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Hypertension is a common problem among patients with glomerular disease and CKD. Optimal blood pressure targets for these patients have been the source of much debate. Careful review of the available data supports a blood pressure target of less than 140/90 mmHg. Consideration for a lower goal of less than 130/80 mmHg should be given for patients with heavy proteinuria. Renin-angiotensin system inhibitors should be used as the cornerstone of therapy for all patients with glomerular disease and CKD.
Copyright © 2014 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.
Radiation exposure to the thorax is associated with substantial risk for the subsequent development of cardiovascular disease. Thus, the increasing role of radiation therapy in the contemporary treatment of cancer, combined with improving survival rates of patients undergoing this therapy, contributes to a growing population at risk of cardiovascular morbidity and mortality. Associated cardiovascular injuries include pericardial disease, coronary artery disease, valvular disease, conduction disease, cardiomyopathy, and medium and large vessel vasculopathy-any of which can occur at varying intervals following irradiation. Higher radiation doses, younger age at the time of irradiation, longer intervals from the time of radiation, and coexisting cardiovascular risk factors all predispose to these injuries. The true incidence of radiation-related cardiovascular disease remains uncertain due to lack of large multicentre studies with a sufficient duration of cardiovascular follow-up. There are currently no consensus guidelines available to inform the optimal approach to cardiovascular surveillance of recipients of thoracic radiation. Therefore, we review the cardiovascular consequences of radiation therapy and focus on the potential role of non-invasive cardiovascular imaging in the assessment and management of radiation-related cardiovascular disease. In doing so, we highlight characteristics that can be used to identify individuals at risk for developing post-radiation cardiovascular disease and propose an imaging-based algorithm for their clinical surveillance.
The major payer of dialysis services in the United States, Medicare, has established incentives to encourage the use of home dialysis. However, this modality remains underutilized. We think that a major cause of this situation is ineffective education of the prospective dialysis population regarding the choices of kidney replacement modalities. We discuss the value of patient education and the consequences of failing to educate prospective dialysis patients. We then explore approaches to achieve patient education goals and the physician's and education team's roles in the development of an individual patient's life plan.
© 2013 Wiley Periodicals, Inc.
This study was conducted to explore whether racial/ethnic differences exist in treatment discussed, preferred, and ultimately received for localized prostate cancer (PCa) as epidemiological data are scant on this issue. The authors recruited 640 localized PCa patients from the Texas Medical Center, Houston, Texas, between 1996 and 2004. The authors used a structured questionnaire to collect data through personal interviews. Three main treatment modalities for localized PCa, consisting of surgery, radiation therapy, and watchful waiting, were considered for this study. It was found that health professionals were less likely to discuss surgery (odds ratio [OR] = 0.35, 95% confidence interval [CI] = 0.18-0.68) and watchful waiting (OR = 0.53, 95% CI = 0.34-0.83) with Hispanics than Whites. However, African Americans were less likely to receive watchful waiting (OR = 0.22, 95% CI = 0.05-0.93). They were more likely to prefer (OR = 1.23, 95% CI = 0.78-1.94) and receive (OR = 1.27, 95% CI = 0.87-1.86) radiation therapy, although they did not achieve statistical significance (p < .05). Higher age was associated with lower likelihood of discussing, preferring, and receiving surgical treatment. Higher Gleason sum was associated with lower likelihood of discussing treatment. A comparison of concordances between treatment preferred by patients and what was actually received, in general, showed a higher agreement for surgery and radiation therapy. More exploration needs to be done in other settings to confirm these findings.
INTRODUCTION - This study examined the association between sociodemographic, cancer treatment, and care delivery factors on young adult cancer survivors' confidence in managing their survivorship care.
METHODS - Survivors aged 18-39 years (n = 376) recruited from the LIVESTRONG™ Survivorship Center of Excellence Network sites completed a survey assessing self-reported receipt of survivorship care planning, expectations of their providers, and confidence in managing their survivorship care. Multivariate logistic regression identified characteristics of those reporting low confidence in managing their survivorship care.
RESULTS - Mean age was 28 years; mean interval from diagnosis was 9 ± 8 years. Seventy-one percent reported currently attending an oncology survivorship clinic. Regarding survivorship care planning, 33% did not have copies of their cancer-related medical records, 48% did not have a treatment summary, and 55% had not received a survivorship care plan. Seventy percent identified the oncologist as the most important health care provider for decisions regarding test and treatment decisions while 10% reported using a "shared-care model" involving both primary care providers and oncologists. Forty-one percent were classified as having low confidence in managing survivorship care. In multivariate analysis, low confidence was associated with non-white ethnicity and lack of a survivorship care plan (both p < 0.05).
DISCUSSION/CONCLUSIONS - Findings suggest that provision of survivorship care plans for young adult cancer survivors can be used to improve confidence in managing survivorship care, particularly for ethnic minorities.
IMPLICATIONS FOR CANCER SURVIVORS - Survivors should consider advocating for receipt of a survivorship care plan as it may facilitate confidence as a consumer of survivorship care.
The use of computer-based documentation tools confers many benefits to the delivery of evidence-based health care. We developed Clictate, a structured reporting environment that utilized standard Windows-based data entry constructs and natural language generation. Clictate has been in use for over 3 years by pediatric providers in an ambulatory setting. More than 50% of our providers use Clictate during the patient encounter. This report describes our results to date, and suggests future opportunities for research and development in the area of computer-based documentation.
OBJECTIVES - Market forces make it essential to know what policies and actions influence patients' reports of hospital services. No studies have examined the role of patient characteristics, labor quality and staff characteristics, nonlabor resources, managerial practices, and employee attitudes within a single investigation.
METHODS - The authors collected, simultaneously, data about labor, management and service processes, nonlabor resources, and employee attitudes on 117 nonintensive medical-surgical inpatient units in 17 hospitals selected from a pool of 69 institutions within a metropolitan area by a stratified random sample. Of the 2,595 patients who agreed to participate, 2,051 (79%) completed telephone interviews regarding their experiences with physical care, education, and pain management services within 26 days of hospital discharge.
RESULTS - A significant amount of variation in patients' service reports was explained (adjusted R2 = 0.41 physical care, 0.35 pain management, 0.44 education). Although the predictors varied for each service report, patient characteristics, especially those related to personal resources, had a large explanatory role. A labor assignment pattern that could explain why earlier studies found labor quality and staff characteristics to have only a weak role in the prediction of patients' service reports was noted.
CONCLUSIONS - The results related to patient characteristics may indicate opportunities to improve care by confronting service design strategies that erroneously rely on a homogeneous patient population. Measurement challenges identified by this study must be addressed to determine the role of labor quantity and staff characteristics.