Search

Background and objectives Individuals receiving in-center hemodialysis experience a high symptom burden that detrimentally affects their quality of life. There are few evidence-based interventions for symptom relief in this population. To stimulate innovation in symptom management, data on patient symptom prioritization and treatment preferences are needed. We undertook this study to (1) identify patient-prioritized symptoms for the development of symptom relief therapies and (2) elicit preferences for treatments among individuals receiving hemodialysis. Design, setting, participants, & measurements We conducted a mixed methods study that included focus groups in Carrboro, North Carolina; Tucson, Arizona; and Seattle, Washington and a nationally distributed online survey. Focus group transcripts were analyzed for patterns, and the highest priority symptoms were determined on the basis of frequency and report severity. We used focus group findings to inform survey items. Focus group and survey results were crossvalidated and synthesized for final symptom prioritization. Results There were 32 participants across three focus groups and 87 survey respondents from 27 states in the United States. The physical symptoms of insomnia, fatigue, muscle cramping, and nausea/vomiting and the mood symptoms of anxiety and depressed mood were reported by participants in all focus groups. Among survey respondents, fatigue (94%), cramping (79%), and body aches (76%) were the most common physical symptoms, and feeling depressed (66%), worried (64%), and frustrated (63%) were the most common mood symptoms. The top-prioritized symptoms were consistent across focus group and survey participants and included the physical symptoms insomnia, fatigue, and cramping and the mood symptoms anxiety, depression, and frustration. Participants indicated that symptom frequency, duration, unpredictability, and social and financial effects factored most heavily into symptom prioritization. Conclusions Patients prioritized the physical symptoms of insomnia, fatigue, and cramping and the mood symptoms of anxiety, depression, and frustration as the top symptoms for which to find new therapies. Podcast This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2018_03_20_CJASNPodcast_18_5_F.mp3

Individuals receiving in-center maintenance hemodialysis bear a high burden of both physical and mood symptoms. More than half of patients on hemodialysis report sleep disturbance, muscle cramps, and fatigue. Patients describe symptoms as having a deleterious effect on their quality of life, suggesting that symptom alleviation may meaningfully improve patient-reported outcomes. Moreover, patients on hemodialysis have identified symptom management as a key area for research and innovation, prioritizing symptom alleviation over other health outcomes such as mortality and biochemical indices. Despite the importance of symptoms to patients, there has been little research explicitly geared toward improving patient symptoms, and therefore minimal innovation in symptom management. In general, the physiologic underpinnings of symptoms are poorly understood, hampering the development of targeted therapies. In fact, there have been few drugs or devices approved by the US Food and Drug Administration for the indication of improving any patient-reported outcomes for patients on hemodialysis. Recognizing this gap in innovation, the Kidney Health Initiative, a public-private partnership between the American Society of Nephrology and US Food and Drug Administration, convened a workgroup to first prioritize symptoms for the development of therapeutic interventions, and then identify near-term actionable research goals for the prioritized physical symptoms of insomnia, muscle cramps, and fatigue. This paper summarizes the pathophysiology of the three prioritized symptoms, identifies key knowledge gaps, acknowledges factors that challenge development of new therapies, and offers the nephrology community actionable research goals for insomnia, muscle cramps, and fatigue.

Un ejemplar de Huttonella bicolor = Gulella bicolor (Hutton, 1834) fue capturado en suelo limo-arenoso en Tabasco, México; el cual constituye el segundo registro para el estado y el tercero para México. Este pequeño gasterópodo es un depredador que se ha extendido como especie exótica en regiones preferentemente tropicales e insulares; destaca su introducción en islas de Asia y del Caribe. La concha tiene forma de pupa con lamelas o dientes en la abertura. Se comparó con la descripción de la especie. La distribución de la especie en México se extiende a los estados de Veracruz y en Tabasco, lo cual confirma el avance en su distribución a lo largo de la costa del Golfo de México de los Estados Unidos hasta Brasil. Las características de este estreptaxcido en cuanto al riesgo a través del tipo de presa preferida son discutidas.

Background: In 2008, the National Heart, Lung, and Blood Institute convened an Implementation Science Work Group to assess evidence-based strategies for effectively implementing clinical practice guidelines. This was part of a larger effort to update existing clinical practice guidelines on cholesterol, blood pressure, and overweight/obesity. Objectives: Review evidence from the published implementation science literature and identify effective or promising strategies to enhance the adoption and implementation of clinical practice guidelines. Methods: This systematic review was conducted on 4 critical questions, each focusing on the adoption and effectiveness of 4 intervention strategies: (1) reminders, (2) educational outreach visits, (3) audit and feedback, and (4) provider incentives. A scoping review of the Rx for Change database of systematic reviews was used to identify promising guideline implementation interventions aimed at providers. Inclusion and exclusion criteria were developed a priori for each question, and the published literature was initially searched up to 2012, and then updated with a supplemental search to 2015. Two independent reviewers screened the returned citations to identify relevant reviews and rated the quality of each included review. Results: Audit and feedback and educational outreach visits were generally effective in improving both process of care (15 of 21 reviews and 12 of 13 reviews, respectively) and clinical outcomes (7 of 12 reviews and 3 of 5 reviews, respectively). Provider incentives showed mixed effectiveness for improving both process of care (3 of 4 reviews) and clinical outcomes (3 reviews equally distributed between generally effective, mixed, and generally ineffective). Reminders showed mixed effectiveness for improving process of care outcomes (27 reviews with 11 mixed and 3 generally ineffective results) and were generally ineffective for clinical outcomes (18 reviews with 6 mixed and 9 generally ineffective results). Educational outreach visits (2 of 2 reviews), reminders (3 of 4 reviews), and provider incentives (1 of 1 review) were generally effective for cost reduction. Educational outreach visits (1 of 1 review) and provider incentives (1 of 1 review) were also generally effective for cost-effectiveness outcomes. Barriers to clinician adoption or adherence to guidelines included time constraints (8 reviews/overviews); limited staffing resources (2 overviews); timing (5 reviews/overviews); clinician skepticism (5 reviews/overviews); clinician knowledge of guidelines (4 reviews/overviews); and higher age of the clinician (1 overview). Facilitating factors included guideline characteristics such as format, resources, and end-user involvement (6 reviews/overviews); involving stakeholders (5 reviews/overviews); leadership support (5 reviews/overviews); scope of implementation (5 reviews/overviews); organizational culture such as multidisciplinary teams and low-baseline adherence (9 reviews/overviews); and electronic guidelines systems (3 reviews). Conclusion: The strategies of audit and feedback and educational outreach visits were generally effective in improving both process of care and clinical outcomes. Reminders and provider incentives showed mixed effectiveness, or were generally ineffective. No general conclusion could be reached about cost effectiveness, because of limitations in the evidence. Important gaps exist in the evidence on effectiveness of implementation interventions, especially regarding clinical outcomes, cost effectiveness and contextual issues affecting successful implementation.

ResumenLa diversidad del phyllum Mollusca distribuida en la extensa costa de México, ha sido difícil de precisar, pero debido a que la riqueza de especies es la principal variable descriptiva de la biodiversidad de un país, el presente trabajo tiene como objetivo primario estimar el número de especies clasificadas en las costas mexicanas. Se hizo una revisión de fuentes de información nacional e internacional, concibiendo su referencia a nivel global y en algunos países del Caribe. La diversidad de moluscos marinos en México se estimó en 4 643 especies, de las cuales 2 576 corresponden a la costa del Pacífico y 2 067 a la del golfo de México y Caribe mexicanos. Se brindan datos sobre la descripción morfológica, nutrición y hábitat, así como componentes endémicos. Se muestra la historiografía de 250 años de las descripciones de especies nuevas de la costa mexicana, las cuales reflejan una gran aportación de especialistas extranjeros. Aún falta mucho por explorar en mares profundos, así como en surgencias hidrotermales, islas, lagunas costeras y arrecifes coralinos.AbstractAssessing the patterns of diversity of the phylum Mollusca along the extensive Mexico’s littoral zones represent a challenging task. However, one can argue that the biodiversity of a country can properly be expressed using descriptive variables such as species richness. With this in mind, the present study attempts to estimate the total number of species composing the marine Mexican mollusk fauna. For this purpose, an extensive literature search was conducted, consulting both national and international sources. This effort revealed the existence of a total of 4 643 marine mollusk species distributed as follows: 2 576 in the Pacific and 2 067 in the Gulf of Mexico and the Caribbean. It is herein included a brief morphological description, nutritional and habitat characteristics, as well as endemic components. The historical records of new species of marine mollusk described in Mexico, mostly made by foreign scientist, dating back 250 years were reviewed. Undoubtedly, the marine mollusk fauna diversity of Mexico would be significantly enriched with the explorations of the deep sea, hidrothermal vents, islands, and with the increasing sampling effort in coastal lagoons and coral reef habitats.