Nephrology training curriculum and implications for optimal kidney care in the developing world.

An effective workforce is essential for delivery of high-quality chronic disease care. Low-income nations are challenged by a dearth and/or maldistribution of an essential workforce required for all chronic disease care including chronic kidney disease (CKD). Nephrology education and training in developed countries have grown at pace with the technological advancement in the practice of medicine in order to meet the standards required of kidney health professionals towards high-quality, patient-centered medical care. The standards designed by institutions and/or professional societies, such as Royal Colleges and Medical Councils in high-income nations with well-developed health systems and infrastructures, are often not easily translatable to issues critical to nephrology practice in low-income nations. Little or no guidance is provided on common nephrological issues of regional nature or pertaining to ethnic minorities and disadvantaged groups living in those countries. There is an emergent need for a training curriculum that meets the needs and peculiarities of the developing nations, and this needs to leverage on the existing and well-validated systems of training across the globe. We evaluated nephrology training programs across 25 upper-middle and high-income nations to identify best practices and opportunities for adoption in low-income nations. We reviewed training guidelines from major professional societies on content and process of training. There are similarities and differences in structure, content, and process of training programs across countries, and there are clearly adoptable concepts/frameworks for application in low-income nations. We provide recommendations and a strategic plan for the future focus of nephrology training in the developing world to align with current trends in technological advancement and development as well as the need for emphasis on prevention of CKD. The essential competencies (patient- and population--based) required of a nephrologist in a developing world setting are outlined with practical measures and an action plan for adoption.

Needs assessment: towards a more responsive Canadian Society of Nephrology Annual General Meeting (CSN AGM) program.

BACKGROUND: A critical feature of any continuing medical education (CME) program is the inclusion of a needs assessment for its target audience. This assessment must identify both perceived and unperceived needs, so as to best capture the entire spectrum of learning opportunities for the group. OBJECTIVE: We describe the process developed by the Canadian Society of Nephrology (CSN) to enhance the educational effectiveness of its Annual General Meeting program. DESIGN: The design of this study is the analysis of a survey questionnaire and of the Canadian Organ Replacement Registry (CORR) database. PARTICIPANTS: We surveyed members of the CSN and analyzed patient data from CORR aggregated by center. MEASUREMENTS: We tabulated votes in the survey by topic. We assessed the extent to which centers achieved CSN guideline targets on the clinical management of patients on dialysis. METHODS: Perceived needs: a CSN panel constructed a list of topics, which was amplified by the inclusion of topics based on members' text responses to open-ended questions during previous iterations of this process. CSN members specified their top five choices, using an online survey instrument. Unperceived needs: an expert panel determined achievable thresholds for a number of quality metrics associated with dialysis. The quality metrics were identified from CSN guidelines. Using patient data in the CORR database, we generated center-specific performance estimates for each quality metric and constructed ratios comparing the performance of each center with the achievable threshold. We triangulated the results of the two assessments. RESULTS: The response rate for the perceived needs assessment survey was 16 %. This assessment identified "Primary and Secondary Glomerulonephritis" as the non-dialysis topics and "Infectious Complications of Dialysis Access" and "Volume Status and Hypertension on Dialysis" as the dialysis topics with the highest perceived learning needs. In the unperceived needs assessment, "Vascular Access Type" and "Vascular Access Monitoring" were identified as having the highest learning needs. Triangulation identified "Vascular Access Type" and "Vascular Access Monitoring" as high needs topics. LIMITATIONS: Perceived needs assessment: Some topics were much more general than others, which could have led to over-selection. The response rate of 16 % limits the robustness of generalization to the membership as a whole or to all meeting attendees. Unperceived needs assessment: The assessment was limited by the data that CORR actually collects; many aspects of general nephrology practice, including glomerulonephritis, are not covered. The level of evidence underlying the various guidelines was variable, and in some cases, poor. A validated approach to data analysis in this area is lacking. CONCLUSIONS: To our knowledge, this is the first published example of a needs assessment for a nephrology CME event that considers both the perceived and unperceived needs of the membership. The results of this exercise are currently being used to assist in the development of a more responsive CME program.

CONTEXTE: Un aspect crucial de tout programme d'enseignement médical continu (EMC) est l'inclusion d'une évaluation des besoins de la clientèle cible. Cet examen se doit de permettre l'identification tant des besoins perçus que des besoins non perçus afin de mieux cerner les occasions d'apprentissage pour le groupe. OBJECTIFS DE L'ÉTUDE: Cet article fait la description de la démarche mise au point par la Société de Néphrologie du Canada (SNC) dans le cadre du programme de son assemblée générale annuelle. Cette démarche vise accroître l'efficacité de la formation. PLAN DE L'ÉTUDE: On a procédé à l'analyse des réponses obtenues lors d'une enquête auprès des membres ainsi qu'à la consultation des métadonnées du Registre Canadien des Insuffisances et des Transplantations d'Organes (RCITO). PARTICIPANTS: Le sondage a été mené auprès des membres de la SCN et on a procédé à l'examen des données du RCITO cumulées dans chaque centre de soins. MESURES: La compilation des réponses au sondage a été effectuée par catégories. Nous avons également évalué dans quelle mesure avaient été atteints les objectifs d'orientation fixés par les lignes directrices de la SCN quant à la conduite du traitement clinique des patients sous dialyse. MÉTHODOLOGIE: Un premier volet s'attardait à définir les besoins perçus. Pour ce faire, le comité de la SCN a dressé une liste de thèmes. Cette liste s'est par la suite allongée avec l'ajout de sujets tirés des réponses des membres aux questions ouvertes colligées lors des versions antérieures du sondage. Les membres de la SCN ont spécifié les cinq thèmes qu'ils jugeaient les plus importants par le biais d'un instrument de sondage en ligne. Un second volet se penchait sur les besoins non perçus. Dans ce deuxième cas, un groupe d'experts a déterminé les seuils réalisables pour un certain nombre de paramètres de la qualité associés à la dialyse. L'identification de ces paramètres était tirée des lignes directrices de la SCN. À l'aide des données des patients contenues dans le RCITO, une appréciation de la performance de chaque centre de soins a été produite pour chacun des paramètres identifiés. Des ratios ont ensuite été construits en comparant la performance de chaque centre de soins avec le seuil réalisable établi précédemment. De plus, les résultats des deux analyses ont été triangulés. RÉSULTATS: Le taux de réponse pour le sondage sur l'analyse des besoins perçus a été de 16 %. Cet examen a permis d'identifier les besoins perçus à considérer en matière de formation pour les futurs néphrologues. Du côté des sujets non reliés directement à la dialyse elle-même, on retrouve la glomérulonéphrite primaire et secondaire ainsi que les complications infectieuses liées au cathéter. Quant aux sujets directement reliés à la dialyse, on a pu identifier la volémie et l'hypertension en dialyse. En ce qui concerne les besoins non perçus, le type d'accès vasculaire et la surveillance de celui-ci ont été identifiés comme étant des sujets important à couvrir lors de la formation. Ces deux derniers sujets sont également ressortis comme très importants à considérer dans les besoins de formation lors de la triangulation des résultats. LIMITES DE L'ÉTUDE: Dans le cas des besoins perçus, certains sujets étaient de nature très générale et ceci pourrait avoir conduit à une sélection excessive. Qui plus est, le très faible taux de réponse limite la robustesse d'une généralisation des résultats à tous les membres ayant participé à l'assemblée. Du côté des besoins non perçus, l'analyse est limitée par les données du RCITO où plusieurs aspects de la pratique générale en néphrologie, notamment la prise en charge de la glomérulonéphrite, ne sont pas couverts. Le degré d'éléments probants sous-jacent les différents principes directeurs s'est avéré variable et dans certains cas, médiocre. Une approche validée face à l'analyse des données dans ce domaine est manquante. CONCLUSIONS: À notre connaissance, cette enquête constitue la première analyse publiée des besoins, réalisée lors d'un événement d'EMC en néphrologie, qui prend en considération les besoins perçus et non perçus de ses membres. Les résultats de cet exercice sont actuellement utilisés dans le développement d'un programme d'EMC mieux adapté.

Calcific uremic arteriolopathy should be treated conservatively.

Calcific uremic arteriolopathy (CUA) is a small vessel vasculopathy affecting mainly stage IV and V renal failure patients. It is characterized typically by non-healing, painful skin ulcerations and carries a poor prognosis. Little is known about the pathogenesis, but abnormal mechanisms of vascular calcification have been postulated to contribute. Available therapies target promotion of wound healing and lowering of elevated parathyroid hormone levels and the calcium-phosphate product. There are no prospective or randomized controlled trials to guide choice of therapeutic agents, yet available therapies may subject patients to adverse side effects, and/or increase program expenditures. Therefore, we favor a graded approach to treatment of CUA, commencing conservatively with the least harmful and most cost-efficient measures available.

Relative abundance of full-length and truncated FOXP1 isoforms is associated with differential NFkappaB activity in Follicular Lymphoma.

FOXP1 is a transcriptional repressor that has been proposed to repress the expression of some NFkappaB-responsive genes. Furthermore, truncated forms of FOXP1 have been associated with a subtype of Diffuse Large B-cell Lymphoma characterised by constitutive NFkappaB activity, indicating that they may inhibit this repression. We have shown that FL tumors have increased relative abundance of truncated FOXP1 isoforms and this is associated with increased expression of NFkappaB-associated genes. Our results provide strong evidence that relative FOXP1 isoform abundance is associated with NFkappaB activity in FL, and could potentially be used as a marker for this gene signature.

Management of paediatric retropharyngeal infections: non-surgical versus surgical.

BACKGROUND: Paediatric retropharyngeal infections are a serious infection associated with morbidity. The relative role of medical versus surgical treatment for these infections is debated. The aims of this study were to analyse the management of retropharyngeal infections with respect to radiological assessment and treatment. METHODS: Medical records from January 1999 to June 2005 were reviewed and analysed. RESULTS: Twenty-four children with retropharyngeal infections were included in the study. Computed tomography had a 75% accuracy of correctly identifying an abscess and 36% of the retropharyngeal abscesses resolved with medical treatment alone, with no difference in duration of hospital stay or morbidity. CONCLUSION: Medical treatment of retropharyngeal abscesses has been successful in selected cases. We can recommend this as a viable alternative to surgery and would suggest a 48-h inpatient i.v. antibiotic trial in selected children before considering surgery.

Management of pediatric lateral neck infections: Does the adage "... never let the sun go down on undrained pus ..." hold true?

OBJECTIVES: Pediatric neck infections are frequently treated by Otolaryngologists, Head and Neck surgeons. The relative role of medical versus surgical treatment of pediatric neck infections is debated. The aims of this study are to analyze the management of pediatric neck infections with respect to clinical assessment, radiological assessment and treatment. METHODS: Medical records from January 1999 to June 2005 were reviewed and analyzed. RESULTS: Two hundred and five children with lateral neck infections were included in the study. The clinical diagnosis correlated with the radiology finding in 73.6% with a sensitivity of 28% and a specificity of 92% for lateral neck abscess recognition. The ultrasound finding correlated with the surgical finding in 65.2% with a sensitivity of 70% and a specificity of 33%. When an ultrasound scan was used it changed the intended treatment plan in 10.5% of children. CONCLUSIONS: Accurate clinical assessment of lateral neck infections is poor, generally under estimating suppuration. However, when an abscess is diagnosed clinically this correlates highly with the surgical finding. Radiological assessment has inaccuracy in identifying suppuration and this should be borne in mind when being used as a diagnostic tool for neck infections.