Crabtree (United States)

My family has had autosomal dominant polycystic kidney disease for more than 100 years. It was not until my dad's generation that having that disease was not a death sentence. Because of the science and advancements of drugs and treatment, he and I have lived amazing lives. Dad passed away in 2025 at the age of 86, a good long life for any man, and I am now 67 and still walking this earth. In the 1960s, my doctor was not a fan of early diagnosis. He felt it would affect my ability to thrive as a kid, but when I turned out to be a great specimen for flag football in middle school, he agreed to have me diagnosed. At 12 years, using radioactive dye and x-rays, it was confirmed that I was the frightened owner of polycystic kidneys and liver. There is a lot to unpack in this sentence, but I shared this with you to show how far technology has come. X-rays and dye that caused most patients to vomit and harmed the very organs we were viewing were the only diagnostic tool available to us. But as the years went on, new and noninvasive diagnostic tools became available. The amount of information available to me to slow down the disease at the time of diagnosis was nonexistent, and even in my 20s, the only thing my doctor could suggest was to control my BP and maybe not drink coffee. As time went on, studies like this one added more information to my toolbox to improve or maintain my health for as long as possible. At the age of 12, I was told my lifespan was <50 years, but, as of authoring this article, I am 67 years old. I hope to live as long as my dad did. With better medications like this study shows, I just might. The study I have been asked to comment on “Efficacy, Mechanisms and Safety of Sodium-Glucose Cotransporter-2 Inhibitors in Kidney Transplant Recipients: A Randomized, Double-Blind, Placebo-Controlled Trial” had the primary objective to evaluate BP lowering with dapagliflozin.1 Secondary outcomes were iohexol-measured GFR, natriuresis, body composition, noninvasive cardiac output monitoring, arterial stiffness, heart rate variability, neurohormones, and safety in kidney transplant patients. Being a lay person, I had some difficulty absorbing the information in this study and spent quite a lot of time asking questions of folks I know who were able to help me understand. With their help and a better understanding of the metrics used, I feel this was an important and meaningful experiment for my family. The connection of polycystic kidney disease and heart disease is truly clear in my family and though few if any of us has died of heart disease, most deaths were complicated by it. Also, post-transplant onset diabetes has affected most of us, although I have remained prediabetic for 15 years, I still hold hope that my path may turn out differently. While the importance of this study is obvious, I think it is crucial to look at the possible weak points. Almost 80% of the subjects were men, and the authors attribute this to a pattern of more men getting transplants than women. From the National Kidney Foundation2 to the National Library of Medicine,3 other works have confirmed this comment. I would like to see more done to find a way to correct this inequality to half of the world's population. I want to thank all the people who have made my life and my family's lives better and are filled with hope for the next new advance that will make the life of the kidney community healthier and more productive as was planned way back in the 70s.

To examine the overall responses of nursing home staff to a newly developed nursing home specific survey instrument to assess patient safety culture (PSC) and to examine whether nursing home staff (including administrator/manager, licensed nurse, nurse aide, direct care staff, and support staff) differ in their PSC ratings. Data were collected in late 2007 through early 2008 using a survey administered to staff in each of 40 nursing homes. In 4 of these nursing homes, the responses of different staff were identified. The Nursing Home Survey on Patient Safety Culture was used to assess the 12 domains of the PSC and identify differences in PSC perceptions between staff. For the 40 nursing homes in the sample, the overall facility response rate was 72%. For the 4 nursing homes of interest, the overall facility response rate was 68.9%. The aggregate Nursing Home Survey on Patient Safety Culture scores, using all staff types for all survey items, show that most respondents report a poor PSC. However, administrators/managers had more positive scores than the other staff types (P < 0.05) across most domains. Staff in nursing homes generally agree that PSC is poor. This may have a significant impact on quality of care and quality of life for residents.

Numerous primary care practice development efforts, many related to the patient-centered medical home (PCMH), are emerging across the United States with few guides available to inform them. This article presents a relationship-centered practice development approach to understand practice and to aid in fostering practice development to advance key attributes of primary care that include access to first-contact care, comprehensive care, coordination of care, and a personal relationship over time. Informed by complexity theory and relational theories of organizational learning, we built on discoveries from the American Academy of Family Physicians' National Demonstration Project (NDP) and 15 years of research to understand and improve primary care practice. Primary care practices can fruitfully be understood as complex adaptive systems consisting of a core (a practice's key resources, organizational structure, and functional processes), adaptive reserve (practice features that enhance resilience, such as relationships), and attentiveness to the local environment. The effectiveness of these attributes represents the practice's internal capability. With adequate motivation, healthy, thriving practices advance along a pathway of slow, continuous developmental change with occasional rapid periods of transformation as they evolve better fits with their environment. Practice development is enhanced through systematically using strategies that involve setting direction and boundaries, implementing sensing systems, focusing on creative tensions, and fostering learning conversations. Successful practice development begins with changes that strengthen practices' core, build adaptive reserve, and expand attentiveness to the local environment. Development progresses toward transformation through enhancing primary care attributes.

Tetrahydrobiopterin (BH4) supplementation improves endothelial function in models of vascular disease by maintaining endothelial nitric oxide synthase coupling and nitric oxide bioavailability. Recent studies using pharmacological and transgenic endothelial-specific BH4 supplementation highlighted the therapeutic potential of BH4 in native atherosclerosis and vascular injury and suggested a potential role for BH4 as regulator of inflammation and vascular remodeling. However, the cellular mechanisms through which this leads to reduced atherosclerosis remain unclear. We have used a pharmaceutical BH4 formulation to address the hypothesis that improved endothelial function resulting from exogenous BH4 supplementation leads to reduced atherosclerosis through effects on vascular inflammation. Single oral dose pharmacokinetic studies revealed rapid BH4 uptake from the gastrointestinal tract into plasma and organs. While in most organs BH4 levels returned to baseline by 8 hours after dosing, BH4 levels in aorta remained markedly increased at 24 hours, suggesting an active mechanism for BH4 retention. Daily oral BH4 supplementation in 8 week old chow-fed ApoE-KO mice for 8 or 12 weeks had no effect on plasma lipids or hemodynamic parameters, but resulted in a significant 45% relative reduction in aortic root atherosclerosis only at 10 mg/kg BH4, compared with placebo controls (0.049 vs. 0.088 mm2, P&lt;0.05 after 8 weeks; 0.142 vs. 0.259 mm2, P&lt;0.05 after 12 weeks). BH4 treatment led to a striking reduction in T cell infiltration, both within plaques (0.001886 vs. 0.006653 mm2; P&lt;0.05) and in the surrounding adventitia (0.007741 vs. 0.020133 mm2; P&lt;0.05). Importantly, BH4 treatment had no effect on circulating leukocyte numbers, and furthermore no evidence for BH4 uptake by peripheral blood mononuclear cells from plasma after single oral supplementation was found. Experiments using endothelium-targeted GTP-cyclohydrolase 1 transgenic mice, with a specific increase in endothelial BH4 levels, revealed a similar reduction in vascular T cell infiltration, suggesting that BH4 supplementation reduces atherosclerosis through a reduction in vascular T cell infiltration mediated by salutary effects on endothelial nitric oxide bioavailability.

Clinical reasoning in occupational therapy has been described using a variety of images. The present paper aims to give an overview of three major images that have been proposed in the occupational therapy literature since 1982. These are reasoning as information processing, thinking in stories or narrative reasoning, and reasoning as an interpersonal process. These three images are compared with the concept of conditional reasoning.

ResponseLucas points out a problem with using diagnoses of nasopharyngeal cancer (NPC) from death certificates.As Lucas noted, the quality of diagnosis of NPC on death certificates is poor.The author contends that the "impact of such misclassification is to overestimate NPC incidence among formaldehyde work-