Synoptic operative reports enhance documentation of best practices for rectal cancer.

BACKGROUND: Implementation of best practices surgical checklists improves patient safety and outcomes. However, documenting performance of these practices can be challenging. The American Society of Colon and Rectal Surgeons developed a Best Practices for Rectal Cancer Checklist (RCC) to standardize and improve the quality of rectal cancer surgery. This study compared the degree to which synoptic (SR) and narrative (NR) operative reports document RCC items. METHODS: Two reviewers independently reviewed a cohort of prospectively collected SR for rectal cancer surgery and a case-matched historical cohort of NR. Reports were reviewed for documentation of performance of operative items on the RCC. Abstraction time and inter-rater agreement were also measured. RESULTS: SR scored significantly higher than NR on the overall checklist score (mean adjusted score ± standard deviation 12.4 ± 0.9 vs. 5.7 ± 1.9, maximum possible score 18, P < 0.001). Reviewers abstracted data significantly faster from SR. Inter-rater agreement between reviewers was high for both types of reports. CONCLUSIONS: SR were associated with reliable and more complete and reliable documentation of items on the RCC. Use of an SR system standardizes operative reporting, providing the opportunity to enhance checklist compliance, and enable timely feedback to improve surgical outcomes for rectal cancer patients.

Assessments of the transmission of Onchocerca volvulus by Simulium sanctipauli in the Upper Denkyira District, Ghana, and the intermittent disappearance of the vector.

Following studies on the transmission of Onchocerca volvulus (Leuckart) by Simulium sanctipauli Vajime & Dunbar (Diptera, Simuliidae) in Upper Denkyira District in Ghana in 2001 and 2002 (Kutin et al., Med Vet Ent 18:167-173, 2004), further assessments were carried out in 2006 and 2013/2014 to determine whether transmission parameters had changed since community-directed ivermectin treatment (CDTI) began in 1999. There were no marked changes of the transmission intensities in 2006. Only slight, but non-significant, reductions were observed in infection rates of parous flies with larval stages (L1-L3) of O. volvulus from 44.1 % (of 1672 parous flies) in 2001/2002 to 42.1 % (506) in 2006 and from 6.5 to 5.9 % of flies carrying infective larvae in their heads. This suggested that there was an ongoing transmission in the area and the parasite reservoir in the human population was still high. Unexpectedly, further assessments conducted in October 2013 and March and October 2014 revealed that the vector S. sanctipauli had apparently disappeared and transmission had ceased, probably as a result of intensified gold mining activities along the rivers Ofin and Pra. The water of both rivers was extremely turbid, heavily loaded with suspended solids, probably preventing the development of blackfly larvae. Some breeding and biting of Simulium yahense Vajime & Dunbar was observed in a small tributary of the Pra, the Okumayemfuo, which is not affected by gold mining. However, the infection rate of flies was low, only 3.7 % of 163 parous flies were infected with first stage (L1) larvae of O. volvulus.

The location of surgical care for rural patients with rectal cancer: patterns of treatment and patient perspectives.

BACKGROUND: Where cancer patients receive surgical care has implications on policy and planning and on patients' satisfaction and outcomes. We conducted a population- based analysis of where rectal cancer patients undergo surgery and a qualitative analysis of rectal cancer patients' perspectives on location of surgical care. METHODS: We reviewed Manitoba Cancer Registry data on patients with colorectal cancer (CRC) diagnosed between 2004 and 2006. We interviewed rural patients with rectal cancer regarding their preferences and the factors they considered when deciding on treatment location. Interview data were analyzed using a grounded theory approach. RESULTS: From 2004 to 2006, 2086 patients received diagnoses of CRC in Manitoba (colon: 1578, rectal: 508). Among rural patients (n = 907), those with rectal cancer were more likely to undergo surgery at an urban centre than those with colon cancer (46.5% v. 28.8%, p < 0.001). Twenty rural patients with rectal cancer participated in interviews. We identified 3 major themes from the interview data: the decision-maker, treatment factors and personal factors. Participants described varying input into referral decisions, and often they did not perceive a choice regarding treatment location. Treatment factors, including surgeon factors and hospital factors, were important when considering treatment location. Personal factors, including travel, support, accommodation, finances and employment, also affected participants' treatment experiences. CONCLUSION: A substantial proportion of rural patients with rectal cancer undergo surgery at urban centres. The reasons are complex and only partly related to patient choice. Further studies are required to better understand cancer system access in geographically dispersed populations and to support cancer patients through the decision-making and treatment processes.

CONTEXTE: Le lieu où les patients atteints du cancer subissent une intervention chirurgicale a des répercussions sur les politiques et la planification, et sur la satisfaction du patient et ses résultats. Nous avons étudié dans une population le lieu où des patients atteints de cancer du rectum subissent leur chirurgie et effectué une analyse qualitative des points de vue exprimés par les patients au sujet du lieu où les soins chirurgicaux sont dispensés. MÉTHODES: Nous avons consulté le Registre du cancer du Manitoba pour trouver des données sur des patients atteints de cancer colorectal diagnostiqué entre 2004 et 2006. Nous avons interviewé des patients de régions rurales atteints de cancer du rectum pour connaître leurs préférences et les facteurs dont ils avaient tenu compte en choisissant le lieu où ils allaient être traités. Nous avons analysé les données recueillies à l'aide d'une méthode théorique fondées sur les faits. RÉSULTATS: Entre 2004 et 2006, au Manitoba, 2086 patients ont reçu un diagnostic de cancer colorectal (cancer du côlon : 1578; cancer du rectum : 508). Parmi les patients qui vivaient en milieu rural (n = 907), ceux atteints d'un cancer du rectum avaient plus tendance à subir leur chirurgie dans un établissement urbain que ceux atteints de cancer du côlon (46,5 % c. 28,8 %, p < 0,001). Vingt patients de milieu rural atteitns de cancer du rectum ont participé aux entrevues. Trois principaux éléments se dégagent des données recueillies : le décideur, des facteurs reliés au traitement et des facteurs d'ordre personnel. Les participants ont décrit diverses contributions qu'ils ont apportées à la décision relative à la référence de leur cas et dit que souvent, ils n'ont pas senti qu'un choix de lieux de traitement leur était offert. Les facteurs liés au traitement lui-même, y compris ceux liés au chirurgien et à l'hôpital, ont été importants dans le choix du lieu de traitement. Les facteurs d'ordre personnel, dont le déplacement, le soutien, l'hébergement, la situation financière et l'emploi ont aussi influé sur l'expérience thérapeutique des participants. CONCLUSION: Une proportion considérable de patients atteints du cancer du rectum et vivant en milieu rural subissent leur chirurgie dans des établissements urbains. Les raisons sont complexes et ne sont qu'en partie reliées au choix du patient. Il faudrait mener d'autres études pour mieux comprendre l'accès aux services offerts aux personnes atteintes de cancer dans les populations géographiquement dispersées et pour les appuyer dans le processus de prise de décision et de traitement.

Spiritual and religious aspects of skin and skin disorders.

Skin and skin disorders have had spiritual aspects since ancient times. Skin, hair, and nails are visible to self and others, and touchable by self and others. The skin is a major sensory organ. Skin also expresses emotions detectable by others through pallor, coldness, "goose bumps", redness, warmth, or sweating. Spiritual and religious significances of skin are revealed through how much of the skin has been and continues to be covered with what types of coverings, scalp and beard hair cutting, shaving and styling, skin, nail, and hair coloring and decorating, tattooing, and intentional scarring of skin. Persons with visible skin disorders have often been stigmatized or even treated as outcasts. Shamans and other spiritual and religious healers have brought about healing of skin disorders through spiritual means. Spiritual and religious interactions with various skin disorders such as psoriasis, leprosy, and vitiligo are discussed. Religious aspects of skin and skin diseases are evaluated for several major religions, with a special focus on Judaism, both conventional and kabbalistic.

Documentation of quality of care data for colon cancer surgery: comparison of synoptic and dictated operative reports.

BACKGROUND: Operative reports are a source of clinical data that can, for quality assurance purposes, be used to document the performance of processes that affect the care of surgical patients. We assessed the degree to which synoptic reports document operative quality indicators for colon cancer surgery. METHODS: Two reviewers independently reviewed 80 prospectively collected synoptic colon cancer operative reports and a case-matched historical cohort of 80 dictated reports. Reviewers rated how well reports documented performance of quality of care indicators using two checklists of previously validated, colon cancer-specific quality measures. Interrater agreement and time to extract data were also recorded. RESULTS: Synoptic reports had significantly higher overall scores on the quality indictors in comparison to dictated reports for both checklist 1 [mean adjusted score ± standard deviation 18.6 ± 1.3 vs. 9.2 ± 3.6, p < 0.01 (maximum score 38)] and checklist 2 [2.0 ± 0.3 vs. 1.3 ± 1.1, p < 0.01 (maximum score 3)]. Interrater agreement was significantly higher between synoptic reports for both checklists (data not shown). Data were extracted significantly more quickly from synoptic reports than dictated reports [mean time (minutes:seconds) ± standard deviation 2:32 ± 0:44 vs. 4:01 ± 1:14, p < 0.01]. CONCLUSIONS: Synoptic reports were associated with more complete documentation of quality indicators for colon cancer resection compared to dictated reports. Although synoptic reports may improve the documentation of quality of care data, further refinement may help to better document performance of quality measures and improve reporting standards.

Identification of FAM111A as an SV40 host range restriction and adenovirus helper factor.

The small genome of polyomaviruses encodes a limited number of proteins that are highly dependent on interactions with host cell proteins for efficient viral replication. The SV40 large T antigen (LT) contains several discrete functional domains including the LXCXE or RB-binding motif, the DNA binding and helicase domains that contribute to the viral life cycle. In addition, the LT C-terminal region contains the host range and adenovirus helper functions required for lytic infection in certain restrictive cell types. To understand how LT affects the host cell to facilitate viral replication, we expressed full-length or functional domains of LT in cells, identified interacting host proteins and carried out expression profiling. LT perturbed the expression of p53 target genes and subsets of cell-cycle dependent genes regulated by the DREAM and the B-Myb-MuvB complexes. Affinity purification of LT followed by mass spectrometry revealed a specific interaction between the LT C-terminal region and FAM111A, a previously uncharacterized protein. Depletion of FAM111A recapitulated the effects of heterologous expression of the LT C-terminal region, including increased viral gene expression and lytic infection of SV40 host range mutants and adenovirus replication in restrictive cells. FAM111A functions as a host range restriction factor that is specifically targeted by SV40 LT.

Filariasis in Africa--treatment challenges and prospects.

Lymphatic filariasis (LF) and onchocerciasis are parasitic nematode infections that are responsible for a major disease burden in the African continent. Disease symptoms are induced by the immune reactions of the host, with lymphoedema and hydrocoele in LF, and dermatitis and ocular inflammation in onchocerciasis. Wuchereria bancrofti and Onchocerca volvulus, the species causing LF and onchocerciasis in Africa, live in mutual symbiosis with Wolbachia endobacteria, which cause a major part of the inflammation leading to symptoms and are antibiotic targets for treatment. The standard microfilaricidal drugs ivermectin and albendazole are used in mass drug administration programmes, with the aim of interrupting transmission, with a consequent reduction in the burden of infection and, in some situations, leading to regional elimination of LF and onchocerciasis. Co-endemicity of Loa loa with W. bancrofti or O. volvulus is an impediment to mass drug administration with ivermectin and albendazole, owing to the risk of encephalopathy being encountered upon administration of ivermectin. Research into new treatment options is exploring several improved delivery strategies for the classic drugs or new antibiotic treatment regimens for anti-wolbachial chemotherapy.

Immunohistological studies on neoplasms of female and male Onchocerca volvulus: filarial origin and absence of Wolbachia from tumor cells.

Up to 5% of untreated female Onchocerca volvulus filariae develop potentially fatal pleomorphic neoplasms, whose incidence is increased following ivermectin treatment. We studied the occurrence of 8 filarial proteins and of Wolbachia endobacteria in the tumor cells. Onchocercomas from patients, untreated and treated with antibiotics and anthelminthics, were examined by immunohistology. Neoplasms were diagnosed in 112 of 3587 female and in 2 of 1570 male O. volvulus. The following proteins and other compounds of O. volvulus were expressed in the cells of the neoplasms: glutathione S-transferase 1, lysosomal aspartic protease, cAMP-dependent protein kinase, alpha-enolase, aspartate aminotransferase, ankyrin E1, tropomyosin, heat shock protein 60, transforming growth factor-beta, and prostaglandin E(2). These findings prove the filarial origin of the neoplasms and confirm the pleomorphism of the tumor cells. Signs indicating malignancy of the neoplasms are described. Wolbachia were observed in the hypodermis, oocytes, and embryos of tumor-harbouring filariae using antibodies against Wolbachia surface protein, Wolbachia HtrA-type serine protease, and Wolbachia aspartate aminotransferase. In contrast, Wolbachia were not found in the cells of the neoplasms. Further, neoplasm-containing worms were not observed after more than 10 months after the start of sufficient treatment with doxycycline or doxycycline plus ivermectin.

Canadian Association of University Surgeons annual symposium: Continuity of care: Toronto, Ontario, Sep. 6, 2007.

This 2007 symposium of the Canadian Association of University Surgeons brought together surgeons from a number of jurisdictions to discuss the challenges and opportunities that reduced physician work hours will bring to the care of the surgical patient. Dr. Brian Taylor, president of the association, underscored the need to find a balance between the benefits of diminished workloads/work hours and the loss of continuity of care. He opined that Canada needs to learn from our European colleagues' experience. Dr. Per-Olof Nyström, professor of surgery, presented the modern Swedish model of surgical care, which had to be developed as a consequence of the European Union's legal restrictions on the amount of time an individual surgeon may work. Sweden employs a team-based shared-care model driven by the individual surgeon's expertise rather than the "village factory" model of the multiskilled, multitasking approach of surgical care more prevalent in Canada. Dr. Chris de Gara, secretary treasurer of the association, presented the evidence base for (and against) work-hour restrictions and how well-designed systems can ensure effective continuity of care. Dr. Stewart Hamilton illustrated how one such system for the delivery of the emergency general surgical services has evolved at the University of Alberta Hospital, which demonstrated its effectiveness in providing quality surgical continuity of care. Dr. Debrah Wirtzfeld underscored the importance of trainee lifestyle and how modern Web-based technologies can ensure reduced errors with the implementation of a "sign-out" system.

Filariasis and lymphoedema.

Among the causes of lymphoedema (LE), secondary LE due to filariasis is the most prevalent. It affects only a minority of the 120 million people infected with the causative organisms of lymphatic filariasis (LF), Wuchereria bancrofti and Brugia malayi/timori, but is clustered in families, indicating a genetic basis for development of this pathology. The majority of infected individuals develop filarial-specific immunosuppression that starts even before birth in cases where mothers are infected and is characterized by regulatory T-cell responses and high levels of IgG4, thus tolerating high parasite loads and microfilaraemia. In contrast, individuals with this pathology show stronger immune reactions biased towards Th1, Th2 and probably also Th17. Importantly, as for the aberrant lymph vessel development, innate immune responses that are triggered by the filarial antigen ultimately result in the activation of vascular endothelial growth factors (VEGF), thus promoting lymph vessel hyperplasia as a first step to lymphoedema development. Wolbachia endosymbionts are major inducers of these responses in vitro, and their depletion by doxycycline in LF patients reduces plasma VEGF and soluble VEGF-receptor-3 levels to those seen in endemic normals preceding pathology improvement. The search for the immunogenetic basis for LE could lead to the identification of risk factors and thus, to prevention; and has so far led to the identification of single-nucleotide polymorphisms (SNP) with potential functional relevance to VEGF, cytokine and toll-like receptor (TLR) genes. Hydrocele, a pathology with some similarity to LE in which both lymph vessel dilation and lymph extravasation are shared sequelae, has been found to be strongly associated with a VEGF-A SNP known for upregulation of this (lymph-)angiogenesis factor.

The history of women in surgery.

The history of women in surgery in Western civilization dates to 3500 before common era (BCE) and Queen Shubad of Ur. Ancient history reveals an active role of women in surgery in Egypt, Italy and Greece as detailed in surgical texts of the time. During the middle ages, regulations forbade women from practising surgery unless they assumed their husbands' practices upon their deaths or unless they were deemed fit by a "competent" jury. King Henry VIII proclaimed that "No carpenter, smith, weaver or women shall practise surgery." The modern period of surgery opens with women impersonating men to practise medicine and surgery (Dr. Miranda Stewart). The first female physicians (Dr. Elizabeth Blackwell and Dr. Emily Jennings Stowe) and surgeons (Dr. Mary Edwards Walker and Dr. Jennie Smillie Robertson) in North America found it difficult to obtain residency education after completing medical school. Dr. Jessie Gray was Canada's "First Lady of Surgery" and the first woman to graduate from the Gallie program at the University of Toronto in the 1940s. Currently, the ratio of women in surgical training is far less than that of women in medical school. The reasons that women choose surgery include appropriate role models and intellectual/technical challenge. Lack of mentorship and lifestyle issues are the strongest deterrents. Consideration of a "controllable lifestyle" by surgical administrators will help with the recruitment of women into surgery.

Concordance with clinical practice guidelines for adjuvant chemotherapy in patients with stage I-III colon cancer: experience in 2 Canadian provinces.

BACKGROUND: Clinical practice guidelines (CPGs) for the adjuvant treatment of colorectal cancer were published by the National Institutes of Health in 1991. The American Society of Clinical Oncology and Cancer Care Ontario have recommended adjuvant chemotherapy for patients with high-risk stage II colon cancer. We evaluated differences in concordance with guidelines in the treatment of patients with stage I-III colon cancer in the Canadian provinces of Newfoundland and Labrador and Ontario. METHODS: We assessed clinical data and treatment from January 1999 to December 2000 for 130 patients from Newfoundland and Labrador and 315 patients from Ontario who had stage I-III colon cancer. The primary outcome was concordance with guidelines for adjuvant treatment. We evaluated factors affecting the use of chemotherapy in patients with stage II disease. RESULTS: No patients received adjuvant therapy for stage I disease. Forty-five of 52 patients (87%) in Newfoundland and Labrador and 108 of 115 patients (94%) in Ontario received adjuvant chemotherapy for stage III colon cancer. Twenty of 55 patients (36%) in Newfoundland and Labrador and 44 of 116 patients (38%) in Ontario received adjuvant therapy for stage II disease. Eighteen of 41 patients (44%) in Newfoundland and Labrador and 30 of 53 patients (57%) in Ontario with high-risk features received adjuvant treatment, which was significantly higher than patients without high-risk features. There was a strong trend toward using chemotherapy in patients with stage II disease who were 50 years or younger, independent of high-risk status. CONCLUSION: Concordance with CPGs for adjuvant chemotherapy in patients with stage II colon cancer was not optimal. This may reflect selection bias among referring surgeons, a paucity of level-I evidence and the belief that other factors such as age may play a role in predicting outcome.

Practice patterns and career satisfaction of Canadian female general surgeons.

BACKGROUND: We wanted to study how female general surgeons in Canada manage lifestyle and career demands. METHODS: All female Canadian general surgeons registered with the Royal College of Physicians and Surgeons of Canada were asked to complete a survey evaluating their practice patterns, personal lives, and levels of satisfaction related to these factors. RESULTS: Eighty-five surveys (66%) were returned. Most respondents work in full-time clinical practices. While it was rare to find women in part-time or shared practices, 35% of women reported interest in these alternative models. Respondents described the necessary factors for a transition into alternative models. Job satisfaction was high (3.8 out of 5), with personal and parenting satisfaction being less highly rated (3.3 and 3.2, respectively). CONCLUSIONS: Canadian female general surgeons have active and satisfying careers, although many would like to work in alternative practice models that better conform to their lifestyle demands. This pressure will have a significant impact on the future surgical workforce.

Pathways of pyrimidine salvage in Pseudomonas and former Pseudomonas: detection of recycling enzymes using high-performance liquid chromatography.

Pyrimidine salvage pathways are vital for all bacteria in that they share in the synthesis of RNA with the biosynthetic pathway in pyrimidine prototrophs, while supplying all pyrimidine requirements in pyrimidine auxotrophs. Salvage enzymes that constitute the pyrimidine salvage pathways were studied in 13 members of Pseudomonas and former pseudomonads. Because it has been established that all Pseudomonas lack the enzyme uridine/cytidine kinase (Udk) and all contain uracil phosphoribosyl transferase (Upp), these two enzymes were not included in this experimental work. The enzymes assayed were: cytosine deaminase [Cod: cytosine + H2O --> uracil + NH3], cytidine deaminase [Cdd: cytidine + H2O --> uridine + NH3], uridine phosphorylase [Udp: uridine + Pi <--> uracil + ribose - 1 - P], nucleoside hydrolase [Nuh: purine/pyrimidine nucleoside + H2O --> purine/pyrimidine base + ribose], uridine hydrolase [Udh: uridine/cytidine + H2O --> uracil/cytosine + ribose]. The assay work generated five different Pyrimidine Salvage Groups (PSG) designated PSG1 - PSG5 based on the presence or absence of the five enzymes. These enzymes were assayed using reverse phase high-performance liquid chromatography techniques routinely carried out in our laboratory. Escherichia coli was included as a standard, which contains all seven of the above enzymes.

Pathways of pyrimidine salvage in Streptomyces.

Using 5-fluoropyrimidine analogues, high-performance liquid chromatography (HPLC), and the feeding of pyrimidine compounds to pyrimidine auxotrophs, the pathways for salvage of exogenous pyrimidine nucleosides and bases in Streptomyces were established. Selection for resistance to the analogues resulted in the isolation of strains of S. griseus lacking the following enzyme activities: uracil phosphoribosyltransferase (upp) and cytidine deaminase (cdd). The conversion of substrates in the pathway was followed using reverse-phase HPLC. The strains deficient in salvage enzymes were also verified by this method. In addition, feeding of exogenous pyrimidines to strains lacking the biosynthetic pathway confirmed the salvage pathway. Data from the analogue, HPLC, and feeding experiments showed that Streptomyces recycles the pyrimidine base uracil, as well as the nucleosides uridine and cytidine. Cytosine is not recycled due to a lack of cytosine deaminase.

Is abdominoperineal resection a good option for stage IV adenocarcinoma of the distal rectum?

BACKGROUND AND OBJECTIVES: The management of the primary lesion in patients with stage IV adenocarcinoma of the distal rectum is controversial. An abdominoperineal resection (APR) may be a good option. METHODS: A retrospective analysis of the medical records of 21 patients with stage IV distal rectal adenocarcinoma treated with an APR between January 1991 to December 2000 was performed. RESULTS: All patients had an Eastern Cooperative Oncology Group (ECOG) performance status of 1 and normal preoperative alkaline phosphatase and total bilirubin levels. Twelve patients (92%) with liver metastases had less than 25% of total liver volume involvement. Twenty patients (95%) had complete resolution of their symptoms related to the primary rectal cancer. The median follow-up was 19 months (range 3-92 months), with a median survival of 21.6 months and a 2-year overall survival of 34%. CONCLUSIONS: Patients with stage IV distal rectal adenocarcinoma who have a good performance status, normal preoperative liver function tests, and minimal metastatic disease to the liver can be offered resective surgery.

Ionized serum calcium levels during acute renal failure: intermittent hemodialysis vs. Continuous hemodiafiltration.

BACKGROUND: Achieving "adequacy of dialysis" includes the maintenance of normal serum ionized calcium concentrations and is an important therapeutic goal in the treatment of acute renal failure (ARF). It is unknown whether this goal is best achieved with intermittent or continuous renal replacement therapy. METHODS: We compared the effects of continuous veno-venous hemodiafiltration (CVVHDF) and intermittent hemodialysis (IHD) on serum ionized calcium concentrations using daily morning blood tests in 88 consecutive intensive care patients of which half were treated with IHD and half with CRRT. RESULTS: Mean patient age was 54 +/- 14 years for IHD and 60 +/- 14 years for CVVHDF (NS). However, patients who received CVVHDF were significantly more critically ill (mean APACHE II scores: 24.4 +/- 5.1 for IHD vs. 29.2 +/- 5.7 for CVVHDF, p < 0.003). Before treatment, the mean ionized calcium concentration was 1.177 +/- 0.03 mmol/l for IHD and 1.172 +/- 0.04 mmol/l for CVVHDF (NS), with abnormal values in 51.6% of IHD patients and in 68% of CVVHDF patients (NS). During treatment, hypocalcemia was significantly more common among CVVHDF patients (24.5% vs. 14.9%; p < 0.011) while hypercalcemia was more frequent during IHD (36.1% vs. 25.6%; p < 0.019). CONCLUSIONS: Abnormal serum ionized calcium concentrations are frequent in ARF patients before and during renal replacement. Once dialytic therapy is applied, CVVHDF is more likely to lower serum calcium concentrations, while IHD is more likely to induce hypercalcemia. Appreciation of these different biochemical effects may assist clinicians in adjusting dialytic therapy in selected patients.