Eye colour and skin pigmentation as significant factors for refractive outcome and residual accommodation in hypermetropic children: a randomized clinical trial using cyclopentolate 1% and tropicamide 1.

PURPOSE: To compare the refractive outcome and residual accommodation with respect to various degrees of iris and skin pigmentation in hypermetropic children using 2 drops of cyclopentolate 1% (C + C) or 1 drop of cyclopentolate 1% and 1 drop of tropicamide 1% (C + T). METHODS: Two hundred fifty-one hypermetropic children were classified according to iris and skin pigmentation (light, medium, dark) and received randomized and double-blind C + C or C + T. Refractive error (spherical equivalent, SEQ) was determined using the Retinomax-K + 3. In 204 subjects, residual accommodation (RA) was determined using the PlusoptiX PowerRefractor. RESULTS: A linear mixed model with a light-irided and light skin-pigmented reference group receiving C + T (mean SEQ +3.10 ± 1.87D) indicated significant less hypermetropia in subjects with a dark iris having a medium- and dark-pigmented skin in C + T, -1.02 ± 0.29 (-1.59/-0.45) and -1.53 ± 0.30 (-2.10/-0.95); and in subjects having a light-, medium- and dark-pigmented skin in C + C, -0.74 ± 0.34 (-1.41/-0.06), -1.26 ± 0.30 (-1.85/-0.66) and -1.84 ± 0.30 (-2.42/-1.26). Similar findings were present for RA. Our model with a light-irided and light skin-pigmented reference group receiving C + T (mean RA +0.84 ± 0.61D) indicated significantly higher RA in dark-irided subjects with medium- and dark-pigmented skin in C + T, +1.05 ± 0.19 (+0.67/+1.43) and +1.35 ± 0.20 (+0.9/+1.74), and in C + C, +1.13 ± 0.21 (+0.71/+1.55) and +1.90 ± 0.19 (+1.51/+2.28). CONCLUSIONS: We found solid evidence that skin pigmentation rather than iris pigmentation is the decisive factor for effectiveness of cycloplegics. Awareness of the limitations of cycloplegic regimens in dark-irided/pigmented children is needed. Our study showed that cyclopentolate 1% combined with tropicamide 1% provides more accurate refractive outcomes both statistically and clinically integrating the factor skin pigmentation for dark-irided subjects.

A randomized clinical trial using atropine, cyclopentolate, and tropicamide to compare refractive outcome in hypermetropic children with a dark iris; skin pigmentation and crying as significant factors for hypermetropic outcome.

Purpose: To evaluate the refractive outcome and influencing factors following atropine 0.5% eye-drops applied twice daily during 2 ½ days at home and two drops of cyclopentolate 1% (C+C) and one drop of cyclopentolate 1% and one drop of tropicamide 1% (C+T) applied in an outpatient clinic, in hypermetropic children with a dark iris. Methods: Double-blind randomized study including 67 3-6-year-old children receiving C+C in one eye and C+T in the other eye. Two weeks later followed by atropine 0.5% in both eyes. Primary outcome measures were: spherical equivalent (SEQ) following C+C, C+T and atropine, and secondarily SEQ with respect to sex, ethnicity, skin pigmentation (light, medium, dark) and crying. Data on atropine are divided in those with C+C (CC) or C+T (CT) as a first intervention. Results: Mean SEQ±SD for C+C, C+T, atropine-(CC) and atropine-(CT) was +1.74 ± 1.35, +1.77 ± 1.34, +2.15 ± 1.43 and +2.10 ± 1.38 diopter (D). Atropine 0.5% revealed significantly more hypermetropia than C+C and C+T; +0.41 ± 0.43, 95%CI +0.31 to +0.52D and +0.33 ± 0.39, 95%CI +0.24 to +0.34D. No significant difference was present between C+C and C+T; -0.03 ± 0.56, 95%CI -0.16 to +0.11D. Ethnicity and skin-color were strongly associated (r = 0.84, p < .001). Sex was not affecting outcomes (p = .101). Ethnicity was borderline significant (p = .049). Skin-color was a highly significant factor (p = .002). A statistical model combining intervention and skin-color, with light-pigmented subjects receiving atropine-(CC) as reference group (mean SEQ +2.61 ± 1.46D), indicated borderline significantly less hypermetropia in atropine-(CC)-dark: mean decrease (95%CI): -0.81 (-1.66 to +0.05)D and atropine-(CT)-dark -0.87 (-1.70 to -0.03)D, furthermore significantly less hypermetropia in C+C-dark: -1.15 (-1.97 to -0.32)D; C+T-dark: -1.21 (-2.03 to -0.39)D, C+C-medium: -1.02 (-1.81 to -0.24)D and C+T-medium: -0.86 (-1.64 to -0.08)D. Adding crying to the model significantly less hypermetropia was found for subjects crying in all interventions; -0.53 (-0.98 to -0.09)D. Within the interventions, with light-pigmented non-crying subjects as reference group (mean SEQ in atropine, C+C, respectively, C+T: +2.62 ± 1.41, +2.33 ± 1.20 and +2.32 ± 1.20D), showed significantly less hypermetropia in dark-pigmented crying subjects in each individual intervention: atropine -1.10 (-2.01 to -0.19), C+C -1.28 (-2.14 to -0.42) and C+T -1.34 (-2.20 to -0.48)D. For medium pigmented crying subjects this was present in atropine: -0.82 (-1.61 to -0.03)D and C+C: -0.86 (-1.68 to -0.04)D, but not in C+T: -0.58 (-1.25 to +0.09)D. Conclusions: Atropine 0.5% revealed a slight significantly higher hypermetropia. A dark-pigmented skin, especially when crying upon application, resulted in lower hypermetropia in all interventions. C+T provided clinically better results in medium pigmented crying subjects compared to C+C, and equal results compared to atropine 0.5%.

Increased analgesia administration in emergency medicine after implementation of revised guidelines.

BACKGROUND: The most common complaint of patients attending the emergency department (ED) is pain, caused by different diseases. Yet the treatment of pain at the ED is suboptimal, and oligoanalgesia remains common. The objective of this study is to determine whether the administration of analgesia at the ED increases by implementation of revised guidelines in pain management. METHODS: We conducted a prospective pre-post intervention cohort study with implementation of a revised guideline for pain management at our ED, in which nurses are allowed to administer analgesia (including low-dosage piritramid (opioid) intravenous) without doctor intervention. Numeric Rating Scales (NRS) were measured, and administration of medication (main outcome) was documented. We included every adult patient presenting with pain (NRS 4-10) at the ED. RESULTS: A total of 2107 patients (1089 pre-implementation phase and 1018 post-implementation phase) were included in our study. During pre-implementation, 25.4 % of the patients with NRS between 4 and 10 received analgesia. After implementation, 32.0 % of these patients received analgesia (p < 0.001). CONCLUSIONS: After implementation of the revised guidelines in pain management at the ED, the administration of pain medication increased significantly. Nevertheless, the percentage of patients in pain receiving analgesia remain low (32 % after implementation).

Effects of emergency department crowding on the delivery of timely care in an inner-city hospital in the Netherlands.

BACKGROUND: The impact of delays in emergency department (ED) care has not been described in European countries where ED crowding is not universally recognized. The aim of this study was to determine the relationship of ED crowding with delays in triage and treatment, and 24-h mortality in patients admitted to the ED. METHODS: Five years of data from adults admitted to the hospital were analysed retrospectively from an inner-city ED in the Netherlands. Variables included the following: crowded versus noncrowded time, time to triage, triage category, time to treatment, age, 24-h mortality and 10-day mortality. RESULTS: A total of 39 110 patients met the inclusion criteria. ED crowding occurred 30.8% of the time. There were no differences in mortality between patients arriving during crowding versus those arriving during noncrowding. Delays in triage during ED crowding occurred 29.7% of the time versus 14.6% during noncrowding. Delays in treatment occurred 11.7 and 7.3% of the time during crowding and noncrowding, respectively. CONCLUSION: In this hospital, ED crowding results in increased times to triage and to treatment, not in increased 24-h or 10-day mortality.

Adverse reactions following routine anticholinergic eye drops in a paediatric population: an observational cohort study.

OBJECTIVES: To investigate the presence, nature and relationship to age, sex, ethnicity and body mass index (BMI) of adverse reactions following routine cycloplegic eye drops in children. DESIGN: Prospective observational cohort study. SETTING: Ophthalmology outpatient clinic Dutch metropolitan hospital; February, March and April 2009. PARTICIPANTS: Children aged 3-14-year-old children receiving two drops of cyclopentolate 1% (C+C) or one drop of cyclopentolate 1% and one drop of tropicamide 1% (C+T). Patients were categorised by age (3-6, 7-10 and 11-14 years), sex, ethnicity and body mass index (BMI) (low, normal or high). OUTCOME MEASURES: Rate and nature of adverse reactions reported at 45 min following treatment. Crude and adjusted ORs for reporting an adverse reaction using stepwise regression analysis with BMI, age, ethnicity and sex. RESULTS: 912 of 915 eligible patients participated (99.7%). Adverse reactions were reported for C+C in 10.3% and in C+T in 4.8% (42/408 and 24/504, p=0.002), respectively. Central effects were present in 95% in C+C and in 92% in C+T. Compared to C+T, an increased risk was present in C+C (crude OR 2.3 (1.4 to 3.9), p=0.002). Forward adjustment showed BMI to be an influencing factor in treatment (OR 3.1 (1.7 to 5.6), p<0.001). In a multivariate model, a dose of cyclopentolate remained associated with adverse reactions. Analysis per BMI and regime and age category and regime, indicated associations with low BMI (OR C+C 21.4 (6.7 to 67.96), p<0.001, respectively, C+T 5.2 (2.1 to 12.8), p<0.001) and young age (OR C+C 8.1 (2.7 to 24.8), p<0.001). CONCLUSIONS: Adverse reactions were common and almost exclusively involved the central nervous system. Both presence and severity were associated with repeated instillation of cyclopentolate 1%, low BMI and young age. In specific paediatric populations, a single dose of cyclopentolate must be considered. Vital function monitoring facilities are advisable. Adjustment of guidelines is recommended.

The nutritional status of patients starting specialized predialysis care.

OBJECTIVE: To examine the prevalence of and risk factors for malnutrition at the start of specialized predialysis care. DESIGN: The present analysis was performed on cross-sectional data collected at inclusion in the study. The study included 25 outpatient clinics delivering specialized predialysis care in the Netherlands. SUBJECTS: Three hundred seventy-six incident patients with advanced chronic kidney disease attending one of the participating outpatient clinics. MAIN OUTCOME MEASURE: Subjective global assessment (SGA) of nutritional status. RESULTS: At the start of specialized predialysis care, 11% of patients suffer from moderate protein-energy wasting as measured by SGA. Independent risk factors are age >75 years (Odds ratio [OR], 3.88 [1.74-8.66]), female gender (OR, 2.95 [1.37-6.32]), and having a body mass index <25 kg/m(2) (OR, 2.56 [1.19-5.49]). Estimated glomerular filtration rate was not significantly associated with SGA (OR, 1.63 [0.76-3.48]). CONCLUSIONS: Eleven percent of patients started on specialized predialysis care suffer from moderate protein-energy wasting; risk factors are age >75 years, female gender, and BMI <25 kg/m(2).

CA 19-9 as a marker in addition to CEA to monitor colorectal cancer.

BACKGROUND: Carcinoembryonic antigen is the commonly used tumor marker in patients with colorectal cancer, and CA 19-9 might be an additional marker. The aim of this retrospective study was to investigate whether CA 19-9 levels can be used to monitor the disease process in patients with colorectal cancer who had no elevated CEA levels. The secondary aim was to determine if preoperative increased levels of CEA and CA 19-9 were associated with mortality. MATERIALS AND METHODS: Two sets of data from patients with histologically confirmed colorectal cancer, were included in a single-center study. First, patients with a minimum of 3 serial measurements of CA 19-9 and CEA tumor markers were related to the clinical course of their disease. Second, patients with preoperative levels of CEA and CA 19-9 were related to survival. RESULTS: In patients with colorectal cancer and 3 serial measurements of tumor markers, 7.3% had only increased CA 19-9 levels without increased CEA levels, and 55.4% of the patients had an increase of CA 19-9 and CEA levels. In the patients with available preoperative markers, patients with only an increase of CA 19-9 had a significantly decreased 5-year survival compared with patients with an increase of only CEA (P = .013). CONCLUSION: CA 19-9 can be used as additional marker to follow the disease process in patients with colorectal cancer without an increase in CEA level. Patients with preoperative increased CA 19-9 level had a poorer 5-year survival than patients with preoperative increased CEA levels.

Effect of sensory stimuli on restless legs syndrome: a randomized crossover study.

STUDY OBJECTIVE: A variety of sensory stimuli relieve restless legs syndrome symptoms. Because systematic evaluations of sensory stimulation in restless legs syndrome are largely lacking, we performed a randomized crossover study to evaluate the effect of external sensory stimulation on restless legs syndrome symptoms. METHODS: Eighteen patients underwent 3 consecutive suggestive immobilization tests with the order of the following 3 conditions randomly assigned: no electrical stimulation (condition 1), tactile and proprioceptive sensory stimulation (condition 2), and tactile sensory stimulation only (condition 3). Restless legs syndrome symptoms were quantified by visual analog scales, and periodic leg movements during wake were measured. RESULTS: Baseline visual analogue scale score was 4.5 (range 0-60) in condition 1, 10.5 (range 0-96) in condition 2, and 8.5 in condition 3 (p = 0.21). There was a tendency towards a higher maximum visual analogue scale score and visual analogue scale score at the end of the suggested immobilization test in the conditions with tactile sensory stimulation, though not significant (p = 0.74 and p = 0.29, respectively). Fifteen patients suffered from periodic leg movements during wake. Median indices were 18 (range 0-145) in condition 1, 26 (range 0-190) in condition 2, and 49 (range 0-228) in condition 3 (p = 0.76). CONCLUSIONS: We found a tendency towards less leg discomfort in the conditions in which an external sensory input was applied. This potential benefit of sensory stimuli on restless legs syndrome severity merits further investigation as this could open new ways towards a better pathophysiological understanding and non-pharmacological treatments.

Haemoglobin levels and health-related quality of life in young and elderly patients on specialized predialysis care.

BACKGROUND: In predialysis patients, the optimal treatment choices for controlling haemoglobin (Hb) are unknown, because targeting high Hb levels has negative effects--poorer survival--but possible positive effects as well--better health-related quality of life (HRQOL). Moreover, these effects may be different in specific subgroups (e.g. young versus elderly). METHODS: In the PREPARE-2 follow-up study, incident predialysis patients were included (2004-2011) when referred to 1 of the 25 participating Dutch outpatient clinics. HRQOL was assessed at 6-month intervals with the short form-36 (SF-36) questionnaire [physical/mental summary measure and eight subscales (range 0-100)]. A linear mixed model was used to associate Hb [<11, ≥ 11 to <12 (reference), ≥ 12 to <13 and ≥ 13 g/dL] with HRQOL, stratified by prescription of anaemia medication (erythropoietin-stimulating agent (ESA)/iron) and age (young: <65 years and elderly: ≥ 65 years). RESULTS: Only elderly patients (n = 214) not prescribed ESA/iron and with a high Hb (≥ 13 versus ≥ 11 to <12 g/dL) had a statistically significant (P < 0.05) and/or clinically relevant (>3-5 points) higher physical [11.9, 95% confidence interval (CI) 1.7, 22.2] and mental (6.4, 95% CI -1.7, 14.6) summary score. High Hb was not associated with a higher HRQOL in elderly patients who were prescribed ESA/iron. However, only young patients (n = 157) prescribed ESA/iron and with a high Hb (≥ 13 versus ≥ 11 to <12 g/dL) had a higher physical (8.9, 95% CI 2.1, 15.8) and mental (6.2, 95% CI -0.4, 12.8) summary score. CONCLUSIONS: The association of Hb levels with HRQOL differs by age and use of ESA/iron medication on predialysis care. Therefore, medical care should aim for shared decision-making regarding the appropriate Hb target leading to more individualized care.

Cardiovascular risk estimation in women with a history of hypertensive pregnancy disorders at term: a longitudinal follow-up study.

BACKGROUND: Cardiovascular disease is associated with major morbidity and mortality in women in the Western world. Prediction of an individual cardiovascular disease risk in young women is difficult. It is known that women with hypertensive pregnancy complications have an increased risk for developing cardiovascular disease in later life and pregnancy might be used as a cardiovascular stress test to identify women who are at high risk for cardiovascular disease. In this study we assess the possibility of long term cardiovascular risk prediction in women with a history of hypertensive pregnancy disorders at term. METHODS: In a longitudinal follow-up study, between June 2008 and November 2010, 300 women with a history of hypertensive pregnancy disorders at term (HTP cohort) and 94 women with a history of normotensive pregnancies at term (NTP cohort) were included. From the cardiovascular risk status that was known two years after index pregnancy we calculated individual (extrapolated) 10-and 30-year cardiovascular event risks using four different risk prediction models including the Framingham risk score, the SCORE score and the Reynolds risk score. Continuous data were analyzed using the Student's T test and Mann-Whitney U test and categorical data by the Chi-squared test. A poisson regression analysis was performed to calculate the incidence risk ratios and corresponding 95% confidence intervals for the different cardiovascular risk estimation categories. RESULTS: After a mean follow-up of 2.5 years, HTP women had significantly higher mean (SD) extrapolated 10-year cardiovascular event risks (HTP 7.2% (3.7); NTP 4.4% (1.9) (p<.001, IRR 5.8, 95% CI 1.9 to 19)) and 30-year cardiovascular event risks (HTP 11% (7.6); NTP 7.3% (3.5) (p<.001, IRR 2.7, 95% CI 1.6 to 4.5)) as compared to NTP women calculated by the Framingham risk scores. The SCORE score and the Reynolds risk score showed similar significant results. CONCLUSIONS: Women with a history of gestational hypertension or preeclampsia at term have higher predicted (extrapolated) 10-year and 30-year cardiovascular event risks as compared to women with a history of uncomplicated pregnancies. Further large prospective studies have to evaluate whether hypertensive pregnancy disorders have to be included as an independent variable in cardiovascular risk prediction models for women.

Is the decline of renal function different before and after the start of dialysis?

BACKGROUND: The presence of glomerular filtration in dialysis patients is associated with improved survival and quality of life. This study explores the time course of the glomerular filtration rate (GFR) between 1 year before and 1 year after the start of haemodialysis (HD) and peritoneal dialysis (PD). METHODS: This study included 1861 incident dialysis patients (NECOSAD cohort; 62% male, 60 ± 15 years, 61% HD, GFR 5.2 ± 3.6 mL/min/1.73 m(2)). A decline of the GFR was estimated using linear mixed-effects models adjusted for age, sex, primary kidney disease, cardiovascular disease and diabetes. The rate of decline was allowed to change at a certain point in time. RESULTS: The decline of the GFR attenuated from -0.53 mL/min/1.73 m(2)/month (95% CI: -0.58, -0.48) in the period before the start of dialysis to -0.12 (95% CI: -0.20, -0.04) at 2-4 months of dialysis in all patients. In HD, decline attenuated from -0.51 (95% CI: -0.57, -0.44) to -0.14 (95% CI: -0.26, -0.02); in PD from -0.55 (95% CI: -0.62, -0.48) to -0.11 (95% CI: -0.23, 0.01). In patients who started dialysis with a GFR equal/above median GFR at dialysis start, the decline attenuated (at 3 months) from -0.70 (95% CI: -0.78; -0.62) to -0.21 (95% CI: -0.36; -0.05). In patients who started dialysis with a GFR below median GFR at dialysis start, the decline attenuated (at 1 month) from -0.73 (95% CI: -0.88; -0.58) to -0.04 (95% CI: -0.27 , 0.19). CONCLUSIONS: The apparent decline of the GFR slows down after 2-4 months of dialysis. This decline was similar in HD and PD patients, although at a different level of GFR. Further studies are needed to examine explanations for this phenomenon.

Illness perceptions and treatment perceptions of patients with chronic kidney disease: different phases, different perceptions?

OBJECTIVES: To examine the variability of illness and treatment perceptions - that have been found to be associated with chronic kidney disease (CKD) patients' outcomes (e.g., quality of life) - across the CKD trajectory, by investigating whether there are differences in perceptions in patients: (1) on varying treatments (pre-dialysis, haemodialysis, peritoneal dialysis), (2) with varying lengths of time on (dialysis) treatment, and (3) over time on dialysis, with an 8-month interval. DESIGN AND METHODS: Mixed cross-sectional and longitudinal design, using self-report questionnaires on illness and treatment perceptions; the study sample consisted of 105 pre-dialysis and 161 dialysis patients; of the 161 dialysis patients, 87 patients filled in the questionnaires again after an 8-month interval. Data were examined using multilevel (multivariate) repeated measurements regression analyses, controlled for background characteristics and repeated measures. RESULTS: Patients on haemodialysis and peritoneal dialysis believed more strongly that their treatment controls their illness (p < .05, p < .01, respectively) and perceived more illness consequences (p < .001, p < .05, respectively) than pre-dialysis patients. Haemodialysis patients perceived more treatment consequences than pre-dialysis (p < .001) and peritoneal dialysis patients (p < .01). The perception of illness understanding fluctuated between patients with varying lengths of time on dialysis (p < .05). Perceived treatment consequences were more negative in patients who were on dialysis for longer lengths of time (p < .01). Lastly, perceptions of illness and treatment varied within dialysis patients over an 8-month interval, with treatment control and personal control showing the lowest correlations. CONCLUSIONS: Findings suggest that illness and treatment perceptions vary across the CKD trajectory. This indicates that perceptions are amenable to influences and that interventions might potentially be helpful in influencing them in order to improve outcomes. STATEMENT OF CONTRIBUTION: What is already known on this subject? Dialysis patients' perceptions of illness understanding and illness symptoms vary over the first year on dialysis. Established haemodialysis patients' perceptions of illness understanding, emotional response and treatment control vary over a 2-year period. Certain illness perceptions as well as treatment perceptions vary as a function of treatment type in patients with CKD stage 5 (dialysis patients, patients with a kidney transplant). What does this study add? Patients' perceptions of illness understanding and treatment consequences vary between patients as a function of length of time on (haemo-, peritoneal-) dialysis, taking into account a wide range of time (0-10 years). Illness perceptions and treatment perceptions of patients on haemodialysis and peritoneal dialysis vary within patients over an 8-month interval, with perceptions of treatment control and personal control showing the highest variations. Perceptions of illness consequences, treatment consequences and treatment control vary as a function of type of treatment, taking into account pre-dialysis treatment (CKD stage 4) and dialysis (haemodialysis, peritoneal dialysis) treatment (CKD stage 5).

Pharmacokinetics of dalteparin during haemodialysis.

BACKGROUND/AIMS: Usually, the appropriate dosage of low-molecular-weight heparin during haemodialysis is empirically based on the clinical effect. We studied the pharmacokinetics of dalteparin during standard haemodialysis in different groups of patients to assess the added value of measuring the anti-Xa activity for dose monitoring and adjustments. METHODS: The pharmacokinetics of intravenously administered dalteparin during haemodialysis was studied in 9 patients during 27 haemodialysis sessions. Six patients received a single bolus dose of dalteparin (group 1), and 3 patients received a higher initial bolus dose of dalteparin followed by a second bolus dose after 2 h (group 2). The clinical effect was evaluated by visual inspection for clot formation in the extracorporeal circuit. RESULTS: The pharmacokinetic curve suggests a zero-order process of elimination. The mean decrease in anti-Xa activity (slope) was comparable in all patients. The mean anti-Xa activity at the end of haemodialysis (Clast) was 0.15 IU/ml in group 1 and 0.60 IU/ml in group 2. CONCLUSION: We conclude that measuring anti-Xa activity can be used to monitor the elimination of dalteparin during haemodialysis and is highly reproducible.

Reduction in STIs in an empowerment intervention programme for female sex workers in Bangalore, India: the Pragati programme.

BACKGROUND/OBJECTIVE: The Pragati programme is an on-going empowerment programme for female sex workers (FSWs) working and living in Bangalore, India. Pragati aims to reduce transmission of HIV and sexually transmitted infections (STIs) among FSWs. This study describes the STI incidence rate, contact rate, and condom use during follow-up years. DESIGN: Between April 2005 and November 2010, 20,330 FSWs participated in the programme. Outcome measures were programme exposure (number of contacts per person-year), STI incidence rate, and condom use. All analyses were stratified by year of follow-up. STIs were diagnosed by syndromic case management in either programme or referral clinics. We restricted our analyses to the period between April 2005 and July 2008 (when the majority of STIs were diagnosed in programme clinics), in order to minimise the possible influence of differences in STI diagnosis between clinic types. RESULTS: Results showed a significant increase of programme exposure (p-value for trend<0.001) and a significant decrease in the STI incidence rate (p-value for trend<0.001) over the follow-up time (between April 2005 and July 2008). Reported condom use at last paid sex increased from 77.6% in year 1 to 100% in year 4 of follow-up (p-value for trend<0.001). CONCLUSION: Our data seem to suggest that the Pragati programme had a positive effect on the STI incidence rate and condom use, possibly as a result of increased programme exposure. We recommend for future studies to invest more in the study design, type of data collection, and recording mechanisms before starting with an intervention. Incorporation of empowerment strategies as an approach in HIV prevention programmes can have a beneficial effect on the lives and livelihoods of FSWs.

Proteinuria as a risk marker for the progression of chronic kidney disease in patients on predialysis care and the role of angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker treatment.

BACKGROUND/AIMS: Proteinuria is a risk marker for progression of chronic kidney disease (CKD) and treatment with an angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker (ACEi/ARB) is beneficial in these patients. However, little is known about proteinuria and ACEi/ARB treatment in patients on specialized predialysis care. Therefore, we investigated the association of urinary protein excretion (UPE) and ACEi/ARB treatment with renal function decline (RFD) and/or the start of renal replacement therapy (RRT) in patients on predialysis care. METHODS: In the PREPARE-1 cohort, 547 incident predialysis patients (CKD stages IV-V), referred as part of the usual care to outpatient clinics of eight Dutch hospitals, were included (1999-2001) and followed until the start of RRT, mortality, or January 1, 2008. The main outcomes were rate of RFD, estimated as the slope of available eGFR measurements, and the start of RRT. RESULTS: Patients with mild proteinuria (>0.3 to ≤1.0 g/24 h) had an adjusted additional RFD of 0.35 ml/min/1.73 m(2)/month (95% CI: 0.01; 0.68) and a higher rate of starting RRT [adjusted HR: 1.70 (1.05; 2.77)] compared with patients without proteinuria (≤0.3 g/24 h). With every consecutive UPE category (>1.0 to ≤3.0, >3.0 to ≤6.0, and >6.0 g/24 h), RFD accelerated and the start of RRT was earlier. Furthermore, patients starting (n = 16) or continuing (n = 133) treatment with ACEi/ARBs during predialysis care had a lower rate of starting RRT compared with patients not using treatment [n = 152, adjusted HR: 0.56 (0.29; 1.08) and 0.90 (0.68; 1.20), respectively]. CONCLUSION: In patients on predialysis care, we confirmed that proteinuria is a risk marker for the progression of CKD. Furthermore, no evidence was present that the use of ACEi/ARBs is deleterious.

Association of blood pressure with the start of renal replacement therapy in elderly compared with young patients receiving predialysis care.

BACKGROUND: In the growing elderly predialysis population, little is known about the effect of identified risk factors on the progression to end-stage renal disease. Therefore, we investigated the association of systolic (SBP) and diastolic blood pressure (DBP) with the start of renal replacement therapy (RRT), in elderly (≥65 years) compared with young (<65 years) predialysis patients. METHODS: In the PREPARE-1 cohort, 547 incident predialysis patients, referred as part of the usual care to eight Dutch predialysis care outpatient clinics, were included (1999-2001) and followed until the start of dialysis, transplantation, death, or until 1 January 2008. The outcome was the start of RRT. All analyses were stratified for age; <65 years (young) and ≥65 years (elderly). RESULTS: In young predialysis patients (n = 268) higher SBP (every 20 mm Hg increase) and high DBP (DBP ≥100 mm Hg compared with 80-89 mm Hg) were associated with a higher rate of starting RRT (adjusted hazard ratio (HR) (95% confidence interval) 1.21 (1.09;1.34) and 1.74 (1.16;2.62), respectively). However, in elderly predialysis patients (n = 240) only patients with SBP ≥180 mm Hg had an increased rate compared with patients with 140-159 mm Hg (adjusted HR 2.33 (1.41;3.87)). Furthermore, patients with DBP <70 or ≥100 mm Hg had an increased rate of starting RRT, independent of SBP, compared with patients with 80-89 mm Hg (fully adjusted HR 1.72 (1.01;2.94) and 2.05 (1.13;3.73), respectively). CONCLUSIONS: The association of SBP and DBP with the start of RRT is different between elderly and young predialysis patients.

Agreement between different parameters of dialysis dose in achieving treatment targets: results from the NECOSAD study.

BACKGROUND: The recommended parameter of dialysis dose differs between K-DOQI and the European Best Practice Guidelines. It is not well known to what extent an agreement exists between the different parameters, nor if target and delivered dialysis dose are prescribed according to the urea reduction rate (URR), single-pool Kt/V (spKt/V) or equilibrated double-pool Kt/V (eKt/V) and which parameter is most strongly related to mortality. METHODS: In 830 haemodialysis patients from the NECOSAD cohort URR, spKt/V and eKt/V were calculated and compared according to a classification regarding the recommended treatment targets (70%, 1.4 and 1.2, respectively) as well as minimum delivered dialysis dose (65%, 1.2 and 1.05, respectively). Moreover, the relation between treatment dose and survival was assessed using Cox regression analysis. RESULTS: A spKt/V of ≥1.4 and URR ≥70% corresponded with eKt/V ≥1.20 (as reference method) in, respectively, 98.0 and 90.6% of patients. spKt/V of ≥1.2 and URR ≥65% corresponded with eKt/V ≥1.05 in, respectively, 95.5 and 91.2% of patients. Deviations from the reference method were significantly related to differences in urea distribution volume (spKt/V), treatment time (URR) and ultrafiltration volume (URR). The adjusted HR (95% CI) was 0.98 (0.96, 0.99) for URR, 0.51 (0.31, 0.84) for spKt/V and 0.46 (0.30, 0.80) for the eKt/V. CONCLUSION: The use of URR leads to larger disagreement with the reference method (eKt/V) treatment target as compared to spKt/V. Low urea distribution volume, short treatment time and low ultrafiltration volumes are predictive parameters for overestimation of dialysis dose when utilizing the alternative methods spKt/V and URR instead of eKt/V. Delivered eKt/V, spKt/V and URR were all positively related to survival.

Survival in dialysis patients is not different between patients with diabetes as primary renal disease and patients with diabetes as a co-morbid condition.

BACKGROUND: On dialysis, survival among patients with diabetes mellitus is inferior to survival of non-diabetic patients. We hypothesized that patients with diabetes as primary renal disease have worse survival compared to patients with diabetes as a co-morbid condition and aimed to compare all-cause mortality between these patient groups. METHODS: Data were collected from the Netherlands Cooperative Study on the Adequacy of Dialysis (NECOSAD), a multicenter, prospective cohort study in which new patients with end stage renal disease (ESRD) were monitored until transplantation or death. Patients with diabetes as primary cause of ESRD were compared with patients with diabetes as co-morbid condition and both of these patient groups were compared to patients without diabetes. Analysis was performed using Kaplan-Meier and Cox regression. RESULTS: Fifteen % of the patients had diabetic nephropathy as primary renal disease (N = 281); 6% had diabetes as co-morbid condition (N = 107) and 79% had no diabetes (N = 1465). During follow-up 42% of patients (N = 787) died. Compared to non-diabetic patients, mortality risk was increased for both patients with diabetes as primary renal disease HR: 1.9 (95% CI 1.6, 2.3) and for patients with diabetes as co-morbid condition HR: 1.7 (95% CI 1.3, 2.2). Mortality was not significantly higher in patients with diabetes as primary renal disease compared to patients with diabetes as co-morbid condition (HR 1.06; 95% CI 0.79, 1.43). CONCLUSIONS: This study in patients with ESRD showed no survival difference between patients with diabetes as primary renal disease and patients with diabetes as a co-morbid condition. Both conditions were associated with increased mortality risk compared to non-diabetic patients.

Association of blood pressure with decline in renal function and time until the start of renal replacement therapy in pre-dialysis patients: a cohort study.

BACKGROUND: To investigate whether high blood pressure accelerates renal function decline in patients with advanced chronic kidney disease (CKD), we studied the association of systolic (SBP) and diastolic blood pressure (DBP) with decline in renal function and time until the start of renal replacement therapy (RRT) in patients with CKD stages IV-V on pre-dialysis care. METHODS: In the PREPARE-1 cohort 547 incident pre-dialysis patients, referred as part of the usual care to outpatient clinics of eight Dutch hospitals, were included between 1999 and 2001 and followed until the start of RRT, mortality, or end of follow-up (January 1st 2008). Main outcomes were rate of decline in renal function, estimated as the slope of available eGFR measurements, and time until the start of RRT. RESULTS: A total of 508 patients, 57% men and median (IQR) age of 63 (50-73) years, were available for analyses. Mean (SD) decline in renal function was 0.35 (0.75) ml/min/1.73 m2/month. Every 10 mmHg increase in SBP or DBP resulted in an accelerated decline in renal function (adjusted additional decline 0.04 (0.02;0.07) and 0.05 (0.00;0.11) ml/min/1.73 m2/month respectively) and an earlier start of RRT (adjusted HR 1.09 (1.04;1.14) and 1.16 (1.05;1.28) respectively). Furthermore, patients with SBP and DBP above the BP target goal of < 130/80 mmHg experienced a faster decline in renal function (adjusted additional decline 0.31 (0.08;0.53) ml/min/1.73 m2/month) and an earlier start of RRT (adjusted HR 2.08 (1.25;3.44)), compared to patients who achieved the target goal (11%). Comparing the decline in renal function and risk of starting RRT between patients with only SBP above the target (≥ 130 mmHg) and patients with both SBP and DBP below the target (< 130/80 mmHg), showed that the results were almost similar as compared to patients with both SBP and DBP above the target (adjusted additional decline 0.31 (0.04;0.58) ml/min/1.73 m2/month and adjusted HR 2.24 (1.26;3.97)). Therefore, it seems that especially having SBP above the target is harmful. CONCLUSIONS: In pre-dialysis patients with CKD stages IV-V, having blood pressure (especially SBP) above the target goal for CKD patients (< 130/80 mmHg) was associated with a faster decline in renal function and a later start of RRT.