By DAVID TULLER
Published: November 17, 2008
A SURPRISE: Rita Miller learned in 2005 that she had chronic kidney disease.
In February 2005, Rita Miller, a party organizer in Chesapeake, Va., felt exhausted from what she thought was the flu. She was stunned to learn that persistent high blood pressure had caused such severe kidney damage that her body could no longer filter waste products from her blood.
“The doctor walked over to my bed and said, ‘You have kidney failure — your kidneys are like dried-up peas,’ ” recalled Ms. Miller, now 65, who had not been to a doctor or had her blood pressure checked for years.
“The doctor said, ‘Get your family here right away,’ ” she said. “They were telling me I might not make it. I was in shock. I started dialysis the next day.”
Ms. Miller, who has since moved to Connecticut to be with her children, was one of the millions of Americans unaware that they are suffering from chronic kidney disease, which is caused in most cases by uncontrolled hypertension (as in her case) or diabetes, and is often asymptomatic until its later stages. The number of people with the disease — often abbreviated C.K.D. — has been rising at a significant pace, thanks in large part to increased obesity and the aging of the population.
An analysis of federal health data published last November in The Journal of the American Medical Association found that 13 percent of American adults — about 26 million people — have chronic kidney disease, up from 10 percent, or about 20 million people, a decade earlier.
“We’ve had a marked increase in chronic kidney disease in the last 10 years, and that continues with the baby boomers coming into retirement age,” said Dr. Frederick J. Kaskel, director of pediatric nephrology at the Children’s Hospital at Montefiore in the Bronx. “The burden on the health care system is enormous, and it’s going to get worse.
“We won’t have enough units to dialyze these patients.”
Concerned about the emerging picture, federal health officials have started pilot programs to bolster public awareness, increase epidemiologic surveillance and expand efforts to screen those most at risk — people with high blood pressure, diabetes or a family history of kidney disease.
Those people, and those who already have the disease, can often be helped by the same kinds of medicine and lifestyle changes used in hypertension and diabetes. They are urged to quit smoking, lose weight, exercise regularly, restrict their diets and, if necessary, control their blood pressure and diabetes with medication. But such efforts cannot restore kidney function that has been lost.
The trouble is that most people know very little about chronic kidney disease and rarely ask their doctors about kidney function. And many of those who have it feel relatively well until late in the illness, although they may experience nonspecific symptoms like muscle cramps, loss of energy and poor concentration.
“When most people think of kidney disease, they think of dialysis or transplantation,” said Dr. Joseph A. Vassalotti, chief medical officer for the National Kidney Foundation, a major education and advocacy group. “They don’t understand that it encompasses a spectrum, and that the majority of patients are unaware they have the condition.”
Chronic kidney disease progresses over the course of years, with its phases determined according to two criteria: the presence of protein in the urine, known as proteinuria, and how effectively the kidneys are processing waste products.
Patients get dialysis or a kidney transplant only when they are in the final stage of the disease, also known as kidney failure or end-stage renal disease. But the path to kidney failure can take years. “Only a tiny percentage of patients with kidney disease need dialysis,” said Dr. Stephen Fadem, a Houston nephrologist and vice president of the American Association of Kidney Patients.
Chronic kidney disease itself can damage the cardiovascular system and lead to other serious medical conditions, like anemia, vitamin D deficiencies and bone disorders. Patients are far more likely to die from heart disease than to suffer kidney failure.
Because African-Americans, Latinos and other minority communities suffer disproportionately from hypertension and diabetes, they experience higher rates of kidney disease and kidney failure. Other cases are caused by genetic disorders, autoimmune ailments like systemic lupus erythematosis, prolonged use of certain medications like anti-inflammatory drugs, and a kidney inflammation called glomerulonephritis.
In 2005, more than 485,000 people were living on dialysis or with a transplant, at a total cost of $32 billion. Medicare pays for much of that, because it provides coverage for patients needing dialysis or transplant even if they are not yet 65. In fact, kidney disease and kidney failure account for more than a quarter of Medicare’s annual expenditures.
The National Kidney Foundation, with an annual budget of $85 million, plays a major role in education, policy, research and treatment. The organization provides free screening for adults at risk for kidney disease, publishes a leading journal in the field, lobbies on treatment and policy issues, and conducts extensive public education and outreach.
But it has come under criticism on several fronts, in particular its close financial ties to the pharmaceutical industry. The agency greatly influences clinical care through the development of guidelines to advise doctors on various aspects of the illness. Critics say the guidelines have benefited drug makers, who are major contributors to the foundation.
“These practice guidelines are widely disseminated and heavily influenced by industry, and they come down on the side of recommending higher levels of treatment,” said Dr. Richard Amerling, director of outpatient dialysis at Beth Israel Medical Center in New York.
In 2006, the organization published new guidelines for treating anemia associated with chronic kidney disease. The guidelines were underwritten with support from Amgen, which markets a drug for anemia, and some members of the panel that developed the guidelines had financial ties to the industry.
The kidney foundation guidelines called for raising red blood cell counts to levels higher than those recommended by the Food and Drug Administration, and many nephrologists criticized the guidelines as biased in favor of industry. After new clinical trials suggested that more aggressive treatment could cause an increase in deaths and heart problems, the foundation revised the guidelines.
Ellie Schlam, a spokeswoman for the foundation, said the organization was vigilant “to ensure that no sponsorship funds contributed to the N.K.F.” would influence the content of any guidelines.
The organization has also been criticized by advocates who support financial compensation for organ donors, which the foundation firmly opposes as unethical and unlikely to increase the availability of organs. (In contrast, the American Association of Kidney Patients supports research into how financial incentives would affect organ donation.)
Even the foundation’s classification of chronic kidney disease into five distinct stages, a framework that has been widely accepted, has come under some challenge.
In 2002, the organization published clinical criteria for determining each stage of the disease. But some experts say those guidelines have the effect of overstating the problem by classifying many elderly patients as having the disease when they actually have standard age-related kidney decline. The foundation replies that a reduced kidney function among the elderly should not be accepted as normal just because it is common.
Because of Medicare’s role in paying for dialysis and transplantation, the federal government knows far more about the epidemiology and costs of end-stage renal disease than about chronic kidney disease over all. In recent years, Congress has directed the Centers for Disease Control and Prevention to fill some of these knowledge gaps.
In particular, the centers are seeking to develop a comprehensive surveillance system for the disease, organizing pilot screening projects for people at high risk in California, Florida, Minnesota and New York. The agency is also studying the financial implications of the disease and the cost-effectiveness of various interventions.
The National Kidney Foundation, which has worked closely with the C.D.C. and the National Institutes of Health on initiatives related to chronic kidney disease, has also focused on education and screening, particularly in minority communities. Terri Smith, the urban outreach director at the foundation’s Connecticut affiliate, says she spends a lot of her time going to black churches and community centers to talk about kidney disease, and has been surprised that so few people know anything about it.
“They’re very aware of hypertension and diabetes, but it was a revelation to me that people didn’t get the connection to kidney disease,” she said. “People have no idea they should eat less than a teaspoon of salt a day. I teach them how to read labels; I give them questions they should be asking the doctor.”
In Michigan, the local N.K.F. affiliate reaches out to hair stylists and other salon workers in minority communities, training them in talking to their clients about getting screened. Several years ago, after Mary Hawkins, 61, a nurse who lives in Grand Rapids, received a warning about kidney disease from a masseuse at her local salon, she made an appointment to see her doctor.
Although she did not have kidney disease, she learned that her blood pressure was high. Now she takes three medications to keep it under control, exercises three times a week, takes tai chi classes, no longer smokes and attends a dance class at the same salon.
“I knew kidney disease existed, but I wasn’t in tune with the risk,” she said. “You get so caught up in your own life that the last thing you think about is your health — even though it should be the first thing.”
Tuesday, November 18, 2008
Monday, November 17, 2008
2008 Images in Mosby’s Nursing Consult
You can now search for images in Mosby’s Nursing Consult by using the new Images tab.
The Images tab allows you to quickly search over 5,000 high-quality clinical images from the renowned nursing and medical e-books in Mosby’s Nursing Consult. Images include photos, tables, graphs, and more.
The Images tab allows you to quickly search over 5,000 high-quality clinical images from the renowned nursing and medical e-books in Mosby’s Nursing Consult. Images include photos, tables, graphs, and more.
Friday, November 14, 2008
Bigger Day Care Puts More Stress On Kids
Levels Of Stress Hormone Cortisol Tested
POSTED: 4:13 am HST November 14, 2008
The stress hormone cortisol usually peaks in people in the morning, then decreases through the day.
But researchers have found that some preschoolers' cortisol levels rise through the day when they are in full-day child care.
Children in classes of 10 or less were more likely to show the normal decrease, but those in classes with closer to 20 others tended to show a rise.
The study of 191 preschoolers at 12 places also found that children who were clingier with teachers had more stress. Researchers surveyed students and teachers, and collected saliva samples from the children
"This study sheds additional light on an as-yet incompletely understood phenomenon among many young children attending full-day child care," wrote lead author Jared A. Lisonbee of Washington State University. "Additionally, the study begins to situate child care-cortisol research in the context of a broader literature on the role of relationships in shaping how children function and how they react to stress."
A news release on the study did not indicate what changes in health or behavior could be expected from children with higher cortisol levels.
The study appears in the November/December 2008 issue of Child Development.
Distributed by Internet Broadcasting. This material may not be published, broadcast, rewritten or redistributed.
POSTED: 4:13 am HST November 14, 2008
The stress hormone cortisol usually peaks in people in the morning, then decreases through the day.
But researchers have found that some preschoolers' cortisol levels rise through the day when they are in full-day child care.
Children in classes of 10 or less were more likely to show the normal decrease, but those in classes with closer to 20 others tended to show a rise.
The study of 191 preschoolers at 12 places also found that children who were clingier with teachers had more stress. Researchers surveyed students and teachers, and collected saliva samples from the children
"This study sheds additional light on an as-yet incompletely understood phenomenon among many young children attending full-day child care," wrote lead author Jared A. Lisonbee of Washington State University. "Additionally, the study begins to situate child care-cortisol research in the context of a broader literature on the role of relationships in shaping how children function and how they react to stress."
A news release on the study did not indicate what changes in health or behavior could be expected from children with higher cortisol levels.
The study appears in the November/December 2008 issue of Child Development.
Distributed by Internet Broadcasting. This material may not be published, broadcast, rewritten or redistributed.
Florence S. Wald, American Pioneer in End-of-Life Care, Is Dead at 91
Published: November 14, 2008
Florence S. Wald, whose vision of bringing the terminally ill peace of mind and, to whatever extent possible, freedom from pain led to the opening of the first palliative care hospice in the United States, died on Saturday at her home in Branford, Conn. She was 91. Her death was confirmed by her son, Joel.
Michael Okoniewski/Associated Press
Mrs. Wald, who was dean of the Yale University School of Nursing from 1959 to 1966, was the prime mover, in 1974, in starting the Connecticut Hospice, the nation’s first home-care program for the terminally ill. Six years later, a 44-patient hospice — where the dying could be comforted by their loved ones around the clock and where the staff would do what it could to alleviate suffering — opened in Branford.
“This hospice became a model for hospice care in the United States and abroad,” the publication Yale Nursing Matters said this week, adding that Mrs. Wald’s role “in reshaping nursing education to focus on patients and their families has changed the perception of care for the dying in this country.”
There are now more than 3,000 hospice programs in the United States, serving about 900,000 patients a year.
In recent years, Mrs. Wald had concentrated on extending the hospice care model to dying prison inmates.
“People on the outside don’t understand this world at all,” Mrs. Wald told The New York Times in 1998. “Most people in prison have had a rough time in life and haven’t had any kind of education in how to take care of their health.”
And, she added, “There is the shame factor, the feeling that dying in prison is the ultimate failure.”
Part of Mrs. Wald’s solution was to train inmate volunteers to care for the dying. Besides comforting the terminally ill, she said, the program would save taxpayers’ money and “have rehabilitative qualities for these volunteers.”
More than 150 inmate volunteers in Connecticut prisons have since been trained, and the model is now being molded for residents of veterans’ homes in the state.
Mrs. Wald’s work brought her many honors. In 1998, she was inducted into the National Women’s Hall of Fame in Seneca Falls, N.Y., along with Madeleine K. Albright, Maya Angelou and Beverly Sills. She was also named a Living Legend by the American Academy of Nursing, and received the Founder’s Award of the American Hospice Association.
Florence Sophie Schorske was born in the Bronx on April 19, 1917, one of two children of Theodore and Gertrude Goldschmidt Schorske. Her husband, Henry Wald, died in 2000. In addition to her son, she is survived by a daughter, Shari Vogler; a brother, Carl Schorske, a Pulitzer Prize-winning historian; and five grandchildren.
As a child, Mrs. Wald was often hospitalized because of a chronic respiratory ailment. The care she received, she said, inspired her to go into nursing. After graduating from Mount Holyoke College in 1938, she received a master’s degree in nursing from Yale in 1941. During World War II, while working as a research technician for the Army Signal Corps, she met a young engineering student — Mr. Wald. Soon after, she turned down his marriage proposal.
She returned to Yale, earned a master’s degree in mental health nursing, and became an instructor in the nursing program. In 1958, at 41, she was appointed dean of the school of nursing.
Mr. Wald, by then a widower, read of her appointment in the newspaper. He got in touch, they started dating, and a year later, she accepted his new proposal.
Four years later, in 1963, a friend at Yale persuaded Mrs. Wald to attend a lecture by Dame Cicely Saunders, a British physician who was then planning to open the world’s first hospice, in Sydenham, south of London. Inspired, Mrs. Wald soon resigned as dean of the Yale nursing school to work on creating a similar center in the United States. She was troubled by a medical ethic that insisted on procedure after procedure.
“In those days, terminally ill patients went through hell, and the family was never involved,” she said. “No one accepted that life cannot go on ad infinitum.”
Dr. Saunders’s hospice, St. Christopher’s, opened in 1967, and Mrs. Wald went there to work and learn. After returning, she and several Yale colleagues joined forces to establish an American hospice. In 1971, Mr. Wald left his engineering firm and returned to Columbia University to earn a degree in hospital planning. His master’s thesis became the proposal for the Connecticut Hospice.
When Mrs. Wald received an honorary doctorate from Yale in 1996, she was introduced as “the mother of the American hospice movement.”
“That’s a completely incorrect description,” she said. “There were many, many people in those days who were just as inspired and motivated as I was.”
Florence S. Wald, whose vision of bringing the terminally ill peace of mind and, to whatever extent possible, freedom from pain led to the opening of the first palliative care hospice in the United States, died on Saturday at her home in Branford, Conn. She was 91. Her death was confirmed by her son, Joel.
Michael Okoniewski/Associated Press
Mrs. Wald, who was dean of the Yale University School of Nursing from 1959 to 1966, was the prime mover, in 1974, in starting the Connecticut Hospice, the nation’s first home-care program for the terminally ill. Six years later, a 44-patient hospice — where the dying could be comforted by their loved ones around the clock and where the staff would do what it could to alleviate suffering — opened in Branford.
“This hospice became a model for hospice care in the United States and abroad,” the publication Yale Nursing Matters said this week, adding that Mrs. Wald’s role “in reshaping nursing education to focus on patients and their families has changed the perception of care for the dying in this country.”
There are now more than 3,000 hospice programs in the United States, serving about 900,000 patients a year.
In recent years, Mrs. Wald had concentrated on extending the hospice care model to dying prison inmates.
“People on the outside don’t understand this world at all,” Mrs. Wald told The New York Times in 1998. “Most people in prison have had a rough time in life and haven’t had any kind of education in how to take care of their health.”
And, she added, “There is the shame factor, the feeling that dying in prison is the ultimate failure.”
Part of Mrs. Wald’s solution was to train inmate volunteers to care for the dying. Besides comforting the terminally ill, she said, the program would save taxpayers’ money and “have rehabilitative qualities for these volunteers.”
More than 150 inmate volunteers in Connecticut prisons have since been trained, and the model is now being molded for residents of veterans’ homes in the state.
Mrs. Wald’s work brought her many honors. In 1998, she was inducted into the National Women’s Hall of Fame in Seneca Falls, N.Y., along with Madeleine K. Albright, Maya Angelou and Beverly Sills. She was also named a Living Legend by the American Academy of Nursing, and received the Founder’s Award of the American Hospice Association.
Florence Sophie Schorske was born in the Bronx on April 19, 1917, one of two children of Theodore and Gertrude Goldschmidt Schorske. Her husband, Henry Wald, died in 2000. In addition to her son, she is survived by a daughter, Shari Vogler; a brother, Carl Schorske, a Pulitzer Prize-winning historian; and five grandchildren.
As a child, Mrs. Wald was often hospitalized because of a chronic respiratory ailment. The care she received, she said, inspired her to go into nursing. After graduating from Mount Holyoke College in 1938, she received a master’s degree in nursing from Yale in 1941. During World War II, while working as a research technician for the Army Signal Corps, she met a young engineering student — Mr. Wald. Soon after, she turned down his marriage proposal.
She returned to Yale, earned a master’s degree in mental health nursing, and became an instructor in the nursing program. In 1958, at 41, she was appointed dean of the school of nursing.
Mr. Wald, by then a widower, read of her appointment in the newspaper. He got in touch, they started dating, and a year later, she accepted his new proposal.
Four years later, in 1963, a friend at Yale persuaded Mrs. Wald to attend a lecture by Dame Cicely Saunders, a British physician who was then planning to open the world’s first hospice, in Sydenham, south of London. Inspired, Mrs. Wald soon resigned as dean of the Yale nursing school to work on creating a similar center in the United States. She was troubled by a medical ethic that insisted on procedure after procedure.
“In those days, terminally ill patients went through hell, and the family was never involved,” she said. “No one accepted that life cannot go on ad infinitum.”
Dr. Saunders’s hospice, St. Christopher’s, opened in 1967, and Mrs. Wald went there to work and learn. After returning, she and several Yale colleagues joined forces to establish an American hospice. In 1971, Mr. Wald left his engineering firm and returned to Columbia University to earn a degree in hospital planning. His master’s thesis became the proposal for the Connecticut Hospice.
When Mrs. Wald received an honorary doctorate from Yale in 1996, she was introduced as “the mother of the American hospice movement.”
“That’s a completely incorrect description,” she said. “There were many, many people in those days who were just as inspired and motivated as I was.”
Monday, November 3, 2008
Keep the Germs Away: Tips for Staying Healthy
There are many ways to prevent the spread of germs and infectious diseases. The Ounce of Prevention campaign was created to give health educators and consumers practical and useful tips.
In preparation for cold and flu season, there are a few things you can do to keep you and your family healthy throughout the winter months. Take time to do an "Ounce of Prevention!" Here are a few tips.
Clean Hands
Keeping hands clean is one of the most important steps we can take to avoid getting sick and spreading germs to others. It is best to wash your hands with soap and clean running water for 20 seconds. However, if soap and clean water are not available, use an alcohol-based product to clean your hands. Alcohol-based hand rubs significantly reduce the number of germs on skin and are fast acting.
When should you wash your hands?
Before preparing or eating food
After going to the bathroom
After changing diapers or cleaning up a child who has gone to the bathroom
Before and after tending to someone who is sick
After blowing your nose, coughing, or sneezing
After handling an animal or animal waste
After handling garbage
Before and after treating a cut or wound
Disinfect Surfaces
Cleaning removes germs from surfaces and disinfecting destroys germs from surfaces. Disinfecting after cleaning gives an extra level of protection from germs. Areas with the largest amounts of germs and frequently used areas—such as the kitchen and bathroom—should be disinfected with a bleach solution or another disinfectant as often as possible to avoid the spread of germs.
Prepare Food Safely
Handle and prepare food safely to prevent the spread of harmful bacteria and germs and reduce the risk of foodborne illness. There are four simple daily practices to food safety and protection from food borne bacteria:
Clean hands and surfaces often.
Separate and don't cross-contaminate one food with another.
Cook foods to proper temperatures by using a food thermometer and observing recommended internal cooking temperatures.
Chill or refrigerate foods promptly by storing leftovers at a temperature of 40°F or below in the refrigerator and 0°F or below in the freezer.
Get Immunizations
Getting immunizations are easy and low-cost ways to save lives. CDC recommends a yearly flu vaccine as the first and most important step in protecting against this serious disease. The vaccine can protect you from getting sick from these three viruses or it can make your illness milder if you get a different flu virus.
Get Smart
Many cold, flu, and sore throats are caused by viruses. Antibiotics do not work on viruses. Antibiotics, when used appropriately, can treat certain bacterial infections. Taking antibiotics when you have a virus may do more harm than good and may increase your risk of getting an infection later that is resistant to antibiotic treatment.
In preparation for cold and flu season, there are a few things you can do to keep you and your family healthy throughout the winter months. Take time to do an "Ounce of Prevention!" Here are a few tips.
Clean Hands
Keeping hands clean is one of the most important steps we can take to avoid getting sick and spreading germs to others. It is best to wash your hands with soap and clean running water for 20 seconds. However, if soap and clean water are not available, use an alcohol-based product to clean your hands. Alcohol-based hand rubs significantly reduce the number of germs on skin and are fast acting.
When should you wash your hands?
Before preparing or eating food
After going to the bathroom
After changing diapers or cleaning up a child who has gone to the bathroom
Before and after tending to someone who is sick
After blowing your nose, coughing, or sneezing
After handling an animal or animal waste
After handling garbage
Before and after treating a cut or wound
Disinfect Surfaces
Cleaning removes germs from surfaces and disinfecting destroys germs from surfaces. Disinfecting after cleaning gives an extra level of protection from germs. Areas with the largest amounts of germs and frequently used areas—such as the kitchen and bathroom—should be disinfected with a bleach solution or another disinfectant as often as possible to avoid the spread of germs.
Prepare Food Safely
Handle and prepare food safely to prevent the spread of harmful bacteria and germs and reduce the risk of foodborne illness. There are four simple daily practices to food safety and protection from food borne bacteria:
Clean hands and surfaces often.
Separate and don't cross-contaminate one food with another.
Cook foods to proper temperatures by using a food thermometer and observing recommended internal cooking temperatures.
Chill or refrigerate foods promptly by storing leftovers at a temperature of 40°F or below in the refrigerator and 0°F or below in the freezer.
Get Immunizations
Getting immunizations are easy and low-cost ways to save lives. CDC recommends a yearly flu vaccine as the first and most important step in protecting against this serious disease. The vaccine can protect you from getting sick from these three viruses or it can make your illness milder if you get a different flu virus.
Get Smart
Many cold, flu, and sore throats are caused by viruses. Antibiotics do not work on viruses. Antibiotics, when used appropriately, can treat certain bacterial infections. Taking antibiotics when you have a virus may do more harm than good and may increase your risk of getting an infection later that is resistant to antibiotic treatment.
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