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- Interdisciplinary Consortium on Advanced Motion Performance (iCAMP), Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA [2]
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- Nephrology Department, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar E-mail: [email protected] [1]
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Exergame: A Gamelike Exercise to Improve Motor Functions and Physical Activities in Diabetic Patients Undergoing Hemodialysis
Background: Balance mobility falls and foot problems are serious detriments for the diabetic patients undergoing hemodialysis (HD) treatment. In addition the HD process often leaves them too fatigued to engage in any physical activity or daily exercise further deteriorating their motor functions. Exercise would be effective for this population. However due to the time availability post-dialysis fatigue as well as limitation of transportation to exercise facility the conventional exercise is impractical. Objective: We are developing an interactive foot and ankle exercise game that can be played during HD sessions to improve mobility and balance as well as reduce foot problems. In this study we examined the feasibility and effectiveness of this innovative wearable sensor based non-weight bearing exercise (Exergame) to improve daily physical activity in diabetic patients undergoing HD treatment. Methods: Thirty-three diabetic subjects receiving HD treatment were recruited and randomized into an intervention group (IG: n = 15 age = 62.2 ± 7.6 years BMI = 29.1 ± 6.1 kg/m2) and a control group (CG: n = 18 age = 66.6 ± 8.7 years BMI = 32.5 ± 9.0 kg/m2). Both groups underwent a 4-week ankle and foot exercise program (30 minutes per session two sessions per week) during HD process. The IG received exercise via the Exergame program which uses wearable sensors attached on subject's feet. The subject's 3-dementional ankle and foot movements were visualized in real-time on a computer screen placed in front of him/her. The subject played some game-like tasks by moving and rotating the foot and ankle. The difficulty level of the task was gradually increased depends on ability of the subject (like a game) from a simple flexion-extension movement to more complex movements including medial-lateral movement with different range of motion. The CG received traditional foot and ankle exercise without technology. Daily physical activity data was assessed for 48 hours (day and night) at baseline and post 4-week exercise using a validated wearable sensor (PAMSysTM). Daily physical activity was quantified by duration spent in each main posture (i.e. lying sitting standing and walking) and activities (e.g. postural transition sedentary behavior etc). Results: All IG subjects achieved to complete all exercise tasks indicating the feasibility of the Exergame platform. No adverse event or difficulty were reported indicating practicality of the exercise program. None subject in the IG was dropped out during the 4-week exercise program. Low dropout rate may indicate acceptability of the proposed Exergame platform. At the end of intervention subjects in the IG were more active than subjects in the CG. In summary the IG performed 53% more posture transitions to walking (Cohen's d effect size = 0.5) and 39% more posture transitions between sitting and walking (d = 0.5) when compared to the CG. Subjects in the IG also had significant less sedentary behavior than subjects in the CG. In summary subjects in the IG spent 5% less time on sitting and lying (p = 0.049 d = 0.7) as well as 47% more time on standing and walking (p = 0.049 d = 0.7) when compared to subjects in the CG. Conclusions: This study demonstrated feasibility acceptability and effectiveness of an innovative Exergame program to improve daily physical activity in diabetic patients undergoing HD treatment. The key innovation of the proposed intervention is its practicality to be done during HD process which could address the limitations of prior exercise interventions in HD patients for example the low adherence of therapeutic exercise. Further studies should be addressed to confirm the observation with larger sample sizes.
GameBased NonWeight Bearing Exercise to Improve Postural Balance in Diabetic Patients Underjoining Hemodialysis
Background: Poor balance falls and foot problems are serious detriments for the diabetic patients due to the obesity and diabetic foot ulcer. In addition for the diabetic patients undergoing hemodialysis (HD) treatment the HD process often leaves them too fatigued to engage in any physical activity or daily exercise further deteriorating their motor functions and increasing risk of falling. Exercise would be effective for this population. However due to the time availability post-dialysis fatigue as well as limitation of transportation to exercise facility the conventional exercise for this population is impractical. Objective: We are developing an interactive foot and ankle exercise game that can be played during HD sessions to improve foot region blood flow as well as reduce foot problems. In this study we examined the feasibility and effectiveness of this innovative wearable sensor based non-weight bearing exercise (Exergame) to improve postural balance in diabetic patients undergoing HD treatment. Methods: Sixty diabetic subjects receiving HD treatment were recruited and randomized into an intervention group (IG: n = 29 age = 63.3 ± 7.9 years BMI = 31.2 ± 6.5 kg/m2 female = 41%) and a control group (CG: n = 31 age = 66.5 ± 10.7 years BMI = 32.3 ± 8.2 kg/m2 female = 55%). Both groups underwent a 4-week ankle and foot exercise program (30 minutes per session two sessions per week) during HD process. The IG received exercise via the Exergame program which uses wearable sensors attached on subject's feet. The subject's 3-dementional ankle and foot movements were visualized in real-time on a computer screen placed in front of him/her. The subject performed some game-like tasks by moving and rotating the foot and ankle. The difficulty level of the task was gradually increased depending on ability of the subject (like a game) from a simple flexion-extension movement to more complex movements including medial-lateral movement with different range of motion. The CG received traditional foot and ankle exercise without any technology. Postural balance was assessed in the semi-tandem test. Balance tests were performed at baseline and conclusion of the program under both eyes-open and eyes-closed conditions. Balance parameters included ankle sway and hip sway in anterior-posterior (AP) direction (degree) medial-lateral (ML) direction (degree) as well as in area (degree2). Results: All IG subjects achieved to complete all exercise tasks indicating the feasibility of the Exergame platform. No adverse event or difficulty were reported indicating practicality of the exercise program. None subject in the IG was dropped out during the 4-week exercise program. Low dropout rate may indicate acceptability of the proposed Exergame platform. Under eyes-open condition the IG had significant ankle sway reduction in the AP direction (Cohens’ d effect size = 0.55 p = 0.037) when comparing with the CG. At conclusion the AP direction ankle sway reduced 18% in the IG while in the CG it increased 58%. More significant improvements of postural balance were observed under eyes-closed condition. When comparing with the CG the IG had significant ankle and hip sway reductions in both AP and ML directions as well as in area (p < 0.050). The highest effect size contrasting changes between the IG and CG was also observed for ankle sway in ML direction (Cohens’ d effect size = 0.76 p = 0.005). Conclusions: This study demonstrated feasibility acceptability and effectiveness of an innovative Exergame program to improve postural balance in diabetic patients undergoing HD treatment. The key innovation of the proposed intervention is its practicality to be done during HD process which could address the limitations of prior exercise interventions in HD patients for example the low adherence of therapeutic exercise.
Mortality of dialysis patients in Qatar: A retrospective epidemiologic study
Background: End-stage kidney disease (ESKD) patients on maintenance renal replacement therapy (RRT) have far lower life spans than those of the general population. No previous studies have been performed to assess the mortality of dialysis patients in the State of Qatar. We designed this study to assess the mortality of dialysis patients in Qatar and the impact of dialysis modality.
Methods: All chronic ambulatory dialysis patients (both on hemodialysis (HD) and peritoneal dialysis (PD) between 2014 and 2016) were included in the study whereas patients undergoing dialysis for less than 3 months were excluded. We reviewed patients’ demographics comorbidities and general laboratory investigations through our electronic record system and collected and analyzed them. We identified patients who died during that period and compared them to those who survived. We performed a subanalysis for HD versus PD patients who died.
Results: The total number of deceased dialysis patients was 164 with an overall crude mortality rate of 6.4%. They were significantly older than those who survived (p = 0.0001). The mortality rate was significantly higher in female than in male patients (51.2% and 38.9% respectively) (p = 0.004) but significantly lower in PD than HD patients (1.36% PD; 5.0% HD; p = 0.007). It was also significantly higher in natives than in the expats (60.3% and 39.6% respectively) (p = 0.0008); however no significant differences were noted between deceased natives and expats in most demographic and laboratory characteristics. The most common cause of patient death was CVD (62 patients 37.8%) followed by sepsis (44 patients 26.8%). Diabetes cerebrovascular accident and dyslipidemia were more common in HD deceased patients than in PD patients (80.6% 47% and 59% respectively in HD patients vs 68.5% 42% and 31% respectively in PD patients). Albumin and potassium levels in deceased PD patients were significantly lower than in HD patients (p = 0.001).
Conclusion: Our study found that the high-risk population had a significant mortality which was higher in HD than PD patients. This is the first study to look at these outcomes in Qatar. We identified multiple mortality associated factors such as comorbid conditions and old age. We believe that improving treatment and close monitoring for comorbid conditions in the dialysis population might improve survival.
Utilizing diabetes mellitus risk assessment tool in screening of hemodialysis patients at risk of diabetes mellitus
Background: Hamad General Hospital is the main provider of hemodialysis (HD) in Qatar for approximately 650 patients per year. Over 60% of these patients have Diabetes Mellitus (DM) and 55% of them suffer from end stage renal disease (ESRD). 2% of ESRD patients develop DM after their first year of dialysis1. The aims of this quality improvement study were early DM detection risk factors modifications and reduction of diabetes complications in our patients. Methods: A risk assessment tool was adapted to identify the risk level of HD patients to develop DM2. They were screened to determine their risk score across 8 categories. Six categories (gender history of gestational diabetes family history of high blood pressure diabetes physical activity and smoking) were scored 0 to 1 age was scored 0 to 3 and relationship between weight and height scored 1 to 3. (Overall score range: 1-12). Patients were classified into two groups: a low-risk group (score < 5) and a high-risk group (score ≥ 5)3. Patients were referred to different medical specialties for further management according to the risk factor and a lifestyle modification management plan was set individually. Results: 189 non-diabetic dialysis patients were screened in the first quarter of 2020 their mean age was 51 years-old and 69% were male. Forty-three percent of patients were found to be at high risk of developing DM. The most important risk factors were family history (55%) obesity (40%) age >60 years (32%) low physical activity (14%) and smoking (11%) (Figure 1). Thirty-seven percent of patients were referred to the obesity clinic 10% to the smoking cessation clinic 5% to physiotherapy and 100% of patients were referred to the multidisciplinary care (Figure 2). Conclusion: Screening for diabetes is pivotal for early detection and risk factor modification in dialysis patients. We recommend quarterly data assessment and evaluation so patients can be managed according to the findings.
Effects of novel anemia nurse manager program on hemodialysis: a retrospective study from Qatar
Introduction: Anemia management in dialysis is challenging. Keeping hemoglobin levels within a tight range is difficult. A new program (anemia nurse manager [ANM]) was started for better anemia management. This study aimed to compare traditional anemia management with the new ANM model regarding the achievement of better hemoglobin targets (range 10–12 g/dL) avoidance of extreme hemoglobin levels ( < 9 or >13 g/dL) and evaluation of the cost-effectiveness of the new model.
Methods: This retrospective observational study compared traditional anemia management with management involving our new ANM model. Patients on hemodialysis in all ambulatory dialysis clinics in Qatar were included. The study included three phases: phase 1 (observation): June 2015 to August 2015 460 patients; phase 2 (pilot): September 2015 to May 2016 211 patients; and phase 3 (expansion in two phases): June 2016 to February 2017 and October 2017 to June 2018 610 patients. Hemoglobin iron saturation and ferritin were evaluated according to the protocol.
Results: In this study 55% of the patients achieved the target hemoglobin in phase 1 compared with 75% in phase 2 (p = 0.0007). The hemoglobin level within the target range was sustained at 72% ± 5% of patients in phase 3. The achievement rate of the target hemoglobin level increased from 56% (May 2015) to 72% (July 2018) (p < 0.001). The proportion of patients with extreme hemoglobin declined from 10.7% in phase 1 to 6.4% in phase 2 and sustained at 8% afterward. Reducing the doses of erythropoietin stimulating agents owing to the use of the ANM model saved costs by approximately 11%.
Conclusions: The ANM model was able to achieve and maintain hemoglobin levels within the target range and decrease extreme hemoglobin levels. These outcomes improved patient care by avoiding high hemoglobin (increase thrombosis cancer recurrence stroke and death) and low hemoglobin (weakness poor quality of life and need for transfusion) levels. The ANM model was cost effective even after including the salaries of nurses. This model can be considered in other aspects of patient care in dialysis.
Cardiovascular calcification in hemodialysis patients: A Qatar-based prevalence and risk factors study
Background: Patients with end-stage kidney disease on hemodialysis (HD) have an increased risk of death due to the high prevalence of cardiovascular disease. Vascular calcification (VC) is predictive of cardiovascular disease and mortality. We conducted a study to evaluate the prevalence and risk factors for VC in dialysis patients in Qatar.
Methods: This is a retrospective nationwide study including all chronic ambulatory dialysis patients in Qatar from 2020 to 2022. We used our national electronic medical record to track demographics clinical characteristics comorbidities laboratory values and diagnostic data for each patient. Calcifications were assessed by echocardiography (routinely done for all our dialysis population per national protocol) computed tomography X-ray and ultrasound. The study protocol was approved by the local medical research ethics committee (MRC-01-20-377).
Results: 842 HD patients were included in this study. Vascular calcifications (VC) were prevalent in 52.6% of patients. The main site of VC was Mitral valve calcifications in 55.5% of patients. Patients with VC were significantly older and had more prevalence of diabetes mellitus (p = 0.001 and p = 0.006 respectively). There was no statistically significant difference between patients with calcifications and patients without calcifications regarding serum calcium phosphorus and PTH level. In multivariate analysis age and diabetes significantly increased the risk factor for calcification (95% CI 1.033–1.065 p < 0.0001 and 95% CI 1.128–2.272 p < 0001 respectively). Moreover higher vitamin D levels and higher doses of IV Alfacalcidol were significant risk factors for calcifications (95% CI 1.005–1.030 p < 0.007 and 95% CI 1.092–1.270 p < 0.0001 respectively).
Conclusion: Our study found that vascular calcification was widespread among our dialysis population in Qatar. Implementing the practice of echocardiography in dialysis patients was extremely helpful and the most productive in detecting vascular calcification. Diabetes mellitus almost doubles the risk for vascular calcifications in dialysis patients. These results are beneficial in identifying risk factors for vascular calcification which can help stratify dialysis patients’ risk of cardiovascular disease and optimize prevention efforts.
Impact of COVID-19 on dialysis patients: Reported experience in Qatar
Background: Patient-centered care is a concept focussing on meeting the specific health needs of patients as expressed by them. Patients Reported Experience Measures (PREM) is another concept associated with patient-centered care. PREM surveys capture information about the healthcare experience as perceived by patients.1 Its importance lies in the incorporation of patient feedback into the clinical decisions and service evolution.2 Dialysis patients play an important role in their treatment and their voice matters to provide proper care. PREM was first conducted in 2019 in our dialysis unit. In 2020 the COVID-19 impacted dialysis services and resulted in many challenges including staff shortage and deployment. Yet the patients’ feedback was evaluated continuously and compared with previous years before the pandemic. Methods: A validated questionnaire from the National Health Service in London was used.3 It consisted of 7 questions covering demographics dialysis options patient portal patient's relationship with the staff teamwork and traveling abroad. The survey involved 317 randomly selected patients who have been at least one year on dialysis. A comparison between 2019 and 2020 results was conducted using the chi-square test. Results: A drop in patients’ experience was observed in many survey components like education on dialysis medication side effects access to the patient portal access to physicians and nurses from home (Figure 2). However in other areas some positive experiences remained unchanged like communication and knowledge among the staff.:Conclusion: Patients’ reported experience helps in the evaluation of health services. After exploring dialysis patients’ experiences it was possible to identify what is going well and how COVID-19 impacted the patients’ perspectives. The PREM survey conducted in this work showed a significant decline in many parameters likely attributed to COVID-19 consequences including the staff shortages.
Vascular calcification: “The silent killer” in the hemodialysis population in Qatar
Background: Calcification is an abnormal deposition of calcium salts in vascular tissue including valves blood vessels and the heart which is highly prevalent in End Stage Renal Disease (ESRD) patients. Vascular calcification is an independent and important risk factor for cardiovascular events in hemodialysis patients and investigators have demonstrated that the extent and histo-anatomic type of vascular calcification are predictors of subsequent vascular mortality1. Cardiovascular mortality risk is elevated 5-10-fold in ESRD patients compared to the general population2. As we recognized the importance of early detection and delaying the complication of calcification this study was initiated in March 2020 among 650 haemodialysis patients in Hamad General Hospital in Qatar. Methods: The haemodialysis multidisciplinary team identified patients with vascular calcification. Data was collected on available imaging study which included echocardiography X-rays and computed tomography (CT) to detect any kind of vascular calcification (e.g. valvular calcified vessels). Our management protocol was updated to decrease the calcium load and active vitamin D. Abnormal serum calcium management was initiated to monitor and delay the progression of vascular calcification through interventions which included dietary control medication and dialysate bath. Results: We were able to screen 86% of dialysis patients (n = 559). Following the interventions the percentage of patients with a calcium level of 2.1-2.55 mmol/l increased by 5 percentage points from 83% in March 2020 to 88% in September 2020 (p value = 0.004). Phosphorus level was maintained in the range of 0.81-1.8 mmol/l for 82% of patients (Figure 1) and parathyroid hormone (PTH) level in the range 150-400 pg/ml for 72% of patients (Figure 2). Conclusion: We implemented a successful screening program for vascular calcification in dialysis patients combined with specific interventions. Reduced hypercalcemia episodes can delay vascular calcification. Serum calcium level was improved and maintained within the target range (2.1 - 2.55 mmol/l) for a larger number of patients.