Preventing repeat hospitalizations in dialysis patients: a call for action

Hospitalizations are frequent among dialysis patients, and reducing repeat hospitalizations could decrease costs and improve outcomes. Chan et al. found that hemoglobin monitoring along with erythropoietin-stimulating agent dose modification and vitamin D administration reduced the risk of repeat hospitalization. These and other interventions, especially those related to close monitoring immediately after hospitalization and better communication between hospital and dialysis providers to assure continuity of care, should be further explored in observational or randomized studies

Analyse de l’activité en ondes lentes et des oscillations lentes précédant le somnambulisme

Diverses études se sont penchées sur les paramètres EEG du sommeil en ondes lentes, y compris l’activité en ondes lentes en lien avec le somnambulisme, mais les résultats se révèlent inconsistants et contradictoires. Le premier objectif de la présente étude était d’analyser quantitativement l’EEG en sommeil en mesurant les fluctuations de puissance spectrale en delta (1-4 Hz) et delta lent (0.5-1 Hz) avant des épisodes de somnambulisme. Le second était de détecter les oscillations lentes (> 75 μV, fréquence d'environ 0.7-0.8 Hz) et très lentes (> 140 μV, fréquence d'environ 0.7-0.8 Hz) afin d'examiner leur changement d'amplitude et de densité avant de tels épisodes. Suite à une privation de sommeil de 25 heures, les enregistrements polysomnographiques de 22 adultes atteints de somnambulisme ont été scrutés. L’analyse des 200 secondes avant les épisodes révèle que ceux-ci ne sont pas précédés d’une augmentation graduelle de puissance spectrale en delta ni en delta lent, tant sur les dérivations frontale, centrale que pariétale. Toutefois, une hausse statistiquement significative de la densité des oscillations lentes et des oscillations très lentes a été observée au cours des 20 sec immédiatement avant le début des épisodes. Reste à déterminer le rôle exact de ces paramètres de l’EEG en sommeil par rapport à la manifestation et au diagnostic des parasomnies en sommeil lent.Several studies have investigated slow-wave sleep EEG parameters, including slow-wave activity (SWA) in relation to somnambulism, but results have been both inconsistent and contradictory. The first goal of the present study was to conduct a quantitative analysis of sleepwalkers’ sleep EEG by studying fluctuations in spectral power for delta (1-4 Hz) and slow delta (0.5-1 Hz) before the onset of somnambulistic episodes. A secondary aim was to detect slow wave oscillations to examine their changes in amplitude and density prior to behavioral episodes of somnambulism. Twenty-two adult sleepwalkers were investigated polysomnographically following 25 h of sleep deprivation. Analysis of patients’ sleep EEG over the 200 sec prior to the episodes’ onset revealed that the episodes were not preceded by a gradual increase in spectral power for either delta or slow delta over frontal, central, or parietal leads. However, time course comparisons revealed significant changes in the density of slow and very slow wave oscillations, with significant increases occurring during the final 20 sec immediately preceding episode onset. The specificity of these sleep EEG parameters for the occurrence and diagnosis of NREM parasomnias remains to be determined

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Alfredo Jaar es un artista, arquitecto y cineasta que vive y trabaja en Nueva York. Su trabajo se ha mostrado ampliamente en todo el mundo. Ha participado en las Bienales de Venecia (1986, 2007, 2009, 2013), Sao Paulo (1987, 1989, 2010, 2020) así como en Documenta en Kassel (1987, 2002). Entre las exposiciones individuales importantes se encuentran el Nuevo Museo de Arte Contemporáneo de Nueva York (1992); Whitechapel, Londres (1992); Moderna Museet, Estocolmo (1994); Museo de Arte Contemporáneo de Chicago (1995) y Museo de Arte Contemporáneo de Roma (2005). Los principales estudios recientes de su obra se han llevado a cabo en el Musée des Beaux Arts, Lausanne (2007); Hangar Bicocca, Milán (2008); Alte Nationalgalerie, Berlinische Galerie y Neue Gesellschaft fur bildende Kunst eV, Berlín (2012); Rencontres d'Arles (2013); KIASMA, Helsinki (2014) y Yorkshire Sculpture Park, Reino Unido (2017). El artista ha realizado más de setenta intervenciones públicas en todo el mundo. Sobre su obra se han publicado más de sesenta publicaciones monográficas. Se convirtió en Guggenheim Fellow en 1985 y MacArthur Fellow en 2000. Recibió el Hiroshima Art Prize en 2018 y el Hasselblad Award en 2020. Su trabajo se puede encontrar en las colecciones del Museo de Arte Moderno y el Museo Guggenheim de Nueva York; Instituto de Arte de Chicago y Museo de Arte Contemporáneo de Chicago; MOCA y LACMA, Los Ángeles; MASP, Museu de Arte de São Paulo; TATE, Londres; Centre Georges Pompidou, París; Nationalgalerie, Berlín; Museo Stedelijk, Amsterdam; Centro Reina Sofía, Madrid; Moderna Museet, Estocolmo; MAXXI y MACRO, Roma; Museo de Arte Moderno de Luisiana, Humlaebeck; Museo de Arte Contemporáneo de la Ciudad de Hiroshima y Museo de Arte Moderno de Tokushima, Japón; M +, Hong Kong; y decenas de instituciones y colecciones privadas en todo el mundo.El artista presenta de modo dinámico una serie de creaciones para debatir cuestiones a partir de la consideración del arte y la arquitectura como disciplinas que reflejan las circunstancias en las que se desarrollan algunos de sus proyectos expositivos. Veremos cómo en su obra interseccionan situaciones históricas, políticas, económicas y sociales que denotan una preocupación absoluta por el presente y los contextos en los que actúa. Muestra diversos proyectos como "Lumières dans la Ville", Montreal, Canadá; "Un millón de pasaportes finlandeses", Helsinki, Finlandia; "La Kunst Halle de Skoghall", Skoghall, Suecia; "Música. Todo lo que se lo aprendí el día que nació mi hijo", Dallas, Tejas, EEUU y la performance realizada en las calles de New York con título "Teach us to outgrow our madness".Universidad de Málaga. Campus de Excelencia Internacional Andalucía Tech

Komplikationen der Endoskopisch Retrograden Cholangiopankreatographie (ERCP) sowie der Endoskopischen Papillotomie (EPT) und ihr Zusammenhang mit bekannten Vorerkrankungen und untersuchungsabhängigen Risiken

Die Ergebnisse einer retrospektiven Auswertung von 333 Patienten, die sich zwischen 1997 und 1998 in der Medizinischen Klinik III und Poliklinik des Klinikums der Justus-Liebig-Universität Gießen eine ERCP/EPT unterzogen haben, wurden dargestellt. Schwerpunkt der Studie war die Erfassung und Analyse der Komplikationen und ihr Zusammenhang zu bekannten Vorerkrankungen und untersuchungsabhängigen Risiken. Die Erfolgsrate der Gallengang- und/oder Pankreasgangdarstellungen lag bei 97,3%. Die hohe Erfolgsrate ist am ehesten auf die große Erfahrung der Untersucher zurückzuführen. Insgesamt traten bei 29 Patienten Komplikationen auf. Das entspricht einer Komplikationsrate von 8,7%. Die am häufigsten zu beobachtende Komplikation stellte mit 5,7% die Post-ERCP Pankreatitis dar, gefolgt von der Cholangitis, auf die eine Häufigkeit von 1,8% entfiel. Die Papillenblutung und die Perforation traten in jeweils 0,6% der Fälle auf und nehmen somit den 3.Platz ein. Komplikationen mit letalem Ausgang wurden nicht registriert. Asymptomatische Hyperamylasämien wurden bei 16,5% der Untersuchungen nachgewiesen. Als wichtigste Risikofaktoren zur Entwicklung einer Hyperamylasämie konnten wir folgende ermitteln: ERP, Precut-Papillotomie, Schnittrichtung auf den Ductus pancreaticus, akute Pankreatitis, chronische Pankreatitis, Konkremente im DP, Pankreaspseudozysten, Pankreas divisum, Periduktale Fibrose, Abbruch des DP, Pankreas-Neoplasie, Öffnung des DP kleiner als der verwendete Katheter. Eine Pankreatitis entwickelten Patienten nach EPT häufiger als nach ERCP bzw. ERC. Auch hier war die Schnittrichtung von Bedeutung, wo diese Komplikation beim Schneiden in Richtung des Ductus pancreaticus häufiger auftrat als in Richtung des DHC. Bei alleiniger Darstellung des Pankreasganges war kein einziger Fall zu verzeichnen. Nach diesen Beobachtungen ist eine erfolgreiche Sondierung und Darstellung des Pankreasganges keine notwendige Voraussetzung für die Entwicklung einer Post-ERCP Pankreatitis. Unter den patientenbezogenen Risikofaktoren fanden wir folgende heraus: präoperatives Fieber, Mikrolithen im DHC und juxtapapilläres Divertikel. Weiterhin konnte gezeigt werden, dass die Entwicklung einer Cholangitis als Untersuchungskomplikation ohne vorherige Kanülierung und Kontrastierung des Ductus choledochus nicht zu erwarten ist. Eine alleinige ERP oder die Papillotomie in Richtung Ductus pancreaticus wurden ursächlich nicht ermittelt. Wir konnten ferner folgende Risikofaktoren zur Entwicklung einer Cholangitis herausfinden: negatives Cholecystogramm, Divertikel, DHC-Mikrolithen, chronische Pankreatitis, Konkremente im DP und Papillitis. In beiden Fällen wurde die Papillenblutung nach EPT in Richtung DHC beobachtet und folgende Risikofaktoren ermittelt: chronische Pankreatitis, exokrine Pankreasisuffizienz, Papillenstenose, DHC- und DP-Öffnung kleiner als der verwendete Katheter. Bei beiden Patienten, die eine Perforation als Untersuchungskomplikation entwickelten, wurden die in der Literatur bereits beschriebenen Risikofaktoren beobachtet, nämlich die Endoskopische Papillotomie und das Vorliegen peripapillärer Divertikel.The aim of our retrospective study was to investigate risk factors for complications emerging from endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (EST). A sample of three hundred thirty-three patients treated with ERCP/EST at the Medizinische Klinik III and Poliklinik between the years 1997 and 1998 were analysed. Procedures were successful in 97.3%. Success depended on the endoscopist’s experience. The occurrence of complications was 8.7% (29 patients): pancreatitis occurred in 5.7% of the patients, Cholangitis in 1.8%, hemorrhage in 0.6% and perforation during EST in 0.6%. None of the patients died. Asymptomatic hyperamylasaemia has been documented in 16,5% of the patients. Depending on the kind of complication we found the following important risk factors: a) Hyperamylasaemia: endoscopic pancreatography (ERP), use of pre-cutting technique, diameter of the pancreatic duct, acute pancreatitis, chronic pancreatitis, biliary stones in the ductus pancreaticus, pancreas divisum, pancreas pseudocysts etc. b) Pancreatitis (increase of Lipase/Amylase, CRP and leucocytes with the existence of pancreatic-type pain, results of sonography and computer tomography): occurs more often after EST than a ERCP or ERC, diameter of the pancreatic duct, fever before procedure, microlihtiasis in the ductus hepatocholedochus, periampullary diverticula. c) Cholangitis: ERC, EST and ERCP, negative cholecystogramm, periampullary diverticula, microlihtiasis in the ductus hepatocholedochus, chronic pancreatitis, biliary stones in the ductus pancreaticus, papillitis. d) Bleeding: EST and diameter of the choledochus duct, chronic pancreatitis, obstruction of the orifice of the papilla of Vater. e) Perforation: EST and periampullary diverticula

Changes in serum calcium, phosphate, and PTH and the risk of death in incident dialysis patients: A longitudinal study

Elevated bone mineral parameters have been associated with mortality in dialysis patients. There are conflicting data about calcium, parathyroid hormone (PTH), and mortality and few data about changes in bone mineral parameters over time. We conducted a prospective cohort study of 1007 incident hemodialysis and peritoneal dialysis patients. We examined longitudinal changes in bone mineral parameters and whether their associations with mortality were independent of time on dialysis, inflammation, and comorbidity. Serum calcium, phosphate, and calcium–phosphate product (CaP) increased in these patients between baseline and 6 months (P<0.001) and then remained stable. Serum PTH decreased over the first year (P<0.001). In Cox proportional hazards models adjusting for inflammation, comorbidity, and other confounders, the highest quartile of phosphate was associated with a hazard ratio (HR) of 1.57 (1.07–2.30) using both baseline and time-dependent values. The highest quartiles of calcium, CaP, and PTH were associated with mortality in time-dependent models but not in those using baseline values. The lowest quartile of PTH was associated with an HR of 0.65 (0.44–0.98) in the time-dependent model with 6-month lag analysis. We conclude that high levels of phosphate both at baseline and over follow-up are associated with mortality in incident dialysis patients. High levels of calcium, CaP, and PTH are associated with mortality immediately preceding an event. Promising new interventions need to be rigorously tested in clinical trials for their ability to achieve normalization of bone mineral parameters and reduce deaths of dialysis patients

Primary care physicians' perceptions of barriers and facilitators to management of chronic kidney disease: A mixed methods study.

BackgroundGiven the high prevalence of chronic kidney disease (CKD), primary care physicians (PCPs) frequently manage early stage CKD. Nonetheless, there are challenges in providing optimal CKD care in the primary care setting. This study sought to understand PCPs' perceptions of barriers and facilitators to the optimal management of CKD.Study designMixed methods study.Settings and participantsCommunity-based PCPs in four US cities: Baltimore, MD; St. Louis, MO; Raleigh, NC and San Francisco, CA.MethodologyWe used a self-administered questionnaire and conducted 4 focus groups of PCPs (n = 8 PCPs/focus group) in each city to identify key barriers and facilitators to management of patients with CKD in primary care.Analytic approachWe conducted descriptive analyses of the survey data. Major themes were identified from audio-recorded interviews that were transcribed and coded by the research team.ResultsOf 32 participating PCPs, 31 (97%) had been in practice for &gt;10 years, and 29 (91%) practiced in a non-academic setting. PCPs identified multiple barriers to managing CKD in primary care including at the level of the patient (e.g., low awareness of CKD, poor adherence to treatment recommendations), the provider (e.g., staying current with CKD guidelines), and the health care system (e.g., inflexible electronic medical record, limited time and resources). PCPs desired electronic prompts and lab decision support, concise guidelines, and healthcare financing reform to improve CKD care.ConclusionsPCPs face substantial but modifiable barriers in providing care to patients with CKD. Interventions that address these barriers and promote facilitative tools may improve PCPs' effectiveness and capacity to care for patients with CKD

Lower Extremity Peripheral Artery Disease and Quality of Life Among Older Individuals in the Community

BACKGROUND: Evidence regarding the association of lower extremity peripheral arterial disease with quality of life (QOL) is mainly from selected clinical populations or relatively small clinical cohorts. Thus, we investigated this association in community-derived populations. METHODS AND RESULTS: Using data of 5115 participants aged 66 to 90 years from visit 5 (2011-2013) of the Atherosclerosis Risk in Communities Study, we quantified the associations of ankle-brachial index (ABI) with several QOL parameters, including 12-item Short-Form Health Survey (SF-12), after accounting for potential confounders using linear and logistic regression models. Peripheral arterial disease defined by an ABI <0.90 (n=402), was independently associated with a low SF-12 Physical Component Summary score (-3.26 [95% CI -5.60 to -0.92]), compared to the ABI reference 1.10 to 1.19 (n=1900) but not with the Mental Component Summary score (-0.07 [-2.21 to 2.06]). A low ABI was significantly associated with poorer status of all SF-12 physical domains (physical functioning, role-physical, bodily pain, and general health) but only vitality out of 4 mental domains. Similarly, low ABI values were more consistently associated with other physically related QOL parameters (leisure-time exercise/activity/walking) than mentally related parameters (significant depressive symptoms and hopeless feeling). Lower physical QOL was observed even in individuals with borderline low ABI (0.90 to 0.99; n=426). CONCLUSIONS: Low ABI (even borderline) was independently associated with poor QOL, especially for physical components, in community-dwelling older adults. QOL is a critical element for older adults, and thus, further studies are warranted to assess whether peripheral arterial disease-specific management can improve QOL in older populations

Burnout Among Nephrologists in the United States: A Survey Study

Rationale & Objective: Burnout decreases job satisfaction and leads to poor patient outcomes but remains under-investigated in nephrology. We explored the prevalence and determinants of burnout among a sample of nephrologists. Study Design: Cross-sectional. Setting & Participants: The nephrologists were approached via the American Medical Association Physicians Masterfile, National Kidney Foundation listserv, email, and social media between April and August 2019. The predictors were demographics and practice characteristics. The outcome was burnout, defined as responding once a week or more on either 1 of the 2 validated measures of emotional exhaustion and depersonalization or both. Analytical Approach: Participant characteristics were tabulated. Responses were compared using χ2 tests. Multivariable logistic regression was used to estimate the odds ratios (ORs) of burnout for risk factors. Free text responses were thematically analyzed. Results: About half of 457 respondents were 40-59 years old (n=225; 49.2%), and the respondents were more predominantly men (n=296; 64.8%), US medical graduates (n=285; 62.4%), and in academic practice (n=286; 62.6%). Overall, 106 (23.2%) reported burnout. The most commonly reported primary drivers of burnout were the number of hours worked (n=27; 25.5%) and electronic health record requirements (n=26; 24.5%). Caring for ≤25 versus 26-75 patients per week (OR, 0.34; 95% confidence interval [95% CI], 0.15-0.77), practicing in academic versus nonacademic settings (OR, 0.33; 95% CI, 0.21-0.54), and spending time on other responsibilities versus patient care (OR, 0.32; 95% CI, 0.17-0.61) were each independently associated with nearly 70% lower odds of burnout after adjusting for age, sex, race, and international medical graduate status. The free text responses emphasized disinterested health care systems and dissatisfaction with remuneration as the drivers of burnout. Limitations: Inability to precisely capture response rate. Conclusions: Nearly one-quarter of the nephrologists in our sample reported burnout. Future studies should qualitatively investigate how the care setting, time spent on electronic medical records, and hours of clinical care drive burnout and explore other system-level drivers of burnout in nephrology