A Holistic Approach to Early Relational Health: Cultivating Culture, Diversity, and Equity.

Early Relational Health (ERH) is the foundation for infant and child emotional and social wellbeing. ERH is a quality of relationships co-created by infants, caregivers, and other members of their families and communities from pregnancy through childhood. Relationships themselves are not ERH; rather, ERH can be a feature of relationships. Those that are characterized by positive, shared emotionality become contexts within which members co-develop mutual capacities that enable them to prevail and flourish. This essay offers a synthesis of current knowledge about ERH in the US and begins to integrate Indigenous and non-Indigenous research and knowledge about ERH in the hope that readers will embrace "Etuaptmumk"-"Two-Eyed Seeing". The authors maintain that systems of care for infants, families, and their communities must first and foremost attend to revitalization, cultural context, diversity, equity, and inclusion. Authors discuss key concepts in ERH; Indigenous and non-Indigenous research that inform ERH; structural and systemic factors in the US that affect ERH ecosystems; the critical intersections of culture, diversity, equity; the broader concept of village support for fostering ERH; and efforts to revitalize ERH discourse, practices, and policies. The authors advocate for a holistic approach to ERH and suggest future directions for research and advocacy.

The context and development of the early relational health screen.

Early relational experiences are key drivers for developing social emotional capacities, educational achievement, mental health, physical health, and overall wellbeing. The child health sectors are committed to promotion, prevention, and early intervention that optimize children's health and development, often employing evidence-based screening as foundational practices. Despite a variety of validated parent-infant observational assessment tools, few are practical within busy practice settings, acceptable with all racial and ethnic groups and ready for universal adoption. In response to this need, a team of clinicians, early childhood educators, researchers and infant mental health specialists collaborated to develop and test a novel video-based, dyadic relational screening and monitoring tool, the Early Relational Health Screen (ERHS). This tool uniquely focuses on the early parent-child relationship (6-24 months), within the construct of early relational health (ERH). Initial testing demonstrated that the ERHS is a valid, reliable, feasible, and useful screening and monitoring tool for clinical applications. The ERHS was further developed within a population-based, prospective research study and adapted with brief video feedback for parents in the home visiting and child health sectors. The ERHS and its adaptations appear to advance ERH and equity within the transforming child health and public health care systems of today.

Las tempranas experiencias de relaciones afectivas son clave para desarrollar las capacidades socioemocionales, para los logros educativos, la salud mental, la salud física y el bienestar en general. Los sectores de salud infantil están comprometidos a promover, prevenir e intervenir a tiempo para que la salud de los niños y su desarrollo sean óptimos, a menudo empleando examinaciones basadas en la evidencia como prácticas fundamentales. A pesar de la variedad de válidas herramientas para la evaluación con base en la observación progenitor-infante, pocas son prácticas dentro del ocupado campo de la práctica, aceptables con todos los grupos raciales y étnicos, y pocas están listas para ser adoptadas en forma generalizada. Como respuesta a esta necesidad, un equipo formado por clínicos profesionales, educadores de la temprana niñez, investigadores y especialistas de la salud mental infantil colaboraron para desarrollar y probar una herramienta novedosa basada en videos, con el fin de examinar y darle seguimiento a la relación de la díada, el Examen del Bienestar de la Temprana Relación (ERHS). Esta herramienta de manera única se enfoca en la temprana relación progenitor-niño (6-24 meses), dentro del marco del temprano bienestar de la relación. La examinación inicial demostró que ERHS es una herramienta de examinación y seguimiento válida, confiable, posible y útil para la aplicación clínica. Entonces ERHS se desarrolló dentro de un estudio de investigación de probabilidades, con base en la población, y se adaptó con breves respuestas en video para progenitores en los sectores de visitas a casa y salud infantil. ERHS y sus adaptaciones parecen avanzar el temprano bienestar de la relación (ERH) y la equidad dentro de los sistemas de salud infantil y cuidado de salud pública en transformación hoy día.

Les expériences relationnelles sont des moteurs essentiels pour le développement des capacités socio-émotionnelles, la réussite scolaire, la santé mentale, la santé physique et le bien-être général. Les secteurs de la santé de l'enfant sont dédiés à la promotion, à la prévention et à l'intervention précoce qui optimisent la santé des enfants et leur développement, en employant souvent des dépistages fondés sur des données probantes en tant que pratiques fondamentales. En dépit d'une variété d'outils d'évaluation observationnelle parent-bébé validés, peu de ces outils sont pratique au sein d'un cabinet de pratique très occupé et peu sont acceptables pour tous groupes raciaux et éthiques ainsi que prêts pour une adoption universelle. Pour répondre à ce besoin une équipe de cliniciens, d'éducateurs de la petite enfance, de chercheurs et de spécialistes de la santé mentale du nourrisson ont collaboré afin de développer et de tester un outil innovateur et basé sur la vidéo de dépistage relationnel dyadique et de suivi, le Dépistage de Santé Relationnelle Précoce (en anglais Early Relational Health Screen dont nous gardons l'abréviation ici, ERHS). Cet outil se concentre uniquement sur la relation précoce parent-enfant (6-24 mois), dans le cadre de la construction de la santé relationnelle précoce. Les essais ont montré que l'ERHS est un outil de dépistage et de suivi valide, fiable, réalisable et utile pour les applications cliniques. L'ERHS a été plus profondément développé au sein d'une étude de recherches de prospection, basées sur certaines populations, et adapté avec de brefs commentaires vidéo pour les parents dans les secteurs des visites à domicile et de la santé de l'enfant. L'ERHS et ses adaptations semblent faire progresser la Santé Relationnelle Précoce et l'équité au sein des transformation de la santé de l'enfant et des systèmes de santé publique d'aujourd'hui.

At the feet of storytellers: Equity in early relational health conversations.

Early Relational Health (ERH) focuses attention on family-baby relationships during the first 1000 days of life. Positive ERH enhances child health and development and family wellbeing. Universal, early identification of RH and vulnerability could add value to care. How to screen, when, where, and with whom is the question. Tools and models for screening are practitioner-centered. Bias can affect family engagement and outcomes. This may be problematic for African American families. Authors present findings of a discourse analysis and phenomenological study of experiences of African American families' and HealthySteps Specialists' (HSS) of color with screening ERH in Washington, D.C., USA (N = 13). Findings indicate relevance, acceptance and utility may be influenced by positionality, cultural context, issues of equity, and engagement in mutual reflection. A family-centered approach that opened space for non-dominant knowledge about ERH made positive differences in engagement and utility for families and practioners alike. Health and vulnerability were detected reliably using this approach. Outcomes include new theories about ERH-focused visits with African American families and infants, and a new model for centering ERH in pediatric practice, entitled Early Relational Health Conversations. ERH-C is a family reflection model, not necessarily dyadic. It may have value for other populations. Future directions in ERH-C research are suggested.

La Temprana Salud de la Relación (ERH) enfoca su atención en las relaciones entre la familia y el bebé durante los primeros 1000 días de vida. Una positiva ERH mejora la salud y el desarrollo del niño y el bienestar de la familia. Una identificación universal y temprana de RH y la vulnerabilidad pudieran ser valiosas para el cuidado. La pregunta es cómo detectar, cuándo, dónde y con quién. Las herramientas y los modelos para la detección se centran en los profesionales de la práctica. Los prejuicios pueden afectar la participación familiar y los resultados. Esto pudiera ser problemático para familias afroamericanas. Los autores presentan resultados de un análisis discursivo y un estudio fenomenológico de experiencias de las familias afroamericanas y los especialistas de HealthySteps (HSS) de raza negra con respecto a la detección de ERH en Washington, D.C. (N = 13). Los resultados indican relevancia, aceptación y utilidad para las familias afroamericanas y que circunstancias de posición, contexto cultural, asuntos de equidad y participación en reflexión mutua pudieran influir a los HSS. Un acercamiento centrado en la familia que abrió la oportunidad para el conocimiento no dominante acerca de ERH produjo diferencias positivas en la participación y utilidad tanto para las familias como los profesionales de la práctica. La salud y la vulnerabilidad se detectaron confiablemente usando este acercamiento. Los resultados incluyen nuevas teorías sobre los acercamientos a la detección y un nuevo modelo de detección: Las Conversaciones de la Temprana Salud de la Relación (ERH-C). ERH-C es un modelo de reflexión familiar, no necesariamente diádico. El mismo pudiera ser valioso para otros grupos de población. Se aportan futuras directrices en la investigación de ERH-C.

La Santé Relationnelle Précoce (SRP en français) met l'attention sur les relations famille-bébé durant les 1000 premiers jours de la vie. Une SRP positive renforce la santé de l'enfant, le développement, et la santé de la famille. Une identification universelle et précoce de la Santé Relationnelle et de la vulnérabilité pourrait ajouter de la valeur aux soins. La question se pose: comment dépister, quand, où et avec qui. Les outils et les modèles de dépistages sont centrés sur les praticiens. La partialité peut affecter l'engagement de la famille et les résultats. Ceci peut s'avérer problématique pour les familles noires. Les auteurs présentent les résultats d'une analyse de discours et d'une étude phénoménologique des expériences des familles noires et des Spécialistes de Healthy Steps (HSS) racialisés avec le dépistage ERH à Washington DC aux Etats-Unis (N = 13). Les résultats indiquent que la pertinence, l'acceptation et l'utilité peuvent être influencées par la position, le contexte culturel, les problèmes d'équité et l'engagement dans une réflexion mutuelle. Une approche centrée sur la famille qui a ouvert un espace pour des connaissances non-dominantes à propos de la SRP a fait une différence positive dans l'engagement et l'utilité pour les familles ainsi que pour les praticiens. La santé et la vulnérabilité ont été détectés avec fiabilité en utilisant cette approche. Les résultats incluent de nouvelles théories sur les visites centrées sur la SRP avec des familles noires et leurs nourrissons, et un nouveau modèle de centrage de la SRP dans la pratique pédiatrique, appelée Conversations sur la Santé Relationnelle Précoce. La C-SRP est un modèle de réflexion familiale, pas nécessairement dyadique. Ce modèle peut avoir une valeur pour d'autres populations. Des directions futures pour des recherches sur la C-SRP sont suggérées.

At the feet of storytellers: Implications for practicing early relational health conversations.

A family- and culturally-centered approach to conversations about early relational health (ERH) can open up opportunities for universal family engagement. The appraisal of family-baby relational health is more trustworthy and useful when there is attunement to family voice and facilitator bias. Early Relational Health Conversations (ERH-C) is a model for ERH promotion and intervention. This model has eight components: preparing and entering the ERH-C space, accessing strength and knowledge in a healing-centered space, pausing and co-creating, storytelling, witnessing, mutual reflection, affirming, and claiming their relationship narrative, and mutual insight. It is a paradigm shift in working with African American families and possibly other historically marginalized families who are also impacted by structural racism. The eight components are explained, and examples are given from the perspective of an Africentric worldview. The importance of cultural humility, attuning to and honoring family culture is emphasized. Insights for implementation in primary care and other settings are provided. Healing-centered engagement practices embedded in ERH-C have the potential to move ERH work into the social justice arena. The ERH-C is a family reflection model. Ideas for future directions for ERH-C are discussed.

Un acercamiento a conversaciones sobre la salud de la temprana relación (ERH) con base en la familia y en el medio cultural puede abrir oportunidades para la participación familiar universal. La evaluación de la salud de la relación familia-bebé es más confiable y útil cuando hay un ajuste a la voz de la familia y a los prejuicios del mediador. Las Conversaciones de la Salud de la Temprana Relación (ERH-C) es un modelo para la promoción e intervención ERH. Este modelo tiene ocho componentes: preparar y entrar en el espacio de ERH-C, evaluar la fortaleza y el conocimiento en un espacio centrado en la sanación, detenerse y co-crear, contar historias, ser testigo, reflexión mutua, afirmar y reclamar la narrativa de su relación, mutuo aporte de ideas. Se trata de un cambio de paradigma cuando se trabaja con familias afroamericanas y posiblemente con otras familias históricamente marginalizadas que también reciben el impacto del racismo estructural. Se explican los ocho componentes y se dan ejemplos desde la perspectiva de una vista mundial afro-céntrica. Se enfatiza la importancia de la humildad cultural, estar en sintonía con y honrar la cultura familiar. Se aportan ideas para la implementación en el cuidado primario y otros escenarios. Las prácticas de participación centradas en la sanación que son parte de ERH-C tienen la posibilidad de incorporar ERH dentro del campo de la justicia social. ERH-C es un modelo de reflexión de familia. Se discuten ideas para directrices futuras de ERH-C.

Une approche aux conversations sur la Santé Relationnelle Précoce (SRP), centrée sur la famille et la culture, peut ouvrir de nouvelles portes pour l'engagement de la famille universel. L'appréciation de la santé relationnelle famille-bébé est plus digne de confiance et utile que lorsqu'il y a une harmonisation avec la voix de la famille et une partialité de la part du facilitateur. Les Conversations sur la Santé Relationnelle Précoce (C-SRP) est un modèle de promotion de ls SRP et d'intervention. Ce modèle comprend huit aspects: la préparation et l'entrée de l'espace C-SRP, l'accès aux forces et aux connaissances dans un espace centré sur la guérison, faire une pause et créer ensemble, la narration, le témoignage, la réflexion mutuelle, l'affirmation de la narration de la relation et sa revendication, et la perspicacité mutuelle. Ce modèle présente un changement de paradigme dans le travail avec les familles noires américaines et peut-être également d'autres familles marginalisées qui sont aussi impactées par le racisme structurel. Les huit composantes sont expliquées et des exemples sont données de la perspective d'une vision du monde africentrique. L'importance de l'humilité culturelle, d'être à l'écoute de la culture de la famille et d'honorer la culture familiale est également soulignée. Des idées pour la mise en pratique au sein des soins primaires et d'autres contextes sont offertes. Des pratiques d'engagement centrées sur la guérison encastrées dans la C-SRP peuvent faire progresser le travail de SRP vers le domaine de la justice sociale. La C-SRP est un modèle de réflexion de la famille. Des idées de directions futures pour la C-SRP sont discutées.

Combination treatment with rituximab, low-dose cyclophosphamide and plasma exchange for severe antineutrophil cytoplasmic antibody-associated vasculitis.

Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis can present with life-threatening lung-kidney syndromes. However, many controlled treatment trials excluded patients with diffuse alveolar hemorrhage or severely impaired glomerular filtration rates, and so the optimum treatment in these cases is unclear. In this retrospective cohort study, we report the outcomes of 64 patients with life-threatening disease treated with a combination regimen of rituximab, low-dose intravenous cyclophosphamide, oral glucocorticoids, and plasma exchange. At entry, the median estimated glomerular filtration rate was 9 mL/min, 47% of patients required dialysis, and 52% had diffuse alveolar hemorrhage. All patients received a minimum of seven plasma exchanges, and the median cumulative doses of rituximab, cyclophosphamide, and glucocorticoid were 2, 3, and 2.6 g, respectively, at six months. A total of 94% of patients had achieved disease remission (version 3 Birmingham Vasculitis Activity Score of 0) at this time point, and 67% of patients who required dialysis recovered independent kidney function. During long-term follow-up (median duration 46 months), overall patient survival was 85%, and 69% of patients remained free from end-stage kidney disease, which compares favorably to a historic cohort with severe disease treated with a conventional induction regimen. Combination treatment was associated with prolonged B cell depletion and low rates of relapse; 87% of patients were in continuous remission at month 36. The serious infection rate during total follow-up was 0.28 infections/patient/year, suggesting that combination treatment is not associated with an enduring risk of infection. Thus, we suggest that combination immunosuppressive therapy may permit glucocorticoid avoidance and provide rapid and prolonged disease control in patients with severe ANCA-associated vasculitis.

Prevalence and predictors of continence containment products and catheter use in an acute hospital: A cross-sectional study.

Although incontinence is common in hospital, the prevalence and predictors of continence aid use (continence wear and catheters) are poorly described. A one-day cross-sectional study was conducted in a large university hospital assessing consecutive inpatients (≥55) for their pre-admission and current use of continence aids. Barthel Index, Clinical Frailty Scale and Charlson Co-morbidity scores were recorded. Appropriateness was defined by local guidelines. 355 inpatients, median age 75±17 years, were included; 53% were male. Continence aid use was high; prevalence was 46% increasing to 58% for those ≥75. All-in-one pads were the most common, an overall prevalence of 31%. Older age, lower Barthel and higher frailty scores were associated with continence aid use in multivariate analysis. Inappropriate use of aids was high at 45% with older age being the only independent predictor. Continence aids are often used inappropriately during hospitalisation by older patients. Concerted efforts are required to address this issue.

Randomized, Controlled Trial of Tacrolimus and Prednisolone Monotherapy for Adults with De Novo Minimal Change Disease: A Multicenter, Randomized, Controlled Trial.

BACKGROUND AND OBJECTIVES: Minimal change disease is an important cause of nephrotic syndrome in adults. Corticosteroids are first-line therapy for minimal change disease, but a prolonged course of treatment is often required and relapse rates are high. Patients with minimal change disease are therefore often exposed to high cumulative corticosteroid doses and are at risk of associated adverse effects. This study investigated whether tacrolimus monotherapy without corticosteroids would be effective for the treatment of de novo minimal change disease. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: This was a multicenter, prospective, open-label, randomized, controlled trial involving six nephrology units across the United Kingdom. Adult patients with first presentation of minimal change disease and nephrotic syndrome were randomized to treatment with either oral tacrolimus at 0.05 mg/kg twice daily, or prednisolone at 1 mg/kg daily up to 60 mg daily. The primary outcome was complete remission of nephrotic syndrome after 8 weeks of therapy. Secondary outcomes included remission of nephrotic syndrome at 16 and 26 weeks, rates of relapse of nephrotic syndrome, and changes from baseline kidney function. RESULTS: There were no significant differences between the tacrolimus and prednisolone treatment cohorts in the proportion of patients in complete remission at 8 weeks (21 out of 25 [84%] for prednisolone and 17 out of 25 [68%] for tacrolimus cohorts; P=0.32; difference in remission rates was 16%; 95% confidence interval [95% CI], -11% to 40%), 16 weeks (23 out of 25 [92%] for prednisolone and 19 out of 25 [76%] for tacrolimus cohorts; P=0.25; difference in remission rates was 16%; 95% CI, -8% to 38%), or 26 weeks (23 out of 25 [92%] for prednisolone and 22 out of 25 [88%] for tacrolimus cohorts; P=0.99; difference in remission rates was 4%; 95% CI, -17% to 25%). There was no significant difference in relapse rates (17 out of 23 [74%] for prednisolone and 16 out of 22 [73%] for tacrolimus cohorts) for patients in each group who achieved complete remission (P=0.99) or in the time from complete remission to relapse. CONCLUSIONS: Tacrolimus monotherapy can be effective alternative treatment for patients wishing to avoid steroid therapy for minimal change disease. PODCAST: This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2020_01_16_CJN06180519.mp3.

Mycophenolate mofetil and tacrolimus versus tacrolimus alone for the treatment of idiopathic membranous glomerulonephritis: a randomised controlled trial.

BACKGROUND: Tacrolimus (TAC) is effective in treating membranous nephropathy (MN); however relapses are frequent after treatment cessation. We conducted a randomised controlled trial to examine whether the addition of mycophenolate mofetil (MMF) to TAC would reduce relapse rate. METHODS: Forty patients with biopsy proven idiopathic MN and nephrotic syndrome were randomly assigned to receive either TAC monotherapy (n = 20) or TAC combined with MMF (n = 20) for 12 months. When patients had been in remission for 1 year on treatment the MMF was stopped and the TAC gradually withdrawn in both groups over 6 months. Patients also received supportive treatment with angiotensin blockade, statins, diuretics and anticoagulation as needed. Primary endpoint was relapse rate following treatment withdrawal. Secondary outcomes were remission rate, time to remission and change in renal function. RESULTS: 16/20 (80%) of patients in the TAC group achieved remission compared to 19/20 (95%) in the TAC/MMF group (p = 0.34). The median time to remission in the TAC group was 54 weeks compared to 40 weeks in the TAC/MMF group (p = 0.46). There was no difference in the relapse rate between the groups: 8/16 (50%) patients in the TAC group relapsed compared to 8/19 (42%) in the TAC/MMF group (p = 0.7). The addition of MMF to TAC did not adversely affect the safety of the treatment. CONCLUSIONS: Addition of MMF to TAC does not alter the relapse rate of nephrotic syndrome in patients with MN. TRIAL REGISTRATION: This trial is registered with EudraCTN2008-001009-41 . Trial registration date 2008-10-08.

Urinary and Faecal Incontinence: Point Prevalence and Predictors in a University Hospital.

Incontinence is common and associated with adverse outcomes. There are insufficient point prevalence data for incontinence in hospitals. We evaluated the prevalence of urinary (UI) and faecal incontinence (FI) and their predictors among inpatients in an acute university hospital on a single day. Continence status was recorded using the modified Barthel Index (BI). Baseline characteristics, Clinical Frailty Scale (CFS) and ward type were recorded. In all, 435 patients were assessed, median age 72 ± 23 years and 53% were male. The median CFS score was 5 ± 3. The point prevalence of UI was 26% versus 11% for FI. While UI and FI increased with age, to 35.2% and 21.1% respectively for those ≥85, age was not an independent predictor. Incontinence also increased with frailty; CFS scores were independently associated with both UI (p = 0.006) and FI (p = 0.03), though baseline continence status was the strongest predictor. Patients on orthopaedic wards had the highest prevalence of incontinence. Continence assessments were available for only 11 (2%) patients. UI and FI are common conditions affecting inpatients; point prevalence increases with age and frailty status. Despite this, few patients receive comprehensive continence assessments. More awareness of its high prevalence is required to ensure incontinence is adequately managed in hospitals.

A survey of exercise professionals' barriers and facilitators to working with stroke survivors.

Stroke survivors (SSs) are largely inactive despite the benefits of exercise. Exercise professionals (EPs), skilled in exercise prescription and motivation, may have a role in promoting exercise among SSs. However, the number of EPs working with SSs is estimated to be low. This study aimed to investigate EPs' opinions on working with SSs by rating their agreement of barriers and facilitators to working with SSs. The study also investigated EPs skills, interest and experience working with SSs and the relationship between EPs' barriers and facilitators with their training on stroke. A descriptive cross-sectional study was conducted using a researcher-designed online survey between October and December 2015. Purposive sampling was used to survey EPs on the Register of Exercise Professionals in Ireland (n = 277). The response rate was 31% (87/277). Only 22% (19/86) of EPs had experience working with SSs. The primary barriers rated by EPs included insufficient training on psychological problems post-stroke (84%; 61/73), unsuitable equipment for SSs (69%; 50/73) and the level of supervision SSs require (56%; 41/73). The primary facilitators rated included access to suitable equipment (97%; 69/71), practical (100%; 71/71) and theoretical training (93%; 66/71) on stroke. Respondents with no training on stroke were significantly more likely to agree that insufficient training on psychological problems post-stroke and lack of experience were barriers. Seventy-six per cent of EPs (58/76) were interested in one-to-one exercise sessions with SSs but only 53% (40/76) were interested in group sessions. Eighty-two per cent of EPs (62/76) rated their motivational skills as good or very good but 42% (32/76) indicated having only acceptable skills dealing with psychological problems. Results indicate that EPs are interested in working with SSs despite limited experience and practical barriers. Training opportunities on stroke need to be developed; taking into account EPs' barriers, facilitators and skills along with access to suitable equipment.

Retrospective analysis of a novel regimen for the prevention of venous thromboembolism in nephrotic syndrome.

BACKGROUND AND OBJECTIVES: Venous thromboembolism (VTE) occurs in 7%-40% of nephrotic patients. The risk of VTE depends on the severity and underlying cause of nephrotic syndrome. This study investigated the use of low-dose prophylactic anticoagulation to prevent VTE in patients with nephrotic syndrome caused by primary glomerulonephritis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Since 2006, all patients presenting with nephrotic syndrome to Imperial College Kidney and Transplant Centre have been considered for treatment with a novel anticoagulation prophylaxis regimen. All cases of nephrotic syndrome secondary to primary membranous nephropathy, minimal-change disease, and FSGS over a 5-year period were retrospectively reviewed. Patients with serum albumin<2.0 g/dl received prophylactic-dose low-molecular-weight heparin or low-dose warfarin; patients with albumin levels of 2.0-3.0 g/dl received aspirin, 75 mg once daily. All thrombotic events and bleeding complications were recorded. RESULTS: A total of 143 patients received the prophylactic anticoagulation regimen. Median follow-up was 154 weeks (range, 30-298 weeks). The cohort had features associated with a high risk of developing VTE; 40% of the cohort had an underlying diagnosis of membranous nephropathy, and the initial median serum albumin was 1.5 g/dl (range, 0.5-2.9 g/dl). No VTE occurred in patients established on prophylaxis for at least 1 week. VTE was diagnosed in 2 of 143 patients (1.39%) within the first week after presentation and starting prophylaxis. In both cases, it is unclear whether the thrombus had developed before or after the start of prophylaxis. One of 143 (0.69%) patients receiving prophylaxis was admitted urgently with gastrointestinal hemorrhage. Two of 143 patients (1.40%) had elective blood transfusions and procedures to manage occult gastrointestinal bleeding. No other bleeding events occurred in patients receiving prophylaxis. CONCLUSIONS: This regimen of prophylactic antiplatelet or anticoagulant therapy appears effective in preventing VTE in nephrotic syndrome, with relatively few hemorrhagic complications.

Prospective observational single-centre cohort study to evaluate the effectiveness of treating lupus nephritis with rituximab and mycophenolate mofetil but no oral steroids.

OBJECTIVES: Lupus nephritis (LN) is a serious complication of systemic lupus erythematosus (SLE). All current treatment regimens include oral steroids, which are associated with severe adverse events and long-term damage. We have piloted a steroid-avoiding protocol (rituxilup) for the treatment of biopsy-proven active International Society of Nephrology/Renal Pathology Society (ISN/RPS) class III, IV, or class V LN. METHODS: We report the findings from the first 50 consecutive patients, treated with 2 doses of rituximab (1 g) and methyl prednisolone (500 mg) on days 1 and 15, and maintenance treatment of mycophenolate mofetil. Patients on maintenance steroids or with life-threatening SLE or requiring dialysis were excluded. Renal remission was defined as serum creatinine no greater than 15% above baseline; complete biochemical remission (CR) was defined as urine protein : creatinine ratio (PCR)<50 mg/mmol or partial remission (PR) if PCR>50 mg/mmol but non-nephrotic and >50% reduction. RESULTS: A total of 45 (90%) patients achieved CR or PR by a median time of 37 weeks (range 4-200). Overall, 72% (n=36) achieved CR (median time 36 weeks (11-58)) and a further 18% (n=9) achieved persistent PR (median time 32 weeks (19-58)). By 52 weeks, CR and PR had been achieved in 52% (n=26) and 34% (n=17) respectively. In all, 12 relapses occurred in 11 patients, at a median time of 65.1 weeks (20-112) from remission. A total of 6/50 patients had systemic flares. Of the 45 responders, only 2 required >2 weeks of oral steroids. Adverse events were infrequent; 18% were admitted, 10% for an infective episode. CONCLUSIONS: The rituxilup cohort demonstrates that oral steroids can be safely avoided in the treatment of LN. If findings are confirmed, it could mark a step change in the approach to the treatment of LN.

Validity of the TAS-45 as a measure of toddler-parent attachment: preliminary evidence from Early Head Start families.

A new observational measure of attachment strategies in the home, the Toddler Attachment Sort-45 (TAS-45) was completed for 59 18- to 36-month-old recipients of EHS. Mothers completed the Brief Infant Toddler Social and Emotional Assessment (BITSEA); children were tested on the Preschool Language Scale (PLS-4); and a mother-child snack was videotaped and coded for dyadic mutuality. The TAS-45 Security score was associated with more dyadic mutuality, higher language and competence scores, and lower problem scores. Discriminant validity was evidenced by a lack of associations with the TAS-45 Dependence score. The TAS-45 Disorganized "hotspot" (cluster) score also showed expected associations with these outcomes. Results are discussed in terms of next steps for use of the TAS-45 in research and practice.

Reversible metronidazole-induced cerebellar toxicity in a multiple transplant recipient.

Metronidazole-induced central nervous system (CNS) toxicity causes a spectrum of neurological symptoms including ataxia, encephalopathy and peripheral neuropathy. It is associated with characteristic MRI changes of high signal intensity in the dentate nuclei. Given the increasing use of metronidazole, it is import to recognise this drug as a cause of ataxia, as it is entirely reversible on drug withdrawal.