ABSTRACT
OBJECTIVES: Extensive discussion with renal patients about treatment intensity is not systematically integrated into their care and often occurs during an acute hospitalization. We conducted a "test-of-change" pilot study to assess the utility of providing an upstream discussion in the ambulatory setting as an additional nephrology consult to assist patients with chronic kidney disease considering treatment choices. METHODS: We randomly assigned patients with Stage 4 or Stage 5 chronic kidney disease who had not yet begun renal dialysis to 1 of 2 groups. The test group received the additional nephrology consult and met with an interdisciplinary team composed of a nephrologist, social worker, and clinical ethicist, and the control group did not. Qualitative data were collected in 2012 and 2013 via oral questionnaire. Both groups received a 6-month follow-up assessment. RESULTS: Patients who received the nephrology consult reported that they experienced help in forming a treatment plan, felt well understood, and had the opportunity to thoroughly discuss questions. The controls had a 26% increased probability of beginning dialysis and had a statistically significant increase in dialysis and clinic visits (p < 0.10 and p < 0.05). Controls also were likelier than the test group to be admitted to the hospital (0.5 vs 0.2 admissions per patient in the test group), spend more days hospitalized (2.8 vs 0.5 bed days per patient), and visit the emergency room (0.73 vs 0.66 visits per patient) and clinic (6.6 vs 3.6 visits per patient). CONCLUSIONS: An additional nephrology consultation proved helpful both qualitatively and quantitatively.
Subject(s)
Nephrology , Referral and Consultation/standards , Renal Dialysis , Renal Insufficiency, Chronic/therapy , Adult , Ambulatory Care Facilities , Communication , Decision Making , Female , Humans , Male , Middle Aged , Patient Participation , Patient Satisfaction , Pilot ProjectsABSTRACT
We present a topological description of a beta-sheet in terms of a piece of helical surface. It requires only two easy-to-handle parameters: the twist, i.e. the turn of the helical surface per residue, and the coiling, which is a curvature along the strands or in the direction perpendicular to the strands of the sheet. This method applies fairly well to three- and four-strand sheets, forming a too limited structure to be able to build a barrel. From an analysis of beta-sheets derived from a structural database, we show that this picture can even be reduced to the use of one main value, the twist angle. The dependence of beta-sheet twisting on the number of strands in a sheet, and also on the length and direction of strands, has been demonstrated. The applications of such a description may include the rapid modeling of 3D structures.
