ABSTRACT
Background: In a 2019 survey given in our cystic fibrosis (CF) clinic, our adult patients identified appointment duration as the most common barrier to coming to the clinic. It is important for us to address this barrier to reduce appointment duration and thereby increase patient satisfaction with the center. The aim was to decrease the length of overall unengaged time between providers from 34 minutes to less than 20 minutes, reducing the ratio of unengaged time to total time between August 2019 through the end of November 2021. Method(s): The process began with identifying length of time spent in clinic, length of nonengaged time between providers, and overall nonengaged time. We collected data between August 2019 and November 2021. The process ended with reducing overall length of clinic visit by reducing nonengaged time between providers and overall nonengaged time. The data collected from August 2019 through November 2019 showed overall median clinic visit length of 104 minutes and overall median unengaged time of 34 minutes (32% of total clinic visit), with a median wait time of 5 minutes between providers. To determine length of clinic visits, we documented what time the clinic visit began and ended for each patient as well as the enter and exit time for each provider. In February 2020, our first intervention was to appoint a monitor to pay attention to which patients were being seen by a provider and which patients were unengaged. The monitor identified unengaged patients and asked a provider to go see the patient. In March 2020, our clinic was forced to pivot to telehealth visits because of the COVID-19 pandemic. For all of April and May 2020, our center did only telehealth visits. In June 2020, we started slowly adding back in-person visits. Because of the pandemic,we had to change the order of clinic flow, which in turn increased the amount of unengaged time. We used this data to convince the administration to let us change clinic flow while still complying with COVID-19 precautions. All data collected between June 2020 through the end of November 2021 included COVID- 19 precautions. Result(s): After the initial intervention of having a monitor keep track of which patients were unengaged and could be seen by other members of the team, the data showed an increase in overall appointment length to a median of 110 minutes from 104 minutes. Overall unengaged time remained the same at a median of 34 minutes, but median betweenprovider time was reduced to 4 minutes from 5 minutes. By instituting the monitor intervention, the ratio of unengaged time to total time decreased from 32% to 30%. Conclusion(s): Althoughwe did not meet our goal,wewere able to maintain overall length of clinic duration despite a global pandemic. Our clinic is no longer required to use strict COVID-19 precautions, so we have returned to our original clinic flow. We will continue to gather data in hopes of decreasing clinic duration and thereby increasing patient satisfaction.Copyright © 2022, European Cystic Fibrosis Society. All rights reserved
ABSTRACT
The Kidney Disease Quality of Life (KDQOL) survey is a review of patients’ quality of life (QOL) on hemodialysis. Lower survey scores in depression, burden of disease, and treatment satisfaction are associated with worse compliance to treatment and poorer outcomes. KDQOL surveys were extracted from and stratified by year, with duplicate entries removed. Annual mean scores for each component of the survey were calculated for each clinic. The KDQOL data represents the mean scores for 2017-2019 compared to the first three quarters of 2021. 2020 was excluded due to sampling challenges and high patient turnover creating potentially inaccurate data. Mean scores were compared by Student’s t-test with Bonferroni adjustment for multiplicity. Phosphorus and PTH levels were used as a surrogate for treatment compliance. Patients reported lower QOL scores during the COVID-19 pandemic compared to pre-pandemic (baseline). All KDQOL metrics were significantly lower in 2021 compared to the mean of three years prior to the pandemic. A two sample Student’s T test was used to determine the change in mean score for each category: Physical Component Score (t(2)= 14.5, p=0.009), Mental Component Score (t(2)= 36.7, p=0.0004), Burden of Kidney Disease (t(2)= 6.1, p=0.01), Symptoms of Kidney Disease (t(2)= 22.8, p=0.0009), Effects of Kidney Disease (t(2)= 8.8, p=0.006). Phosphorus was significantly higher in 2021 compared to the mean of 2018 and 2019 when calculated via t-test (t(31)= -2.72, p=0.01). Parathyroid Hormone quarterly data was evaluated via t-test for 2018 to 2020 vs. the first three quarters of 2021 (t(12)= -7.15, p=0.01) Using the KDQOL survey to measure patients’ QOL, we found that all measures were significantly lower in 2021 following the pandemic. Using markers of bone metabolism as measures of treatment compliance, phosphorus and PTH levels were also significantly higher in 2021. In ESRD patients who survived the trauma of the pandemic, QOL is perceived to be worse and is likely affecting compliance. Social workers and staff need to be aware of these trends to provide the appropriate counselling and resources to meet the needs of these patients.
ABSTRACT
Introduction: Elexacaftor-tezacaftor-ivacaftor was approved for cystic fibrosis (CF) patients ≥12 years old in October 2019. Clinical studies have shown impressive weight gain in patients on this triple combination therapy (TCT). There are no body composition goals set for CF patients as these standards have not yet been validated in the CF population and there are no data showing the effects of TCT on body composition. There are limitations of BMI, such as the lack of knowledge of the patient's body fat percentage (BF%) and skeletal muscle mass (SMM). We aim to improve our knowledge of TCT effects on CF patient's body composition over time so we may provide more effective nutritional and physical activity recommendations with a goal towards health weight gain. Method: The clinic offers InBody Bioelectrical Impedance Analysis scans. The care team then evaluates the patient, reviews results and offers dietary and exercise recommendations. Our patients were instructed to continue their previous nutritional recommendations, exercise regimens, and daily activities after starting TCT. Eligible patients received a pre- and post-InBody assessment using the following criteria: they must have had InBody test prior to starting TCT and be in the clinic for post-testing within 3 months of starting TCT. We measured weight, BMI, skeletal muscle mass, and body fat percentage (BF%) before starting TCT and at post-testing. Results: The adult center has 143 patients. Of these, 38 completed baseline InBody testing, exercise and nutrition assessment prior to starting TCT. Eighteen out of the 38 patients (47%) completed the study with a post-TCT assessment. Study patients showed significant weight gain with mean weight increasing from 144 to 151 pounds. Mean BMI increased from 23 to 24. There was an improvement in SMM (60.23 to 61.7 lb), with minimal change in BF% (24.6% to 24.8%). After starting TCT, 11/18 (61%) reported increased appetite, prolonged stamina during exercise, and increased appetite after exercise. Conclusion: In this study there was a notable increase in SMM with minimal change in BF%. SMM increases are more desirable due to skeletal tissue's roles in the body as it contributes to mobility, stability, posture, circulation, and digestion. TCT promoted weight gain and improvements in SMM with minimal change in BF%. Given this preliminary data it is unknown if these changes in body composition are directly related to TCT or an effect of the improved energy levels and exercise tolerance, that were seen in the majority of our patients. Larger studies are needed to further evaluate these results. As CF patients live longer it is imperative that healthcare providers prepare them for healthy aging. Part of this is encouraging proper exercise and the intake of a healthy diet. The COVID-19 pandemic impacted our study by decreasing our sample size dramatically, hence it is not statistically significant. Post-assessments were halted due to cancellations of in-clinic visits. Our clinic will continue to measure baseline- and post-assessments, focusing on sustainable clinic flow operations, increasing education, and increasing sample size through collaboration with the pediatric CF center.
ABSTRACT
Background: Kidney injury molecule-1 (KIM-1), a type-1 transmembrane glycoprotein, has been well studied as a specific injury marker for proximal tubules (PT). KIM-1 functions as a receptor for apoptotic fragments through a phagocytic process. KIM-1 (also called TIM-1) serves as a receptor for hepatitis A virus and Ebola virus, and possibly for severe respiratory syndrome-coronavirus (SARS-CoV-1). During the pandemic spread of coronavirus disease 2019 (COVID-19), many patients have suffered from acute kidney injury (AKI) as well as lung damage, Viral upkake has been attributed to interactions with ACE2, a receptor for the virus. The goal of this study was to investigate whether there is kidney histological data that KIM-1 may also serve as a receptor for SARS-CoV-2 to infect the PT. Methods: Two patients (one adult and one child) who died of COVID19 and 10 patients with AKI but no COVID19 (control group) were included in the study. All kidney tissue sections were stained for KIM-1 (monoclonal AKG7 antibody) and scored from 0 to 3+. Electron microscopy was conducted using kidney tissue of the COVID19+ patients. Results: Both COVID19+ patients had normal pre-mortem levels of serum creatinine (sCr) (adult 0.63 and child 0.17 mg/dl), whereas the control cases all had elevated sCr (1.9 to 10.7 mg/dl). Control renal biopsies revealed positive KIM-1 staining ranging from 1+ to 3+ along the surface of PT in a patchy pattern involving 20 to 80% of the cortex;no cytoplasmic granular materials were identified. By contrast, the KIM-1 staining in COVID19+ kidneys revealed spotty granular staining in the cytoplasm and diffuse surface 2+ to 3+ staining in most PTs, while glomeruli stained negatively for KIM-1 as internal negative controls. In the two COVID19+ patients, SARS-CoV-2 particles showed spiking-crown appearances with sizes ranging from 70 to 110 nm in the PT cytoplasm by ultrastructural studies. Conclusions: Our initial evidence suggests there is an atypical staining pattern of KIM-1 in the PT of COVID19+ patients, raising a possibility that KIM-1 may serve as a receptor for SARS-CoV-2. KIM-1 may also serve to internalize the virus into the PT. In addition the two COVID+ patients had normal sCr levels but positive KIM-1 staining, indicating that sCr underestimates renal injury caused by SAR-CoV-2 infection.