Recently reported cases of lupus complicated by a thrombotic thrombocytopenic purpura(TTP)-like syndrome suggest a survival benefit to early treatment with plasma exchange. The following is a report ...of the eighth such case in the last ten years. A 44-yearold lady known for lupus presented with the nephrotic syndrome and a renal biopsy was consistent with class 4G lupus nephritis. She was given high-dose steroids and cytotoxic therapy, but her induction therapy was complicated by the classic pentad of TTP. She was subsequently treated with another course of high-dose steroids, a different cytotoxic agent, and plasma exchange, with clinical resolution shortly thereafter. Similar to seven recently reported cases of microangiopathy in lupus, this lady’s TTP-like syndrome improved dramatically after initiation of plasma exchange, despite not having a severely deficient ADAMTS13. This has implications on both current clinical practice and on the pathogenesis of TTP-like syndromes in lupus.
Purpose of review:
Volume overload and hypovolemia-induced symptoms are common in the hemodialysis (HD) population and frequently result in emergency department visits and hospitalization. A ...structured strategy for the reporting, evaluation, and management of disordered volume status may improve clinical outcomes and the patient experience. We developed a new strategy that systematically addresses volume issues by leveraging the electronic medical record, technological adjuncts, and multidisciplinary expertise to institute new processes of care in our HD unit.
Sources of information:
This initiative was implemented in a unit located in an urban academic hospital where 250 patients receive maintenance HD. This initiative involved a multidisciplinary team of health professionals including physicians, nurse practitioners, social workers, and dieticians.
Methods:
We generated volume metrics for HD recipients based on routinely collected data from the unit’s electronic medical record. We then engaged stakeholders in a root cause analysis to identify the major causes of abnormal volume metrics locally. We subsequently developed interventions that were designed to address each of the major causes in a pragmatic and sustainable program.
Key findings:
The final product was a local volume management program with 3 components. First, we integrated volume metric reporting into the routine surveillance bloodwork reports across our unit. This enabled the clinical teams to more easily target patients at risk for volume-related adverse events and provide them with closer surveillance. Those identified with abnormal volume metrics were then evaluated with the use of technologic adjuncts such as lung ultrasound and bioimpedance spectroscopy to complement traditional assessments of volume status. Finally, those with abnormal volume metrics underwent rigorous interdisciplinary review for potential nutritional/social interventions.
Limitations:
While we report the successful initial implementation of the program within a single center, it remains unclear whether this initiative will lead to meaningful benefits for HD recipients, be readily applicable in other centers, or be sustainable in the long term.
Implications:
This volume management program will need further evaluation linked to outcome assessment and feasibility in other centers before wider adoption is advocated.
Background:
Quality metrics or indicators help guide quality improvement work by reporting on measurable aspects of health care upon which improvement efforts can focus. For recipients of in-center ...hemodialysis (ICHD) in Canada, it is unclear what ICHD quality indicators exist and whether they adequately cover different domains of health care quality.
Objectives:
To identify and evaluate current Canadian ICHD quality metrics to document a starting point for future collaborations and standardization of quality improvement in Canada.
Design:
Environmental scan of quality metrics in ICHD, and subsequent indicator evaluation using a modified Delphi approach.
Setting:
Canadian ICHD units.
Participants:
Sixteen-member pan-Canadian working group with expertise in ICHD and quality improvement.
Measurements:
We classified the existing indicators based on the Institute of Medicine (IOM) and Donabedian frameworks.
Methods:
Each metric was rated by a 5-person subcommittee using a modified Delphi approach based on the American College of Physicians/Agency for Healthcare Research and Quality criteria. We shared these consensus ratings with the entire 16-member panel for additional comments.
Results:
We identified 27 metrics that are tracked across 8 provinces, with only 9 (33%) tracked by multiple provinces (ie, more than 1 province). We rated 9 metrics (33%) as “necessary” to distinguish high-quality from low-quality care, of which only 2 were tracked by multiple provinces (proportion of patients by primary access and rate of vascular access-related bloodstream infections). Most (16/27, 59%) indicators assessed the IOM domains of safe or effective care, and none of the “necessary” indicators measured the IOM domains of timely, patient-centered, or equitable care.
Limitations:
The environmental scan is a nonexhaustive list of quality indicators in Canada. The panel also lacked representation from patients, administrators, and allied health professionals, with more representation from academic sites.
Conclusions:
Quality indicators in Canada mainly focus on safe and effective care, with little provincial overlap. These results highlight current gaps in quality of care measurement for ICHD, and this initial work should provide programs with a starting point to combine highly rated indicators with newly developed indicators into a concise balanced scorecard that supports quality improvement initiatives across all aspects of ICHD care.
Trial Registration:
not applicable.
Abstract Introduction Care of patients with vestibular symptoms focuses primarily on physical otoneurologic disorders; however, psychological factors can sustain symptoms, confound assessment, and ...adversely affect treatment. Health anxiety is a particularly pernicious process that simultaneously magnifies physical symptoms and inhibits medical care. Objective To demonstrate the excess morbidity caused by vestibular health anxiety and its successful management in a patient with otoneurologic disease. Method Report of a 41-year-old woman with recurrent benign paroxysmal positional vertigo, vestibular migraine, and chronic subjective dizziness, who expressed grave concerns about her health, repeatedly questioned her otoneurologic diagnoses, and failed physical therapy and medication treatment until her health anxiety and otoneurologic illnesses were addressed simultaneously. Conclusion Health anxiety is an empirically validated concept that explains troublesome health-related beliefs and behaviors. It is frustrating for patients and health care teams, but can be treated successfully in otoneurology practice, thereby reducing physical symptoms, emotional distress, functional impairment, and health care overutilization.
Studies have shown that achieving a time in therapeutic range (TTR) for warfarin of greater than 60% is associated with a lower risk of bleeding. However, many patients on hemodialysis (HD) do not ...achieve this target.
We audited TTR achievement at the in-center HD unit of our hospital in 2017 and found that only 40% of patients had achieved a TTR >60%. We aimed to improve the percentage of HD patients achieving target TTR within 2 years. We reported each patient's individualized trend in quarterly TTR to their primary warfarin prescriber as an audit-feedback report. These reports were generated, disseminated, and subsequently improved following a series of plan-do-study-act cycles. We then used statistical process control to assess for changes in the percentage of HD patients achieving target TTR over time.
In the primary analysis, 28 patients were included in the baseline period, and 46 were included in the intervention period. At baseline, the percentage of patients achieving a TTR >60% varied between 33% and 45% (mean ± SD, 40% ± 5%); post-intervention, this metric improved and varied between 52% and 71% (mean ± SD, 61% ± 8%). In time-series analysis, there was evidence of statistically significant variation between the 2 periods and evidence of sustained improvement.
A quality improvement program consisting of an audit-feedback report that raises awareness of the quality gap in TTR achievement can result in substantial improvement in the safe and efficacious administration of warfarin to patients receiving maintenance hemodialysis.
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Kidney injury associated with COVID-19 Blum, Daniel; Meraz-Munoz, Alejandro; Harel, Ziv
Canadian Medical Association journal (CMAJ),
09/2020, Letnik:
192, Številka:
37
Journal Article
Recenzirano
Odprti dostop
Several facts about acute kidney injury (AKI) are presented. Among other things, AKI is a common complication of coronavirus disease 2019 (COVID-19) and is usually related to disease severity. ...Accordingly, it typically occurs in patients who are critically ill, those with pre-existing conditions, older adults and Black people.
The assembly of the peroxisomal translocon involves the transition of a soluble form of the peroxisomal targeting receptor PEX5 into a membrane-bound form, which becomes an integral membrane ...component of the import pore for peroxisomal matrix proteins. How this transition occurs is still a mystery. We addressed this question using a artificial horizontal bilayer in combination with fluorescence time-correlated single photon counting (TCSPC) and electrophysiological channel recording. Purified human isoform PEX5L and truncated PEX5L(1-335) lacking the cargo binding domain were selectively labeled with thiol-reactive Atto-dyes. Diffusion coefficients of labeled protein in solution show that PEX5L is monomeric with a rather compact spherical conformation, while the truncated protein appeared in a more extended conformation. Labeled PEX5L and the truncated PEX5L(1-335) bind stably to horizontal bilayer thereby accumulating around 100-fold. The diffusion coefficients of the membrane-bound PEX5L forms are 3-4 times lower than in solution, indicating the formation of larger complexes. Electrophysiological single channel recording shows that membrane-bound labeled and non-labeled PEX5L, but not the truncated PEX5L(1-335), can form ion conducting membrane channels. The data suggest that PEX5L is the pore-forming component of the oligomeric peroxisomal translocon and that spontaneous PEX5L membrane surface binding might be an important step in its assembly.
Coronavirus disease 2019 (COVID-19) may be associated with high rates of acute kidney injury (AKI) and kidney replacement therapy (KRT), potentially overwhelming health care resources. Our objective ...was to determine the pooled prevalence of AKI and KRT among hospitalized patients with COVID-19.
Systematic review and meta-analysis.
MEDLINE, Embase, the Cochrane Library, and a registry of preprinted studies, published up to October 14, 2020.
Eligible studies reported the prevalence of AKI in hospitalized patients with COVID-19 according to the Kidney Disease: Improving Global Outcomes (KDIGO) definition.
We extracted data on patient characteristics, the proportion of patients developing AKI and commencing KRT, important clinical outcomes (discharge from hospital, ongoing hospitalization, and death), and risk of bias.
We calculated the pooled prevalence of AKI and receipt of KRT along with 95% CIs using a random-effects model. We performed subgroup analysis based on admission to an intensive care unit (ICU).
Of 2,711 records reviewed, we included 53 published and 1 preprint study in the analysis, which comprised 30,657 hospitalized patients with COVID-19. Data for AKI were available for 30,639 patients (n=54studies), and receipt of KRT, for 27,525 patients (n=48studies). The pooled prevalence of AKI was 28% (95% CI, 22%-34%; I2=99%), and the pooled prevalence of KRT was 9% (95% CI, 7%-11%; I2=97%). The pooled prevalence of AKI among patients admitted to the ICU was 46% (95% CI, 35%-57%; I2=99%), and 19% of all ICU patients with COVID-19 (95% CI, 15%-22%; I2=88%) commenced KRT.
There was significant heterogeneity among the included studies, which remained unaccounted for in subgroup analysis.
AKI complicated the course of nearly 1 in 3 patients hospitalized with COVID-19. The risk for AKI was higher in critically ill patients, with a substantial number receiving KRT at rates higher than the general ICU population. Because COVID-19 will be a public health threat for the foreseeable future, these estimates should help guide KRT resource planning.
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