-
JAMA Network Open May 2024People with kidney failure receiving maintenance dialysis visit the emergency department (ED) 3 times per year on average, which is 3- to 8-fold more often than the...
IMPORTANCE
People with kidney failure receiving maintenance dialysis visit the emergency department (ED) 3 times per year on average, which is 3- to 8-fold more often than the general population. Little is known about the factors that contribute to potentially preventable ED use in this population.
OBJECTIVE
To identify the clinical and sociodemographic factors associated with potentially preventable ED use among patients receiving maintenance dialysis.
DESIGN, SETTING, AND PARTICIPANTS
This cohort study used linked administrative health data within the Alberta Kidney Disease Network to identify adults aged 18 years or older receiving maintenance dialysis (ie, hemodialysis or peritoneal dialysis) between April 1, 2010, and March 31, 2019. Patients who had been receiving dialysis for more than 90 days were followed up from cohort entry (defined as dialysis start date plus 90 days) until death, outmigration from the province, receipt of a kidney transplant, or end of study follow-up. The Andersen behavioral model of health services was used as a conceptual framework to identify variables related to health care need, predisposing factors, and enabling factors. Data were analyzed in March 2024.
MAIN OUTCOMES AND MEASURES
Rates of all-cause ED encounters and potentially preventable ED use associated with 4 kidney disease-specific ambulatory care-sensitive conditions (hyperkalemia, heart failure, volume overload, and malignant hypertension) were calculated. Multivariable negative binomial regression models were used to examine the association between clinical and sociodemographic factors and rates of potentially preventable ED use.
RESULTS
The cohort included 4925 adults (mean [SD] age, 60.8 [15.5] years; 3071 males [62.4%]) with kidney failure receiving maintenance hemodialysis (3183 patients) or peritoneal dialysis (1742 patients) who were followed up for a mean (SD) of 2.5 (2.0) years. In all, 3877 patients had 34 029 all-cause ED encounters (3100 [95% CI, 2996-3206] encounters per 1000 person-years). Of these, 755 patients (19.5%) had 1351 potentially preventable ED encounters (114 [95% CI, 105-124] encounters per 1000 person-years). Compared with patients with a nonpreventable ED encounter, patients with a potentially preventable ED encounter were more likely to be in the lowest income quintile (38.8% vs 30.9%; P < .001); to experience heart failure (46.8% vs 39.9%; P = .001), depression (36.6% vs 32.5%; P = .03), and chronic pain (60.1% vs 54.9%; P = .01); and to have a longer duration of dialysis (3.6 vs 2.6 years; P < .001). In multivariable regression analyses, potentially preventable ED use was higher for younger adults (incidence rate ratio [IRR], 1.69 [95% CI, 1.33-2.15] for those aged 18 to 44 years) and patients with chronic pain (IRR, 1.35 [95% CI, 1.14-1.61]), greater material deprivation (IRR, 1.57 [95% CI, 1.16-2.12]), a history of hyperkalemia (IRR, 1.31 [95% CI, 1.09-1.58]), and historically high ED use (ie, ≥3 ED encounters in the prior year; IRR, 1.46 [95% CI, 1.23-1.73).
CONCLUSIONS AND RELEVANCE
In this study of adults receiving maintenance dialysis in Alberta, Canada, among those with ED use, 1 in 5 had a potentially preventable ED encounter; reasons for such encounters were associated with both psychosocial and medical factors. The findings underscore the need for strategies that address social determinants of health to avert potentially preventable ED use in this population.
Topics: Humans; Male; Female; Emergency Service, Hospital; Middle Aged; Renal Dialysis; Aged; Alberta; Adult; Cohort Studies; Kidney Failure, Chronic
PubMed: 38809552
DOI: 10.1001/jamanetworkopen.2024.13754 -
AACE Clinical Case Reports 2024Pheochromocytoma can recur years after curative surgical resection. Rarely, it may reoccur as metastasis. Here, we present a case of metastatic pheochromocytoma to the...
BACKGROUND/OBJECTIVE
Pheochromocytoma can recur years after curative surgical resection. Rarely, it may reoccur as metastasis. Here, we present a case of metastatic pheochromocytoma to the bones in a patient with neurofibromatosis type 1 (NF1), 8 years after initial resection of primary bilateral adrenal pheochromocytomas without metastases.
CASE REPORT
A 44-year-old woman presented with diffuse body pain and palpitations. Her past medical history included NF1 and hypertension. Eight years prior to her current presentation, she had undergone a bilateral adrenalectomy for the management of bilateral adrenal pheochromocytomas. Her plasma metanephrines normalized after surgery and remained normal at her 1-year postoperative visit. She was subsequently lost to follow-up until her current presentation. Our evaluation revealed significantly elevated urine and plasma metanephrines as well as innumerable DOTATATE avid lesions along the axial and perpendicular spine compatible with a metastatic neuroendocrine tumor. She was started on doxazosin and metoprolol and discharged home with a plan to be seen by Oncology to discuss systemic therapy.
DISCUSSION
Predicting malignant disease in patients with primary tumors without metastases is challenging. There is no single factor that can reliably predict tumor behavior. It is unknown if individuals with NF1, who have a genetic predisposition for developing pheochromocytomas, are at an increased risk of malignant disease.
CONCLUSION
Due to a lack of accurate predictors, annual biochemical testing is recommended after primary tumor resection and in patients with a genetic predisposition. Strict lifelong follow-up should be strongly considered due to a possible higher risk of malignant disease.
PubMed: 38799052
DOI: 10.1016/j.aace.2024.02.006 -
The Journal of International Medical... May 2024Prostatic stromal tumors, encompassing prostatic sarcoma and stromal tumors of uncertain malignant potential (STUMP), represent an exceedingly rare category of prostatic... (Review)
Review
Prostatic stromal tumors, encompassing prostatic sarcoma and stromal tumors of uncertain malignant potential (STUMP), represent an exceedingly rare category of prostatic diseases, with a prevalence of less than 1%. We present a rare case involving a man in his early 40s diagnosed with STUMP. Despite presenting with normal prostate-specific antigen (PSA) concentrations, the patient experienced persistent dysuria and gross hematuria for >7 months, leading to an initial misdiagnosis of benign prostatic hyperplasia. Persistent symptoms prompted further investigation, with magnetic resonance imaging (MRI) revealing a suspicious lesion on the left side of the prostate, initially thought to be malignant. Transrectal prostatic biopsy subsequently confirmed the presence of mucinous liposarcoma, with no medical history of diabetes, coronary heart disease, or hypertension. The treatment approach comprised robot-assisted laparoscopic radical prostatectomy, culminating in a postoperative pathological definitive diagnosis of STUMP. This case underscores the indispensable role of early MRI in the diagnostic process, highlighting the necessity of detailed pathological examination for a conclusive diagnosis. Our report aims to illuminate the diagnostic challenges and potential treatment pathways for STUMP, emphasizing its consideration in the differential diagnosis of prostatic tumors to advance clinical outcomes in this rare but important condition.
Topics: Humans; Male; Prostatic Neoplasms; Magnetic Resonance Imaging; Adult; Diagnosis, Differential; Prostatectomy; Prostate; Prostate-Specific Antigen; Prostatic Hyperplasia; Sarcoma
PubMed: 38796313
DOI: 10.1177/03000605241253756 -
Cureus Apr 2024Impella 5.5 (Abiomed Inc., Danvers, MA, USA) is a surgically implanted mechanical circulatory support device that helps support hemodynamically compromised patients. The...
Impella 5.5 (Abiomed Inc., Danvers, MA, USA) is a surgically implanted mechanical circulatory support device that helps support hemodynamically compromised patients. The device's risks and benefits must be entirely known, especially in the electrophysiology lab. Due to unexpected hemodynamic changes during pace mapping and ablation, such as ventricular tachycardia (VT) and asystole, it is sometimes necessary to implement chemical support with inotropic agents such as epinephrine or mechanical support with devices such as an Impella. We present the case of a 72-year-old male with a biventricular implantable cardioverter-defibrillator (ICD) (Medtronic, Minneapolis, MN, USA) placed for refractory VT presenting for VT ablation. He had ischemic cardiomyopathy with a left ventricular ejection fraction (LVEF) of 33% and medical history of cardiac sarcoidosis, hypertension, hyperlipidemia, pulmonary embolism, left bundle branch block, and coronary artery disease. Due to the nature of the procedure and his history of arrhythmia, the patient was deemed a candidate for Impella 5.5. After evaluating patient risk factors, the cardiothoracic anesthesia team developed a strategic approach with imaging (including radiographic and echocardiographic imaging), Impella monitoring, and pharmacologic management with inotropes and vasopressors, allowing for uncomplicated perioperative management during the ablation. Given the procedure's intricacies and the patient's arrhythmia history, the medical team identified the patient as suitable for Impella 5.5 due to better performance and greater cardiac output than Impella 2.5 (Abiomed Inc., Danvers, MA, USA). Following a thorough assessment of the patient's risk factors, the cardiothoracic anesthesia team devised a comprehensive strategy to facilitate smooth perioperative management during the ablation, minimizing complications. The VT ablation procedure was performed successfully and effectively terminated the arrhythmia. However, the patient developed multifaceted postoperative complications, including cardiogenic shock, hemorrhagic shock, dyspnea, anemia, gastrointestinal abnormalities, and sepsis. This case represents a highly complex patient scenario under the care of the cardiovascular anesthesiologist due to the nature of the procedure and numerous cardiovascular comorbidities, low ejection fraction, ICD placement, and malignant ventricular arrhythmia. We discuss the various perioperative management strategies and how they are tailored to such patients, including pharmacologic intervention, anesthesia administration, imaging modalities, and postoperative care. The purpose of this case report is to delineate the role of Impella 5.5 in perioperative care for high-risk VT ablation patients. We discuss the progression, pathophysiology, and management of this patient's multisystem complications following the procedure. We also highlight the use of Impella 5.5 in the electrophysiology lab and the anesthesia considerations, safeguards, and management strategies to optimize perioperative outcomes and avoid complications.
PubMed: 38770455
DOI: 10.7759/cureus.58642 -
Journal of the American Heart... May 2024Lipoprotein (a) [Lp(a)] is a robust predictor of coronary heart disease outcomes, with targeted therapies currently under investigation. We aimed to evaluate the...
BACKGROUND
Lipoprotein (a) [Lp(a)] is a robust predictor of coronary heart disease outcomes, with targeted therapies currently under investigation. We aimed to evaluate the association of high Lp(a) with standard modifiable risk factors (SMuRFs) for incident first acute myocardial infarction (AMI).
METHODS AND RESULTS
This retrospective study used the Mass General Brigham Lp(a) Registry, which included patients aged ≥18 years with an Lp(a) measurement between 2000 and 2019. Exclusion criteria were severe kidney dysfunction, malignant neoplasm, and prior known atherosclerotic cardiovascular disease. Diabetes, dyslipidemia, hypertension, and smoking were considered SMuRFs. High Lp(a) was defined as >90th percentile, and low Lp(a) was defined as <50th percentile. The primary outcome was fatal or nonfatal AMI. A combination of natural language processing algorithms, () codes, and laboratory data was used to identify the outcome and covariates. A total of 6238 patients met the eligibility criteria. The median age was 54 (interquartile range, 43-65) years, and 45% were women. Overall, 23.7% had no SMuRFs, and 17.8% had ≥3 SMuRFs. Over a median follow-up of 8.8 (interquartile range, 4.2-12.8) years, the incidence of AMI increased gradually, with higher number of SMuRFs among patients with high (log-rank =0.031) and low Lp(a) (log-rank <0.001). Across all SMuRF subgroups, the incidence of AMI was significantly higher for patients with high Lp(a) versus low Lp(a). The risk of high Lp(a) was similar to having 2 SMuRFs. Following adjustment for confounders and number of SMuRFs, high Lp(a) remained significantly associated with the primary outcome (hazard ratio, 2.9 [95% CI, 2.0-4.3]; <0.001).
CONCLUSIONS
Among patients with no prior atherosclerotic cardiovascular disease, high Lp(a) is associated with significantly higher risk for first AMI regardless of the number of SMuRFs.
Topics: Humans; Female; Lipoprotein(a); Male; Middle Aged; Myocardial Infarction; Registries; Retrospective Studies; Aged; Incidence; Adult; Heart Disease Risk Factors; Risk Assessment; Biomarkers; Risk Factors
PubMed: 38761082
DOI: 10.1161/JAHA.123.034493 -
BMJ Open May 2024The administration of immune checkpoint inhibitors (ICIs) may lead to renal adverse events, notably including renal dysfunction. To early predict the probability of...
Development and validation of a nomogram for predicting the occurrence of renal dysfunction after treatment of immune checkpoint inhibitor: a retrospective case-control study.
PURPOSE
The administration of immune checkpoint inhibitors (ICIs) may lead to renal adverse events, notably including renal dysfunction. To early predict the probability of renal dysfunction after ICIs therapy, a retrospective case-control study was conducted.
METHODS
Clinical information on ICIs-treated patients was collected. Multivariable logistic regression was applied to identify risk factors for renal dysfunction after ICIs treatment. Moreover, a nomogram model was developed and validated internally.
RESULTS
A total of 442 patients were included, among which 35 (7.9%) experienced renal dysfunction after ICIs treatment. Lower baseline estimated glomerular filtration rate (eGFR) (OR 0.941; 95% CI 0.917 to 0.966; p<0.001), concurrent exposure of platinum(OR 4.014; 95% CI 1.557 to 10.346; p=0.004), comorbidities of hypertension (OR 3.478; 95% CI 1.600 to 7.562; p=0.002) and infection (OR 5.402; 95% CI 1.544 to 18.904; p=0.008) were found to be independent associated with renal dysfunction after ICIs treatment. To develop a predictive nomogram for the occurrence of renal dysfunction after ICIs treatment, the included cases were divided into training and validation groups in a ratio of 7:3 randomly. The above four independent risk factors were included in the model. The area under the receiver operating characteristic curves of the predictiive model were 0.822 (0.723-0.922) and 0.815 (0.699-0.930) in the training and validation groups, respectively.
CONCLUSIONS
Lower baseline eGFR, platinum exposure, comorbidities of hypertension and infection were predictors of renal dysfunction in ICIs-treated patients with cancer. A nomogram was developed to predict the probability of renal dysfunction after ICIs treatment, which might be operable and valuable in clinical practice.
Topics: Humans; Nomograms; Male; Female; Retrospective Studies; Immune Checkpoint Inhibitors; Middle Aged; Case-Control Studies; Aged; Glomerular Filtration Rate; Risk Factors; Logistic Models; Neoplasms; Renal Insufficiency; Kidney Diseases
PubMed: 38760047
DOI: 10.1136/bmjopen-2023-082484 -
Alternative Therapies in Health and... May 2024This study aims to investigate the influencing factors of transient hypoparathyroidism following thyroidectomy and assess the effects of rehabilitation treatment,...
OBJECTIVE
This study aims to investigate the influencing factors of transient hypoparathyroidism following thyroidectomy and assess the effects of rehabilitation treatment, focusing on enhancing management and outcomes for patients.
METHODS
In this retrospective study, 90 patients who underwent thyroidectomy in our hospital from February 2021 to February 2023 were collected. According to the postoperative level of parathyroid hormone (PTH), the patients were divided into normal group [(no hypoparathyroidism, ≥ 0.27 pmol/l), n=65] and hypoparathyroidism (transient hypoparathyroidism, < 0.27 pmol/l, n=25). We retrospectively analyzed 90 thyroidectomy patients, categorizing them into normal and hypoparathyroidism groups based on postoperative parathyroid hormone levels. Logistic regression and ROC curve analysis were employed to evaluate the factors influencing transient hypoparathyroidism and predict recovery.Clinical data of the two groups of patients were collected, and the relationship between postoperative 1dPTH (Parathyroid hormone levels on the first postoperative day) level and recovery effect was analyzed. Logistic regression was used to analyze the influencing factors of temporary hypoparathyroidism after thyroidectomy, and a ROC curve was used to predict the efficacy of the 1dPTH level on postoperative PTH recovery time.
RESULTS
There were no differences in gender, hypertension, diabetes and hyperlipidemia between the two groups (P > .05). The age and tumor diameter of the normal group were lower than those of the hypoactive group, and the proportion of patients with thyroiditis and malignant tumors, as well as patients undergoing total thyroidectomy and removal of tracheoesophageal lymph nodes in the normal group were significantly lower than those in the hypoactive group. The above differences were statistically significant (P < .05). Logistic regression analysis showed that older age, malignant tumor, larger tumor diameter, total thyroidectomy, and tracheoesophageal lymph node dissection were independent risk factors for transient hypoparathyroidism after thyroidectomy (P < .05). The level of PTH on the 1st day after surgery in patients with recovery time ≤ 1 month was higher than that in patients with recovery time > 1 month, and the difference was statistically significant (P < .05). ROC curve showed that the PTH level on the 1st day after surgery had a certain predictive value on PTH recovery time, and the AUC value (area under the curve) was 0.873 (P < .05). These findings suggest that patients with older age, malignancy, larger tumor diameter, total thyroidectomy, and removal of tracheoesophageal lymph nodes are more likely to develop transient hypoparathyroidism after thyroidectomy. This understanding is crucial for the management of postoperative patients, and physicians may need to pay special attention to these high-risk patients and implement appropriate interventions to reduce the occurrence of hypoparathyroidism. Significant factors contributing to transient hypoparathyroidism included older age, malignant tumors, larger tumor diameter, total thyroidectomy, and tracheoesophageal lymph node dissection. These findings, backed by statistical significance, underline the clinical relevance of these risk factors in postoperative management.
CONCLUSION
The study identifies key risk factors for transient hypoparathyroidism post-thyroidectomy, emphasizing the need for tailored postoperative care. The predictive value of immediate postoperative PTH levels could guide clinical management to mitigate hypoparathyroidism risks.
PubMed: 38758154
DOI: No ID Found -
BMC Nephrology May 2024Multiple myeloma (MM) is a malignant disorder characterized by monoclonal differentiated plasma cells. While it is more commonly diagnosed in elderly individuals, it can...
BACKGROUND
Multiple myeloma (MM) is a malignant disorder characterized by monoclonal differentiated plasma cells. While it is more commonly diagnosed in elderly individuals, it can also affect younger populations, though with a lower incidence.
CASE PRESENTATION
Here, we present the case of a 32-year-old woman diagnosed with IgA lambda MM. She presented with fatigue, nausea, acute kidney injury (AKI) with a rapid increase in creatinine, and anemia. A kidney biopsy was done to rule out a rapidly progressive glomerular disease and a diagnosis was thus reached. A genetic workup revealed t(14;16) translocation and an extra copy of TP53. The patient received aggressive intravenous steroids and intravenous fluid resuscitation, resulting in an improvement in renal function. Treatment with daratumumab in combination with bortezomib, thalidomide, and dexamethasone was initiated and well tolerated. Despite the generally poor prognosis of IgA MM, our case emphasizes the importance of considering MM in young patients with unexplained kidney injury.
CONCLUSION
Early recognition and prompt intervention are essential in managing MM patients, especially in those with high-risk cytogenetic abnormalities. This case serves as a reminder for clinicians to maintain a high index of suspicion for MM, even in younger populations, when presented with unexplained kidney injury.
Topics: Humans; Female; Adult; Multiple Myeloma; Proteinuria; Translocation, Genetic; Acute Kidney Injury; Immunoglobulin A; Immunoglobulin lambda-Chains; Chromosomes, Human, Pair 14
PubMed: 38755555
DOI: 10.1186/s12882-024-03600-3 -
Journal of Atherosclerosis and... May 2024The present study aimed to determine whether decreased masticatory performance and tongue-lip motor function are associated with an increased incidence of adverse health...
AIM
The present study aimed to determine whether decreased masticatory performance and tongue-lip motor function are associated with an increased incidence of adverse health events in patients with metabolic disease.
METHODS
One thousand patients with metabolic diseases including diabetes, dyslipidemia, hypertension, and hyperuricemia were recruited. Masticatory performance was assessed using a gummy jelly test, wherein glucose elution from chewed gummy jelly was measured. The tongue-lip motor function was measured using repeatedly pronounced syllables per second. Their association with the incidence of adverse health events (a composite of all-cause death, cardiovascular disease, bone fracture, malignant neoplasm, pneumonia, and dementia) was investigated using the generalized propensity score (GPS) method.
RESULTS
During a median follow-up period of 36.6 (interquartile range, 35.0-37.7) months, adverse health events were observed in 191 patients. The GPS adjusted dose-response function demonstrated that masticatory performance was inversely associated with the incidence of adverse health events. The 3-year incidence rate was 22.8% (95% confidence interval, 19.0-26.4%) for the lower quartile versus 13.6% (10.5-16.7%) for the upper quartile (P<0.001). Similarly, the tongue-lip motor function was inversely associated with the incidence of adverse health events, with a 3-year incidence rate of 23.6% (20.0-27.0%) for the lower quartile versus 13.2% (10.4-15.9%) for the upper quartile (P<0.001).
CONCLUSIONS
Decreased masticatory performance and tongue-lip motor function were associated with an increased incidence of adverse health events in patients with metabolic disease.
PubMed: 38749716
DOI: 10.5551/jat.64909 -
Hypertension (Dallas, Tex. : 1979) Jun 2024
Topics: Humans; Hypertension; Emergency Service, Hospital; Male; Female; Middle Aged; Diagnosis, Differential
PubMed: 38748766
DOI: 10.1161/HYPERTENSIONAHA.123.22108