To determine the feasibility of whole-body diffusion-weighted (DW) magnetic resonance (MR) imaging for assessment of treatment response in myeloma.
This prospective single-institution study was ...HIPAA-compliant with local research ethics committee approval. Written informed consent was obtained from each subject. Eight healthy volunteers (cohort 1a) and seven myeloma patients (cohort 1b) were imaged twice to assess repeatability of quantitative apparent diffusion coefficient (ADC) estimates. Thirty-four additional myeloma patients (cohort 2) underwent whole-body DW imaging before treatment; 26 completed a posttreatment imaging. Whole-body DW data were compared before and after treatment by using qualitative (ie, observer scores) and quantitative (ie, whole-body segmentation of marrow ADC) methods. Serum paraproteins and/or light chains or bone marrow biopsy defined response.
Whole-body DW imaging scores were significantly different between observers (P < .001), but change in scores between observers after treatment was not (P = .49). Sensitivity and specificity for detecting response according to observer scores were 86% (18 of 21 patients) and 80% (4 of 5 patients) for both observers. ADC measurement was repeatable: mean coefficient of variation was 3.8% in healthy volunteers and 2.8% in myeloma patients. Pretreatment ADC in cohort 2 was significantly different from that in cohort 1a (P = .03), but not from that in cohort 1b (P = .2). Mean ADC increased in 95% (19 of 20) of responding patients and decreased in all (five of five) nonresponders (P = .002). A 3.3% increase in ADC helped identify response with 90% sensitivity and 100% specificity; an 8% increase (greater than repeatability of cohort 1b) resulted in 70% sensitivity and 100% specificity. There was a significant negative correlation between change in ADC and change in laboratory markers of response (r = -0.614; P = .001).
Preliminary work demonstrates whole-body DW imaging is a repeatable, quantifiable technique for assessment of treatment response in myeloma.
Prior research characterizes mainly male veteran preferences at end of life using the Veterans Administration Advance Directive (VA AD), there has been no specific studies focusing on women veteran’s ...preferences concerning whether the AD is to be strictly (S) followed or to serve as a general guide (G). The purpose of this study was to describe women veteran preferences for life-sustaining treatments (LSTs) in various illness situations to assist providers in discussing end-of-life decisions. Additionally, we compared previously published LST preferences of male veterans with the study’s sample. Using a descriptive retrospective approach, data was collected from 484 women veterans ADs between January 2010 and December 2019. Findings revealed that women tended to trend in the same direction as men, preferring to have advance directives serve as general guidance over being strictly followed. Unconscious/Coma/Vegetative was the only factor that was statistically significant for affecting the choice of following the AD.
Introduction: Organ Procurement Organizations seek authorization for tissue donation from next-of-kin of deceased patients. Best practices for achieving contact and authorization are unknown, ...notably, authorization rates are lower for Black compared to White patients. Research Questions: Can next-of-kin (NOK) contact and authorization rates be improved if they are texted prior to telephone contact? Is a text message containing an infographic more effective, and does an infographic culturally tailored to Black families improve contact and authorization rates in the Black population? Design: This three-armed randomized trial compared (1) telephonic contact initiation (control condition); (2) generic text messaging prior to telephonic contact; and (3) text messaging one of two versions of an infographic prior to telephonic contact: (a) a generic infographic or (b) a culturally tailored infographic (sent to Black NOK only) at one Northeastern Organ Procurement Organization. Results: Tissue Donation Professionals (N = 47) and 2399 White and 745 Black NOK were included, of which 35.6% were registered donors. Authorization rates were much higher for White than Black (40.1% v 16.3%, P < 0.0001). The generic infographic resulted in significantly lower rates of contact for White NOK compared to the control condition 83.5% v 89.5%, P = 0.002), but study arm assignments were not otherwise associated with differences in contact or authorization rates. Conclusion: Although the analysis did not find a benefit for text messaging, it is possible that training for staff making requests and refining the content of the messaging could be more effective.
To describe the clinical characteristics and organ donation rate of patients supported by extracorporeal membrane oxygenation (ECMO) at the time of death.
Retrospective observational study. Pearson ...chi-square and Fisher exact tests were used in statistical analyses.
One hundred twenty-seven acute care hospitals in New Jersey, Pennsylvania, and Delaware.
Adult and pediatric patients who were on ECMO at the time of referral to a large organ procurement organization (OPO) between 2016 and 2020.
None.
Nineteen thousand nine hundred thirty patients were referred to the OPO between November 2016 and September 2020, of which 5,034 were medically suitable potential donors. Of this cohort, 143 patients were supported on ECMO at the time of OPO referral and 141 were included in analyses (median age 47 yr, 60% male). Thirty-three percent (46/141, median age 48 yr, 52% male) donated organs, compared with 50% of non-ECMO patients (
≤ 0.0005). ECMO and non-ECMO patients had organs recovered but not transplanted at similar rates (11% vs 10%,
= 0.8). There were no significant differences in sex (
= 0.16) or ethnicity (
= 0.50) between organ donor and nondonor groups. Fifty-one percent (21/41) of organ donors donated after circulatory death and 49% (20/41) after brain death. Patients declared dead by neurologic criteria were more likely to donate (51%) than those declared dead by circulatory criteria (21%,
< 0.001). Frequency of cardiac arrest prior to ECMO was similar between donors and nondonors (
= 0.68). Thirty-nine percent (16/41) of donors had an out-of-hospital cardiac arrest (OHCA) and 51% (21/41) were cannulated via extracorporeal cardiopulmonary resuscitation (ECPR). The most common reason patients were not donors was that family declined (57%).
One-third of patients referred to the OPO on ECMO at the time of death donated organs. While donation occurred less frequently after ECMO, ECMO and non-ECMO patients had organs used rather than discarded at a similar rate. Patients successfully donated following OHCA and/or ECPR. Clinicians should not consider ECMO a barrier to organ donation.
Background. Organ donors supported by extracorporeal membrane oxygenation (ECMO) have historically been considered high-risk and are judiciously utilized. This study examines transplant outcomes ...using renal allografts from donors supported on ECMO for nondonation purposes. Methods. Retrospective review of the Gift of Life (Pennsylvania, New Jersey, Delaware) organ procurement organization database, cross-referenced to the Organ Procurement and Transplantation Network database, assessed kidney transplants using donors supported on venoarterial (VA) and venovenous (VV) ECMO for nondonation purposes. Transplants using VA- and VV-ECMO donors were compared with Kidney Donor Profile Index (KDPI)-stratified non-ECMO donors. Regression modeling of the entire ECMO and non-ECMO populations assessed ECMO as predictive of graft survival. Additional regression of the ECMO population alone assessed for donor features associated with graft survival. Results. Seventy-eight ECMO donors yielded 128 kidney transplants (VA: 80, VV: 48). Comparing outcomes using these donors to kidney transplants using organs from KDPI-stratified non-ECMO donors, VA- and VV-ECMO donor grafts conferred similar rates of delayed graft function and posttransplant renal function to KDPI-matched non-ECMO counterparts. VA-ECMO kidneys demonstrated superior graft survival compared with the lowest-quality (KDPI 86%–100%) non-ECMO kidneys and similar graft survival to KDPI <85% non-ECMO kidneys. VV-ECMO showed inferior graft survival to all but the lowest-quality (KDPI 86%–100%) non-ECMO kidneys. VV-ECMO, but not VA-ECMO, was associated with increased risk of graft loss on multivariable regression (hazard ratios—VA: 1.02, VV: 2.18). Higher KDPI, advanced age, increased body mass index, hypertension, and diabetes were identified as high-risk features of ECMO donors. Conclusions. Kidney transplantation using appropriately selected ECMO donors can safely expand the donor pool. Ongoing studies are necessary to determine best practice patterns using kidneys from these donors.
INTRODUCTION
Approximately 37 million U.S. adults have chronic kidney disease (CKD), characterized by reduced glomerular filtration rate (GFR). Previous work has shown GFR to be sensitive to certain ...environmental features, such as heightened temperature and pollution. Other components of climate merit investigation.
PURPOSE
To examine the effects of temperature, air pressure, and humidity on GFR.
METHODS
We evaluated 322 nephrology patients who were consecutively admitted to a single hospital between January 2017 and July 2018. At intake, patients were assessed for demographic, anthropometric, and cardiometabolic parameters, and a detailed medical history was collected. The exact ambient temperature, air pressure, and humidity was documented for each patient corresponding to their time of admission. We characterized the study sample with basic descriptive statistics. Linear regression tested the effect of climate variables on GFR holding all significant confounders constant.
RESULTS
Patients were 65.8 ± 17.0 years old, 50.9% were male, 42.3% were obese, 12.3% reported smoking, 21.9% reported drinking, 16.8% had a diagnosis of cancer, 48.1% had diabetes, 26.1% had coronary artery disease, 1.9% had hepatitis, 6.5% had end‐stage renal disease, 3.4% had a kidney transplant, and 8.4% had used dialysis (either currently or in the past). Systolic blood pressure was 134.5 ± 37.2 mmHg, diastolic pressure was 72.8 ± 18.4 mmHg, hemoglobin was 11.6 ± 2.6 g/dL, creatinine was 2.8 ± 1.5 mg/L, and GFR was 26.5 ± 12.3 mL/min. GFR was correlated with humidity (p=0.029) but not temperature (p=0.170) or air pressure (p=0.404). Linear regression found each additional percentage point of humidity at the time of intake to correspond to a reduction in GFR of 7.6 mL/min (p=0.018; 95% CI: ‐1.314 to ‐13.899) holding all significant confounders constant: sex (p=0.027), diastolic blood pressure (p=0.033), hemoglobin (p<0.001), diagnosis of cancer (p=0.001), diagnosis of coronary artery disease (p=0.028), diagnosis of peripheral vascular disease (p=0.041), diagnosis of hepatitis (p=0.020), hyperglycemia (p=0.001), current alcohol intoxication (p=0.023), and use of dialysis (p<0.001). The overall model was significant (p<0.001; r2=0.317). Using all of the same predictors, but holding constant CKD stage (p<0.001), humidity remained significant (β = ‐6.837; p=0.029; 95% CI: ‐0.703 to ‐12.970). Temperature and air pressure were insignificant in both models (p>0.500); humidity remained significant (p<0.025) when controlling for them. All other potential confounders were tested; none were significant (p>0.100) and all combinations of inclusion in the model preserved the significance (p<0.025) and magnitude (β < ‐7.000) of humidity.
CONCLUSIONS
Ambient humidity demonstrated a robust and resilient effect on kidney function. Higher humidity corresponded to a reduction in estimated GFR across all stages of CKD and within stages. Other climate factors exhibited no effect. A possible mechanism is the decrease in evaporative cooling leading to additional sweat loss, reduced plasma volume, and a lower blood pressure gradient in the glomerulus.
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