified strategies to overcome them.

Perspectives on Kidney Disease Education and Recommendations for Improvement Among Latinx Patients Receiving Emergency-Only Hemodialysis

IMPORTANCE

In most states, undocumented Latinx immigrants with kidney failure receive dialysis in acute care settings on an emergency-only basis. How much kidney disease education Latinx immigrants receive and how to improve kidney disease education and outreach among Latinx populations are unknown.

OBJECTIVE

To understand the kidney disease educational gaps of Latinx individuals who need but lack access to scheduled outpatient dialysis.

DESIGN, SETTING, AND PARTICIPANTS

This qualitative study used semistructured interviews in a Texas hospital system from March 2020 to January 2021 with 15 individuals who received emergency-only dialysis when they were first diagnosed with kidney failure. Demographic information was collected, and a thematic analysis was performed using the constant comparative method on interviews after they were audio-recorded, translated, and transcribed verbatim. Data analysis was performed from April 2020 to February 2021.

MAIN OUTCOMES AND MEASURES

Subthemes and themes from semistructured interviews.

RESULTS

All 15 persons interviewed (9 male individuals [60%]; mean [SD] age, 51 [17] years) identified as Hispanic, 11 (73%) were born in Mexico, and none reported knowing about their kidney disease more than 6 months before starting dialysis. The themes identified were (1) lack of kidney disease awareness, (2) education provided was incomplete and poor quality, (3) lack of culturally concordant communication and care, (4) elements that Latinx patients receiving emergency-only dialysis want in their education, (5) facilitators of patient activation and coping, and (6) Latinx patient recommendations to improve community outreach.

CONCLUSIONS AND RELEVANCE

Latinx adults receiving emergency-only dialysis are usually unaware of their kidney disease until shortly before or after they start dialysis, and the education they receive is poor quality and often not culturally tailored. Participants made feasible recommendations on how to improve education and outreach among Latinx communities.

Confirmed tumor response by molecular subtype in patients with metastatic breast cancer: Sub-analysis from a phase 3 clinical study comparing oral paclitaxel and encequidar to IV paclitaxel

1073

Background: Paclitaxel, a foundation treatment in MBC, is hydrophobic and must be formulated for IV administration with Cremophor EL, increasing the risk of infusion reactions and necessitating pre-treatment with corticosteroids and antihistamines. Paclitaxel cannot be administered orally because it is a substrate for P-gp. The oral bioavailability of paclitaxel is improved when administered 1 hour after the highly selective, potent, and minimally absorbed P-gp inhibitor encequidar. As oral paclitaxel is Cremophor-free there is no need for pretreatment for infusion reactions. While targeted therapies have improved outcomes in patients with HER2+ tumors there is still an unmet need for therapies that prolong survival with reduced toxicity across all tumor subtypes. Methods: A phase 3, open-label, randomized, multicenter study in women with histologically- or cytologically-confirmed MBC for whom treatment with IV paclitaxel monotherapy had been recommended by their oncologist randomized 402 patients 2:1 to either oral paclitaxel and encequidar (oPac+E) or IV paclitaxel (IVPac). Oral paclitaxel 205 mg/m2 was administered once daily for 3 consecutive days, weekly. Encequidar 12.9 mg was administered 1 hour before each dose of oral paclitaxel. IV paclitaxel 175 mg/m2 was infused over 3 hours on day 1 of every 3 weeks. Results: In the ITT population oPac+E was superior to IV paclitaxel with a confirmed tumor response rate of 35.8% vs 23.4% for IVPac: a difference of 12.4% (p = 0.0107). A post-hoc subgroup efficacy analysis was conducted based on tumor subtypes, however, the study was not powered to detect statistical differences within these subgroups. Patients in the HR+/HER2- subgroup had a better tumor response to oPac+E (44.8% vs 21.4% IVPac-response rate difference of 23.4%) as did patients in the TNBC (30.5% vs 20.2%-response rate difference of 10.3%) subgroup. Responses were similar (49% vs 47.4% IVPac) in the HER2+ subgroup. Patients with unknown HER2 status receiving oPac+E had a 58.8% response rate vs 14.3% with IVPac (response rate difference of 44.5%). Conclusions: oPac+E is the first oral taxane to demonstrate superiority in radiologically confirmed tumor response rate compared to IVPac in a group of 402 women with metastatic breast cancer. Patients with HR+/HER2-, TNBC, and Unknown subtypes responded considerably better to oPac+E vs IVPac—especially the HR+/HER2- subtype which represented 63% of the patients treated with oPac+E and 55% of the patients treated with IVPac. Clinical trial information: NCT 02594371 .

KX-ORAX-001: An open label, randomized, multicenter, phase III registrational study to determine the safety, tolerability, and tumor response of oraxol (HM30181A + oral paclitaxel) and its comparability to IV paclitaxel in patients with metastatic breast cancer (MBC)

TPS1116

Background: Paclitaxel is used in multiple cancer types including the treatment of breast cancer after failure of combination chemotherapy for metastatic disease or relapse within six months of adjuvant chemotherapy. Due to poor oral absorption, paclitaxel is administered IV and is associated with extra administration costs, inconvenience, burden for the patient, and hypersensitivity reactions to the solubilizing agent Cremophor EL. HM30181A is an intestinal P-gp pump blocker that, when administered orally with paclitaxel capsules (Oraxol), enhances paclitaxel absorption. Interim data from a phase I crossover study showed Oraxol (15-mg HM30181A + 205 mg/m2) 3 days/week had similar AUC0-∞ to IV paclitaxel 80 mg/m2 over 1 hour (Oraxol 5078 ng*hr/mL vs. IV paclitaxel 5652 ng*hr/mL), however the Cmax was substantially lower with Oraxol which may result in lower incidence of neuropathy. In a phase II single arm study of Oraxol in MBC 45.8% and 41.7% of subjects had PR or SD according to RECIST 1.1. Methods: KX-ORAX-001 is a, multi-national open-label, randomized (2:1 Oraxol to IV paclitaxel) phase III registration study comparing Oraxol (15-mg HM30181A + paclitaxel 205 mg/m2 daily x 3 days QW) to IV paclitaxel 175 mg/m2 over 3 hours every third week, in female patients with histologically- or cytologically-confirmed MBC for whom treatment with IV paclitaxel monotherapy has been recommended. The study is powered to demonstrate the superiority of Oraxol on confirmed tumor response rate vs IV Paclitaxel 175mg/m2 q3weeks. The primary efficacy endpoint is confirmed tumor response according to a blinded central radiologist using RECIST 1.1 criteria. The study is designed to enroll approximately 360 evaluable subjects. Two interim DSMB reviews were conducted at approximately 90 and 180 evaluable subjects for safety, futility, and efficacy. Enrollment was initiated Dec 2015 at 45 sites in Central and South America and enrollment has been completed. At final analysis, if there is an approximate difference of ≥10% favoring Oraxol, a p-value of 0.045 [2-tailed] will be achieved. Secondary endpoints are PFS and OS. Clinical trial information: NCT02594371.

A new Palaeocene crocodylian from southern Argentina sheds light on the early history of caimanines

Caimanines are crocodylians currently restricted to South and Central America and the oldest members are from lower Palaeocene localities of the Salamanca Formation (Chubut Province, Argentina). We report here a new caimanine from this same unit represented by a skull roof and partial braincase. Its phylogenetic relationships were explored in a cladistic analysis using standard characters and a morphogeometric two-dimensional configuration of the skull roof. The phylogenetic results were used for an event-based supermodel quantitative palaeobiogeographic analysis. The new species is recovered as the most basal member of the South American caimanines, and the Cretaceous North American lineage 'Brachychampsa and related forms' as the most basal Caimaninae. The biogeographic results estimated north-central North America as the ancestral area of Caimaninae, showing that the Cretaceous and Palaeocene species of the group were more widespread than thought and became regionally extinct in North America around the Cretaceous-Palaeocene boundary. A dispersal event from north-central North America during the middle Late Cretaceous explains the arrival of the group to South America. The Palaeogene assemblage of Patagonian crocodylians is composed of three lineages of caimanines as a consequence of independent dispersal events that occurred between North and South America and within South America around the Cretaceous-Palaeogene boundary.

Individualised perioperative open-lung approach versus standard protective ventilation in abdominal surgery (iPROVE): a randomised controlled trial

BACKGROUND

The effects of individualised perioperative lung-protective ventilation (based on the open-lung approach [OLA]) on postoperative complications is unknown. We aimed to investigate the effects of intraoperative and postoperative ventilatory management in patients scheduled for abdominal surgery, compared with standard protective ventilation.

METHODS

We did this prospective, multicentre, randomised controlled trial in 21 teaching hospitals in Spain. We enrolled patients who were aged 18 years or older, were scheduled to have abdominal surgery with an expected time of longer than 2 h, had intermediate-to-high-risk of developing postoperative pulmonary complications, and who had a body-mass index less than 35 kg/m². Patients were randomly assigned (1:1:1:1) online to receive one of four lung-protective ventilation strategies using low tidal volume plus positive end-expiratory pressure (PEEP): open-lung approach (OLA)-iCPAP (individualised intraoperative ventilation [individualised PEEP after a lung recruitment manoeuvre] plus individualised postoperative continuous positive airway pressure [CPAP]), OLA-CPAP (intraoperative individualised ventilation plus postoperative CPAP), STD-CPAP (standard intraoperative ventilation plus postoperative CPAP), or STD-O₂ (standard intraoperative ventilation plus standard postoperative oxygen therapy). Patients were masked to treatment allocation. Investigators were not masked in the operating and postoperative rooms; after 24 h, data were given to a second investigator who was masked to allocations. The primary outcome was a composite of pulmonary and systemic complications during the first 7 postoperative days. We did the primary analysis using the modified intention-to-treat population. This trial is registered with ClinicalTrials.gov, number NCT02158923.

FINDINGS

Between Jan 2, 2015, and May 18, 2016, we enrolled 1012 eligible patients. Data were available for 967 patients, whom we included in the final analysis. Risk of pulmonary and systemic complications did not differ for patients in OLA-iCPAP (110 [46%] of 241, relative risk 0·89 [95% CI 0·74-1·07; p=0·25]), OLA-CPAP (111 [47%] of 238, 0·91 [0·76-1·09; p=0·35]), or STD-CPAP groups (118 [48%] of 244, 0·95 [0·80-1·14; p=0·65]) when compared with patients in the STD-O₂ group (125 [51%] of 244). Intraoperatively, PEEP was increased in 69 (14%) of patients in the standard perioperative ventilation groups because of hypoxaemia, and no patients from either of the OLA groups required rescue manoeuvres.

INTERPRETATION

In patients who have major abdominal surgery, the different perioperative open lung approaches tested in this study did not reduce the risk of postoperative complications when compared with standard lung-protective mechanical ventilation.

FUNDING

Instituto de Salud Carlos III of the Spanish Ministry of Economy and Competitiveness, and Grants Programme of the European Society of Anaesthesiology.

Ataxia Severity Correlates with White Matter Degeneration in Spinocerebellar Ataxia Type 7

BACKGROUND AND PURPOSE

There is a scarcity of information on the effect of white matter degeneration in patients with spinocerebellar ataxia type 7. Therefore, we investigated the WM integrity in a large group of patients with spinocerebellar ataxia type 7 by using Tract-Based Spatial Statistics.

MATERIALS AND METHODS

Thirty-three patients with a molecular diagnosis of spinocerebellar ataxia type 7 and their age- and sex-matched healthy controls participated in this study. The patients' ataxia severity was evaluated with the Scale for the Assessment and Rating of Ataxia. Voxelwise analyses of diffusion metrics, including fractional anisotropy and mean diffusivity, were performed with Tract-Based Spatial Statistics. The correlation between WM abnormalities and ataxia severity was then calculated.

RESULTS

Tract-Based Spatial Statistics analysis revealed WM abnormalities in the cerebellum and the cerebellar peduncles, as well as in other major cortical and subcortical pathways. Further analysis between the Scale for the Assessment and Rating of Ataxia score and WM mean diffusivity showed significant associations only in key areas related to motor control and visuospatial processing, including the cerebellar WM, the middle occipital WM, the superior cerebellar peduncle, and bilateral anterior thalamic radiation. No significant associations between fractional anisotropy and the Scale for the Assessment and Rating of Ataxia were found.

CONCLUSIONS

These results suggest a significant contribution of local cerebellar and cerebellar-midbrain connections to ataxic impairment in spinocerebellar ataxia type 7. The results also suggest an involvement of cortical WM abnormalities including tracts within the occipital and frontal cortices. These findings contribute to a more comprehensive view of the clinical impact of the white matter degeneration in spinocerebellar ataxia type 7.

Range extension and geographic distribution of the poorly known species, Contomastix leachei Peracca, 1897 (Squamata: Teiidae)

The records of distribution of Contomastix leachei Peracca, 1897 indicate that this species is endemic of Southeast Jujuy Province, occurring only in the Ledesma Department. Here, we report the southernmost known locality of this species, from Alemanía, Salta Province, Argentina. This record represents the southern limit of distribution of the species. We also provide an updated range map for this species based on data from museum records and field studies. 

[Ultrasound-guided infraclavicular axillary vein cannulation]

BACKGROUND AND OBJECTIVE

Percutaneous central venous cannulation is a challenging procedure. Traditionally, an external landmark technique has been used to identify puncture site. We wanted to evaluate an ultrasound-guided technique for the axillary vein cannulation, looking specifically at the ease of use, success rate and decreased complications.

METHODS

Sixty consecutive surgical patients scheduled for central venous catheter placement were registered. An ultrasound scanner made for guiding an in plane puncture of axillary vein was used. After locating the vessels, an echo-guided sterile procedure was performed to cannulate the vein.

RESULTS

Cannulation was successful in all patients, and there were no complications during insertion of the catheters. Both axillary veins were cannulated, and the vein was punctured successfully at first attempt in 95% of the patients. The median time from the start of the first puncture (of the skin) until the aspiration of blood was 15 (7- 135) seconds.

CONCLUSION

This ultrasound-guided technique for inserting central venous catheters in axillary vein was easy to apply. This procedure could increase precision and safety in patients undergoing axillary vein cannulation.

Oral autopsy of unidentified burned human remains. A new procedure

Forensic dentistry plays an increasingly important role in medicolegal investigation and identification procedures. The oral examination may be difficult because of postmortem changes, especially those of carbonized corpses. We present a new technique of oral autopsy that includes a new means of access to the oral cavity designed for application on unidentified burned human remains. This technique preserves the facial configuration of the cadaver, allowing visual recognition by family members or other persons that is fundamental if the antemortem dental records do not exist or are not available. Also, this technique permits adequate work productivity by the forensic team members and can be used in difficult working conditions, such as mass-disaster scenarios.

Base rate and simulated symptoms of mild head injury among normals

This study examined the vulnerability of several self-report instruments commonly used in neuropsychological evaluation - the Iowa Interview for Partial Seiwre-Like Symptoms, Postconcussion Checklist (PCL). Postconcussion Syndrome Checklist (PCSC), and Beck Depression Inventory (BDI) - to exaggerated or feigned complaints. Two hundred twenty-nine college student volunteers completed the instruments under one of three conditions: I) Base Rate/Control; simulated Head Injured, but 2) without or 3) with prospect of financial gain for the injury. Although the simulated Head Injured groups did not differ significantly from one another, both groups endorsed more symptoms than the Base Rate group, suggesting that the instruments are vulnerable, to simulation. Base rates of head injury symptoms in the normal population, laypersons' knowledge about the sequelae of mild head injury, and implications of using symptom checklists in medicolegal evaluations were discussed, as was the desirability of replicating this study with noncollege student populations.

Reference values of immunoglobulin E in umbilical cord sera

The National Program for the Prevention of Allergic Diseases, including the determination of IgE concentrations in umbilical cord serum at birth began in 1986. Research was conducted to determine normal umbilical cord serum values in Cuban children since no previous research had been performed. The values consulted corresponded to children from other countries with different characteristics from ours. A total of 900 neonates were examined, excluding those whose mothers had been affected by factors that increase serum IgE concentrations. IgE values higher than 10 IU/ml were also regarded as abnormal. The microELISA-IgE technique, a heterogenous immunoenzymatic sandwich type assay, was used. As reference values, a 0.64 mean, 0.06 lower limit and a 6.83 upper limit were obtained.

Prevention of allergic diseases and IgE dosification in cord sera

In 1986, a Program on Prevention of Allergic Diseases was initiated in our country which was possible on account of the organization conditions of our health system. The program includes IgE measurement in umbilical cord serum by means of an ultramicroanalytic technique for IgE quantification. This is an heterogeneous sandwich-type immunoassay that requires only 10 microliters of reactive on each reaction step and its processing is carried out on the Cuban SUMA equipment. Two groups of children were selected and followed-up: group I included 80 one-year-old infants and group II included 60 18-months-old infants. Both groups followed hypoallergenic diets and had minimal exposure to aeroallergens within their microenvironment. Results were compared with those of respective control groups. Compliance of both groups with the prophylactic measures brought about a reduction in the existence of allergic diseases and a comparison with the control groups offered a statistically significant difference (p less than 0.001). Similarly, incidence of asthma was found more reduced in groups I and II than in the control groups (p less than 0.001). Within the groups treated under the Program on Prevention of Allergic Diseases, IgE values were lower, while the control groups exhibited a higher number of infants with figures of 200 IU/ml or more (p less than 0.05). Our results support the usefulness of preventive measures in avoiding the presence of atopic diseases.