Prevalence of non-tuberculous mycobacteria among previously treated TB patients in the Gulf of Guinea, Africa.

Objective: Differentiation between non-tuberculous mycobacteria (NTM) and Mycobacterium tuberculosis complex (MTBC) is crucial for case management with the appropriate antimycobacterials. This study was undertaken in three West and Central African countries to understand NTM associated with pulmonary tuberculosis in the sub-region. Methods: A collection of 503 isolates (158 from Cameroon, 202 from Nigeria and 143 from Ghana) obtained from solid and liquid cultures were analysed. The isolates were tested for drug susceptibility, and MTBC were confirmed using IS6110. All IS6110-negative isolates were identified by 65-kilodalton heat shock protein (hsp65) gene amplification, DNA sequencing and BLAST analysis. Results: Overall, the prevalence of NTM was 16/503 (3.2%), distributed as 2/202 (1%) in Nigeria, 2/158 (1.3%) in Cameroon and 12/143 (8.4%) in Ghana. The main NTM isolates included 5/16 (31.3%) M. fortuitum, 2/16 (12.5%) M. intracellulare and 2/16 (12.5%) M. engbaekii. Eight (57.1%) of the 14 previously treated patients harboured NTM (odds ratio 0.21, 95% confidence interval 0.06-0.77; P=0.021). Three multi-drug-resistant strains were identified: M. engbaekii, M. fortuitum and M. intracellulare. Conclusion: NTM were mainly found among individuals with unsuccessful treatment. This highlights the need for mycobacterial species differentiation using rapid molecular tools for appropriate case management, as most are resistant to routine first-line antimycobacterials.

An Electromyography-Based Constitutive Law for Force Generation in Skeletal Muscle-Part I: Model Development.

This paper proposes a new method for estimating skeletal muscle forces using a model derived from dimensional analysis. It incorporates electromyography signals and muscle force-length, force-velocity, and force-frequency relationships as inputs. The purpose of this model is to provide more accurate estimates of individualized muscle forces to better predict surrounding musculoskeletal tissue and joint contact loading. The derivation begins with dimensional analysis and a selection of critical parameters that define muscle force generation. The resulting constitutive equation gives way to a unique application of inverse-dynamics, one which avoids the issue of indeterminacy when reaction moments and ligament loading are minimized in a joint. The ankle joint is used as an example for developing the equations that culminate into a system of linear equations. A muscle force model capable of being calibrated and then used to predict joint contact and surrounding tissue loading is critical in advancing biomechanics research areas like injury prevention, performance optimization, and tissue engineering, among others. This model's foundation in dimensional analysis, along with its inclusion of electromyography signals, gives promise that it will be physiologically relevant and suitable for application-based studies. A following paper, Part II, will evaluate this premise in an experimental setting.

Channel catfish ovarian fluid differentially enhances blue catfish sperm performance.

For externally fertilizing fishes, interactions between male and female gametes have been shown to have remarkable impacts on sperm performance. Ovarian fluid (OF) and its ability to alter the swimming behavior of fish sperm makes it a determining factor of fertility. With the expansion of channel catfish (Ictalurus punctatus) ♀ × blue catfish (Ictalurus furcatus) ♂ hybrid aquaculture, it is essential to understand the impacts during fertilization and the magnitude such gametic interactions have on sperm performance and subsequent male fertility potential. This study was conducted to address the following: 1) activate blue catfish sperm with/without channel catfish OF to determine impacts on sperm performance and 2) assess if sperm behave differently when activated in the OF from individual females. Sperm (n = 4 males) were activated without OF (control) and with diluted OF from unique females (n = 6), creating 24 experimental crosses. Sperm motility (%), velocity (VCL), and longevity were analyzed using computer assisted sperm analyses software. With OF incorporated in the activation media, sperm velocity was significantly higher than the control at 10, 20, and 30 s post-activation. OF did not have an impact on motility for any females at 10 s and 20 s post-activation but became significantly higher than the control at 30 s. In all cases, OF treatments greatly increased longevity. Male × female interactions were highly significant, such that motility, velocity, and longevity were dependent on specific male-female pairs. This information shows that OF should be incorporated in aquatic media to simulate natural spawning conditions and accurately assess the fluid mechanics of sperm propulsion for each male. Additionally, there are mechanisms that drive gamete interactions that need to be explored further, which may improve selection of male-female pairs for in-vitro fertilization. On a broad scale, our results also help to shed light on the complexities of fertilization and fish reproduction overall, which may have implications for recruitment variability and recovery strategies of threatened and/or endangered freshwater species.

LTA1 is a safe, intranasal enterotoxin-based adjuvant that improves vaccine protection against influenza in young, old and B-cell-depleted (µMT) mice.

Enterotoxin-based adjuvants including cholera toxin and heat-labile toxin (LT) are powerful manipulators of mucosal immunity; however, past clinical trials identified unacceptable neurological toxicity when LT or mutant AB5 adjuvant proteins were added to intranasal vaccines. Here, we examined the isolated enzymatic A1 domain of LT (LTA1) for intranasal safety and efficacy in combination with influenza (flu) vaccination. LTA1-treated mice exhibited no neurotoxicity, as measured by olfactory system testing and H&E staining of nasal tissue in contrast with cholera toxin. In vaccination studies, intranasal LTA1 enhanced immune responses to inactivated virus antigen and subsequent protection against H1N1 flu challenge in mice (8-week or 24-months). In addition, lung H1N1 viral titers post-challenge correlated to serum antibody responses; however, enhanced protection was also observed in µMT mice lacking B-cells while activation and recruitment of CD4 T-cells into the lung was apparent. Thus, we report that LTA1 protein is a novel, safe and effective enterotoxin adjuvant that improves protection of an intranasal flu vaccination by a mechanism that does not appear to require B-cells.

Acute phase proteins and IP-10 as triage tests for the diagnosis of tuberculosis: systematic review and meta-analysis.

OBJECTIVES: We examined the data reported in studies for diagnostic purposes and to discuss whether their intended use could be extended to triage, as rule-in or rule-out tests to select individuals who should undergo further confirmatory tests. METHODS: We searched Scopus, PubMed and Web of Science with the terms 'acute phase proteins,' 'IP-10,' 'tuberculosis,' 'screening' and 'diagnosis,' extracted the sensitivity and specificity of the biomarkers and explored methodologic differences to explain performance variations. Summary estimates were calculated using random-effects models for overall pooled accuracy. The hierarchical summary receiver operating characteristic model was used for meta-analysis. RESULTS: We identified 14, four and one studies for C-reactive protein (CRP), interferon γ-induced protein 10 (IP-10) and alpha-1-acid glycoprotein (AGP). The pooled CRP sensitivity/specificity (95% confidence interval) was 89% (80-96) and 57% (36-65). Sensitivity/specificity were higher in high-tuberculosis-burden countries (90%/64%), HIV-infected individuals (91%/61%) and community-based studies (90%/62%). IP-10 sensitivity/specificity in TB vs. non-TB studies was 85%/63% and in TB and HIV coinfected vs. other lung conditions 94%/21%. However, IP-10 studies included diverse populations and a high risk of bias, resulting in very low-quality evidence. AGP had 86%/93% sensitivity/specificity. CONCLUSIONS: Few studies have evaluated CRP, IP-10 and AGP for the triage of symptomatic patients. Their high sensitivity and moderate specificity warrant further prospective studies exploring whether their combined use could optimize performance.

Are patients with pulmonary tuberculosis who are identified through active case finding in the community different than those identified in healthcare facilities?

The lack of healthcare access contributes to large numbers of tuberculosis (TB) cases being missed and has led to renewed interest in outreach approaches to increase detection. It is however unclear whether outreach activities increase case detection or merely identify patients before they attend health facilities. We compared adults with cough of >2 weeks' duration recruited in health facilities (1202 participants) or in urban slums (2828 participants) in Nigeria. Participants provided demographic and clinical information and were screened using smear microscopy. The characteristics of smear-positive and smear-negative individuals were compared stratified by place of enrolment. Two hundred nine health facility participants (17.4%) and 485 community-based participants (16.9%) were smear positive for pulmonary TB. Community-based smear-positive cases were older (mean age, 36.3 vs. 31.8 years), had longer cough duration (10.3 vs. 6.8 weeks) and longer duration of weight loss (4.6 vs. 3.6 weeks) than facility-based cases; and they complained more of fever (87.4% vs. 74.6%), chest pain (89.0% vs. 67.0%) and anorexia (79.5% vs. 55.5%). Community smear-negative participants were older (mean, 39.4 vs. 34.0 years), were more likely to have symptoms and were more likely to have symptoms of longer duration than smear-negative facility-based participants. Patients with pulmonary TB identified in the community had more symptoms and longer duration of illness than facility-based patients, which appeared to be due to factors differentially affecting access to healthcare. Community-based activities targeted at urban slum populations may identify a different TB case population than that accessing stationary services.

Patient perceptions of a 1-h art-making experience during blood and marrow transplant treatment.

Patients with various forms of cancer receiving blood and marrow transplant (BMT) treatment at an outpatient clinic develop chemotherapy-related symptoms and an increased desire to use complementary and alternative medicine in order to address these symptoms. Art-making offers an inexpensive way to pass time and relieve symptoms during long hours in treatment. Twenty-one BMT patients painted a tile and participated in research. Researchers used semi-structured interviews to understand patients' experiences with art-making. Interviews were recorded, transcribed and coded independently by researchers who met to agree on themes. Ten themes emerged from the data including, meaningful activity (32.2%), expression (18.7%), passing time (13.2%), BMT process (12.1%), social outlet (8.1%), therapy-related symptoms (7.3%), negative aspects of painting (5.9%) and encouragement to paint (2.6%). The results of this study revealed that art-making experience can provide patients a meaningful activity during treatment and an outlet to express their feelings.

Thematic analysis of tiles painted by blood and marrow transplant patients during treatment.

The majority of research on understanding the illness focuses on analysing the written or verbal content. Thematic analysis of images is a novel qualitative approach that can enhance knowledge of the experience of illness. This study used thematic analysis to examine 171 tiles painted by patients through the Tiles of Hope programme in an outpatient blood and marrow transplant unit. Major themes identified in this study were Faith, Hope, Positive Attitude, Nature and Social Support. These themes provided a better understanding of patients' perceptions in relation to their experience with illness through the art-making process.

B-Cell Depletion is Protective Against Anti-AAV Capsid Immune Response: A Human Subject Case Study.

Gene therapy strategies for congenital myopathies may require repeat administration of adeno-associated viral (AAV) vectors in response to several limitations inherent to the clinical design: 1) administration of doses below therapeutic efficacy in patients enrolled in early phase clinical trials; 2) progressive reduction of the therapeutic gene expression over time as a result of increasing muscle mass in patients treated at a young age; and 3) a possibly faster depletion of pathogenic myofibers in this patient population. Immune responses triggered by the first vector administration, and to subsequent ones, represent a major obstacle for successful gene transfer in young patient population. Anti-capsid and anti-transgene product related humoral and cell-mediated responses have been previously observed in all preclinical models and human subjects who received gene therapy or ERT treatment for congenital myopathies. Immune responses may result in reduced efficacy of the gene transfer over time and/or may preclude for the possibility of re-administration of the same vector. This study presents a case of Pompe patient dosed with an AAV1-GAA vector after receiving Rituximab and Sirolimus to modulate the immune responses. A key finding of this single subject case report is the observation that B-cell ablation with rituximab prior to AAV vector exposure results in non-responsiveness to both capsid and transgene, therefore allowing the possibility of repeat administration in the future. This observation is significant for future gene therapy studies and establishes a clinically relevant approach to blocking immune responses to AAV vectors.

First Report of Pseudocercospora angolensis Causing Fruit and Leaf Spot of Citrus in Ghana.

Citrus is one of the most important crops in Ghana, representing a large proportion of the fresh fruit consumed in the country. In 2004, symptoms consisting of necrotic leaf spots of about 1 cm in diameter with light brown centers and dark brown margins surrounded by a yellow halo were first observed in sweet orange (Citrus sinensis) and mandarin (C. reticulata) orchards in the Eastern Region of Ghana. Fruits with raised corky lesions of up to 3 to 4 cm in diameter with yellow halos were also observed. Affected fruit had longitudinal and transversal cracks in the rind with the internal locules exposed. Juice content in diseased fruit was strongly reduced, making them unsuitable for fresh consumption or processing. The disease expanded to the Central and Ashanti Regions, with incidences over 95% and estimated yield losses of about 50 to 90%. Symptomatic leaves and fruit collected in Kade in the Eastern Region were surface disinfested with 0.5% NaOCl for 5 min and small fragments from lesions were plated onto malt extract agar (MEA). Slow-growing fungal colonies were isolated from about 5% of the affected tissues plated after 5 days of incubation at 24 to 26°C, and were transferred to V-8 juice agar and MEA. Plates were incubated for 30 days at 24 to 26°C with 12 h of fluorescent light and 12 h of dark for morphological examination. Colonies were gray in the upper side and dark green on the underside. Conidia produced in culture were mostly solitary or in short chains of 2 to 6 spores, hyaline to pale brown, cylindrical, with rounded apex and base truncated. Conidia were 24 to 82 × 4 to 6 µm, with up to 3 to 5 transverse septa and no longisepta. The 5.8S, ITS2, and 28S ribosomal RNA (rRNA) regions were amplified using the primers ITS1 and ITS4 (3) and sequenced from DNA extracted from the isolate MC-39, obtained from sweet orange leaves in Kade (GenBank Accession No. KF111755). The sequence had 99% identity (total score 819, 85% coverage) with that of Pseudocercospora angolensis (T. Carvalho & O. Mendes) Crous & U. Braun epitype strain CBS 112933 (GU269836) (1). Pathogenicity tests were performed twice on 12-week-old detached fruit of sweet orange cv. Valencia Late of about 4 to 5 cm in diameter. Inoculations were performed using a conidial suspension (3.0 × 105 conidia/ml water) by spraying fruit to run off, brushing the rind, dipping for 6 min, or injecting 2 ml in the albedo. Twenty-two isolates were evaluated and 18 fruit were used for each inoculation technique, isolate and experiment. Fruit treated with sterile distilled water were used as controls. Inoculated fruit were maintained in humid chambers at 24 to 26°C. Disease incidence on inoculated fruit varied from 40.7% to 92.6% and severity from 2 to 3 to 3 to 11 lesions per fruit, depending on the isolate and inoculation technique. No symptoms were observed on control fruit. Fungal colonies morphologically identified as P. angolensis were reisolated from lesions on inoculated fruit, but not from asymptomatic control fruit. Based on these results, the disease was identified as Pseudocercospora fruit and leaf spot of citrus caused by P. angolensis. Until this present report, Ghana was considered one of the few countries in Central Africa that was still free of this citrus disease (2). References: (1) P. W. Crous et al. Stud. Mycol. 75:37, 2013. (2) A. A. Seif and R. J. Hillocks. Int. J. Pest Manag. 39:44, 1993. (3) T. J. White et al. Pages 315-322 in: PCR Protocols: A Guide to Methods and Applications. Academic Press, San Diego, 1990.

Mucosal immune responses induced by transcutaneous vaccines.

The skin has been investigated as a site for vaccine delivery only since the late 1990s. However, much has been discovered about the cell populations that reside in the skin, their active role in immune responses, and the fate of trans- cutaneously applied antigens. Transcutaneous immunization (TCI) is a safe, effective means of inducing immune responses against a number of pathogens. One of the most notable benefits of TCI is the induction of immune responses in both systemic and mucosal compartments. This chapter focuses on the transport of antigen into and beyond intact skin, the cutaneous sentinel cell populations that play a role in TCI, and the types of mucosal immune responses that have been generated. A number of in vivo studies in murine models have provided information about the broad responses induced by TCI. Cellular and humoral responses and protection against challenge have been noted in the gastrointestinal, reproductive, and respiratory tracts. Clinical trials have demonstrated the benefits of this vaccine delivery route in humans. As with other routes of immunization, the type of vaccine formulation and choice of adjuvant may be critical for achieving appropriate responses and can be tailored to activate specific immune-responsive cells in the skin to increase the efficacy of TCI against mucosal pathogens.

Patient perceptions of an art-making experience in an outpatient blood and marrow transplant clinic.

This study explored blood and marrow transplantation (BMT) patients' perceptions of an art-making experience during BMT treatment. Participants including patients receiving BMT for a variety of cancers (10 men/10 women, aged 20-68) were offered a 1 hour tile-painting activity during treatment. Participants with cognitive impairment and respiratory precautions were excluded from the study. Researchers followed immune precaution protocols for the safety of participants. Data were collected through semi-structured, in-depth interviews with 20 participants to gather information about their perceptions of the art-making experience in a BMT clinic setting. Interview recordings were transcribed verbatim and analysed. Researchers coded transcripts independently and discussed outcomes together to achieve agreement on themes. Twelve themes emerged from the data, with the three most prevalent themes being Occupying Time (20.5%), Creative Expression (13.5%), and Reactions to Tile Painting (13.5%). Other themes included Support (12.2%), Side Effects (7.3%), Other Activities Suggested by Patients (7%), BMT Treatment Process (6.2%), Shared Painting Experience (5.9%), Life Outlook (5.2%), BMT Life Changes (3.8%), Spirituality (3%) and Barriers (1.9%). Through analysis of these themes, researchers have identified this art-making experience as a diversional or meaningful way to spend time during treatment, a medium for creative expression, and a distraction from negative side effects of the BMT process.

Resistance to first-line tuberculosis drugs in three cities of Nigeria.

OBJECTIVES: To determine the levels of resistance to first-line tuberculosis drugs in three cities in three geopolitical zones in Nigeria. METHODS: A total of 527 smear-positive sputum samples from Abuja, Ibadan and Nnewi were cultured on BACTEC- MGIT 960. Drug susceptibility tests (DST) for streptomycin, isoniazid, rifampicin and ethambutol were performed on 428 culture-positive samples on BACTEC-MGIT960. RESULTS: Eight per cent of the specimens cultured were multi-drug-resistant Mycobacterium tuberculosis (MDR-TB) with varying levels of resistance to individual and multiple first-line drugs. MDR was strongly associated with previous treatment: 5% of new and 19% of previously treated patients had MDR-TB (OR 4.1 (95% CI 1.9-8.8), P = 0.001) and with young adult age: 63% of patients with and 38% without MDR-TB were 25-34 years old (P = 0.01). HIV status was documented in 71%. There was no association between MDR-TB and HIV coinfection (P = 0.9) and gender (P > 0.2 for both). CONCLUSIONS: MDR-TB is an emerging problem in Nigeria. Developing good quality drug susceptibility test facilities, routine monitoring of drug susceptibility and improved health systems for the delivery of and adherence to first- and second-line treatment are imperative to solve this problem.

Pilot study on multidrug resistant tuberculosis in Nigeria.

BACKGROUND: Drug resistant tuberculosis (TB) has lately emerged and it represents a serious public health problem. We set out to determine drug resistance among TB patients. METHODS: Using automated BACTEC cultures, multidrug resistant-tuberculosis (MDR-TB) was investigated in 117 diagnosed cases in Abuja, Nigeria. RESULTS: Ten (31%) of 32 culture-positive patients were resistant to at least one and four (13%) to all of the four drugs tested. No association between drug resistance and human immunodeficiency virus (HIV) infection was found. CONCLUSIONS: MDR-TB is present in Nigeria and larger studies are urgently required. TB clinical management and control efforts should be improved.

Successful AV fistula creation does not lead to higher catheter use: the experience by the Northwest Renal Network 16 Vascular Access Quality Improvement Program. Four years follow-up.

BACKGROUND: In 2002, the Center for Medicare and Medicaid Services (CMS) required all 18 Renal Networks to participate in a Vascular Access Quality Improvement Program (QIP). The Northwest Renal Network (NWRN 16) chose to increase arteriovenous fistula (AVF) use. NWRN 16 hypothesized that strategies which targeted the improvement of AVF rate and the reduction of catheter use were the same. In December 2001, 44.2% of hemodialysis (HD) patients in the NWRN 16 received HD using an AVF which met the Dialysis Outcome Quality Initiative (K/DOQI) 40% AVF guideline for prevalent patients. However, 43% of HD facilities (2869 patients) had less than 40% of AVF and higher HD catheter rates than the average Network catheter rates (25.0 vs. 20.3%). To address the needs of underperforming facilities, NWRN 16 provided education and tools for their vascular access decision makers to promote AVF creation and catheter reduction. METHODS: In 2002, NWRN 16 sponsored four regional workshops targeted at nephrologists, vascular surgeons, HD nurses, and interventional radiologists. RESULTS: Percentage of AVFs in use in invited facilities increased from 31.3% pre-intervention to 56.2% at 4 yrs: 78% increase (99% confidence interval: 77.8% to 81.5%). Percentage of catheters increased from 25% to 25.8%: 3.2% change over 4 yrs (99% confidence interval: 2.5% to 4%). CONCLUSION: The success of Network 16's AVF interventions demonstrates the effectiveness of Network education promoting multidisciplinary teamwork, and innovative strategies to increase dramatically AVF use without substantial increase in catheter use.

Sex differences in the clinical presentation of urban Nigerian patients with pulmonary tuberculosis.

BACKGROUND: Differences in clinical presentation of tuberculosis (TB) have been reported in different age groups, gender and in different parts of the world. Study of gender differences in clinical presentation of patients will assist in targeting those at higher risk and ensure successful TB control planning. OBJECTIVE: To describe the differences in clinical presentation and risk factors for TB in male and female Nigerian patients with pulmonary tuberculosis (PTB). METHODS: Patients with cough of more than three weeks duration attending hospitals in Abuja, Nigeria were interviewed with a structured questionnaire. After clinical examination, sputum samples were examined by smear microscopy and one sample was cultured. Haematological examination, serum chemistries, HIV serology, and chest X-ray evaluation were also evaluated. RESULTS: Of 1186 patients who had sputum culture, 731 (62%) were positive for TB: 437 (60%) males and 394 (40%) females. The mean (SD) age of males was significantly greater than that of females, 34 (11) vs. 31 (12) years, rp = 0.001. Male patients were more likely to be employed and better educated than women. More men than women smoked cigarettes. Women were more likely to be co-infected with HIV and less likely to be smear-positive than men. Male patients had more severe radiological disease. CONCLUSION: More men than women appear to present with TB at hospitals in Abuja. Male patients were older and are more likely to have smear-positive TB, whereas, female patients were more likely to be co-infected with HIV.

Multidrug-resistant tuberculosis at the National Hospital, Abuja, Nigeria

Five hundred (500) cases of pulmonary tuberculosis (TB) were seen at the Chest Clinic of the National Hospital; Abuja; Nigeria over a 2-year period (2004-2005). The diagnosis and management of multidrug-resistant (MDR) TB were studied as part of DOTS-Plus: Directly Observed Treatment Short-course (DOTS) programmes that add components for MDR-TB diagnosis; management; and treatment. The cases of pulmonary TB that showed mycobacterium resistance to rifampicin and isoniazid (MDR-TB) using the Lowenstein Jensen (solid medium) slope at the National Hospital and later using BACTEC 460 available at Zankli Medical Center at Abuja; were treated with the standard WHO recommended regimen for MDR-TB and the outcomes were studied. Twenty cases (4) of MDRTB were recorded; all 20 were also HIV-positive. One (8) died and 19 (95) were apparently cured at the end of therapy. This is the first report of MDR-TB and DOTS-Plus in Nigeria. There is an urgent need to study the MDR-TB pattern in Nigeria as extensive resistant TB (XDR-TB) has now been reported which is even worse prognostically than MDR-TB

Same-day smears in the diagnosis of tuberculosis.

OBJECTIVE: To assess the feasibility of completing the diagnosis of tuberculosis (TB) in 1 day by collecting only on-the-spot specimens. METHODS: Individuals with suspected TB attending district hospitals in Abuja submitted three sputum samples for routine diagnosis (the standard approach). One additional sample was collected 1 h after the first sputum (the same-day approach). One sputum sample was cultured. Blood samples were tested for HIV. RESULTS: Two hundred and twenty-four patients with chronic cough had 135/672 (20%) positive on-the-spot smears and 47/224 (21%) positive morning smears. The same-day and internationally recommended approaches identified 44 and 45 of the 78 patients with positive cultures, respectively. 106/194 (55%) patients were HIV positive. Only 9-11% of their smears were positive compared with 30-32% for HIV negatives (P < 0.01). CONCLUSION: It could be possible to diagnose TB in a single day by examining two spot specimens, but the feasibility needs to be confirmed on a larger scale.

Use of nanocarriers for transdermal vaccine delivery.

Transdermal delivery is a safe, noninvasive method of administering vaccines directly onto bare skin, offering several potential advantages over traditional needle delivery. This technology is limited by the relative inefficiency of transport of large-molecular-weight vaccine antigens across intact skin. Recent evidence has shown that this barrier can be overcome by properly structured nanosized particles (nanocarriers). The specialized assembly of each type of nanocarrier gives each unique properties and different interactions within the stratum corneum. The use of nanocarriers for vaccine delivery is a platform technology, applicable to delivery of a variety of existing and potential vaccines.

Successful multidisciplinary interventions for arterio-venous fistula creation by the Pacific Northwest Renal Network 16 vascular access quality improvement program.

BACKGROUND: In December 2001, 44.2% of hemodialysis (HD) patients in the Northwest Renal Network (NWRN 16) received dialysis using an arteriovenous fistula (AVF). Substantial differences were noted in percentages of patients with AVF, ranging from 5% to 90% of the facility population, suggesting wide variation in physician practice patterns within the Network. To address the needs of facilities having < 40% AVF, NWRN 16 provided education and tools for their vascular access decision-makers to promote AVF creation. METHODS: In 2002, the Network sponsored 4 regional workshops targeted to nephrologists, vascular surgeons, dialysis nurses, and interventional radiologists. RESULTS: 46 facilities (43% of all Network facilities) had <40% AVF in use in December, 2001, dialyzing 2940 patients (Invited Units). Percent AVF in use in all the Invited Facilities increased from 31.3% pre-intervention to 39.8% at 1 year (p<0.001 vs pre) to 56.2% at four years: 79.8% increase in the prevalent AVF rate over a four-year period (95% confidence interval: 77.8% to 81.7%). CONCLUSION: Low prevalent AVF rates in many NWRN 16 facilities may have resulted from differences in physician practice patterns. The success of Network 16 AVF Intervention demonstrates the effectiveness of Network education promoting multidisciplinary teamwork, innovative strategies to increase AVF rates among dialysis patients.