Association Between Causative Pathogen and Occurrence of Infection-Related Glomerulonephritis in Infective Endocarditis.

Among patients with pathologically proven infective endocarditis, the association of pathogen with occurrence of infection-related glomerulonephritis (IRGN) was examined in 48 case patients with IRGN and 192 propensity score-matched controls. Bartonella was very strongly associated with IRGN (odds ratio, 38.2 [95% confidence interval, 6.7-718.8]; P < .001); other microorganisms were not.

Comparison of CT acquired cardiac valvular calcification scores in hemodialysis and peritoneal dialysis patients undergoing open heart surgery.

Study objective: Data is scarce regarding which dialysis modality portends more severe cardiac valvular calcification (CVC). Our aim was to compare the degree of CVC in hemodialysis (HD) and peritoneal dialysis (PD) patient cohorts prior to open heart surgery (OHS) using a CT calcium score. Design setting and participants: Dialysis patients who underwent OHS at our institution from 2009 to 2019 and who had pre-surgical cardiac CT were included in our study. We obtained duration of dialysis modality prior to their surgical date. There were two study cohorts to evaluate outcomes of interest: mitral and aortic calcification. CVC was assessed using the Agatston score. Logistic regression was performed to test for the association of PD and HD cumulative dialysis duration with presence of CVC. Results: A total of 214 and 166 patients met inclusion for the mitral and aortic strata, respectively. Age, female sex, and BMI were associated with higher odds of presence of mitral calcification. Age and BMI were associated with higher odds of presence of aortic calcification, while female sex was associated with lower odds in the aortic strata. Cumulative years on PD and cumulative years on HD were not significantly associated with presence of CVC in either cohort. Conclusion: Presence of mitral and aortic calcification for patients undergoing OHS was not significantly associated with cumulative length of PD or HD after adjusting for age, gender, and BMI suggesting that there may be more factors at play in the progression of CVC in end stage renal disease patients than what was previously established.

Dysnatremias, Mortality, and Kidney Failure in CKD: Findings From the Chronic Renal Insufficiency Cohort (CRIC) Study.

Rationale & Objective: Dysnatremias have been associated with an increased risk of mortality in the chronic kidney disease (CKD) population. Our objective is to identify the prevalence of and risk factors associated with dysnatremias in a CKD population and assess the association of dysnatremias with kidney failure and mortality among patients with CKD enrolled in the Chronic Renal Insufficiency Cohort Study. Study Design: Analysis of prospective cohort study. Setting & Participants: Adult patients aged 21-74 years with CKD from the Chronic Renal Insufficiency Cohort study. Predictors: Baseline and time-dependent hyponatremia and hypernatremia. Outcomes: All-cause mortality and kidney failure. Analytical Approach: Baseline characteristics were compared using χ2 tests for categorical variables, analysis of variance for age, and Kruskal-Wallis tests for laboratory variables. Cox proportional hazards models and competing risk models were used to evaluate the association between baseline sodium level and overall mortality. Results: Of a total of 5,444 patients with CKD, 486 (9%) had hyponatremia and 53 (1%) had hypernatremia. Altogether, 1,508 patients died and 1,206 reached kidney failure. In adjusted Cox models, time-dependent dysnatremias were strongly associated with mortality for both hyponatremia (HR, 1.38; 95% CI, 1.16-1.64) and hypernatremia (HR, 1.54; 95% CI, 1.04-2.29). Factors associated with hyponatremia included female sex, diabetes, and hypertension. Regardless of age, time-dependent hypernatremia was associated with an increased risk of kidney failure (HR, 1.64; 95% CI, 1.06-2.53). Baseline and time-dependent hyponatremia were associated with an increased risk of kidney failure in patients younger than 65 (baseline hyponatremia HR, 1.30; 95% CI, 1.03-1.64 and time-dependent hyponatremia HR, 1.36; 95% CI, 1.09-1.70) but not among patients aged >65 years. Limitations: Inability to establish causality and lack of generalizability to hospitalized patients. Conclusions: Dysnatremias are prevalent among ambulatory CKD patients and are associated with mortality and kidney failure. Time-dependent dysnatremias were significantly associated with mortality in patients with CKD. Time-dependent hypernatremia was associated with progression to kidney failure. Baseline and time-dependent hyponatremia were associated with an increased risk of progression to kidney failure in those younger than 65 years.

Comparison of Spinopelvic Configuration and Roussouly Alignment Types Between Pediatric and Adult Populations.

STUDY DESIGN: Retrospective cross-sectional study. OBJECTIVE: The aim was to describe spinopelvic alignment types by pelvic incidence (PI) and age to compare the Roussouly classification between pediatric and adult populations. SUMMARY OF BACKGROUND DATA: The Roussouly classification was validated for adults. Alignment types may vary during growth. MATERIALS AND METHODS: Radiographs of 1706 non pathologic individuals (5-49 yr) were analyzed. Individuals ≤19 years were stratified by chronological age and skeletal maturity (triradiate cartilage, Risser), and compared with adults. Global and spinopelvic alignment parameters were assessed. Roussouly Types 1, 2, 3, 3A (anteverted pelvis), and 4 were determined. The distribution of parameters was analyzed by Bayesian inference. The relationship between PI and age by Roussouly type was modeled by linear regression. RESULTS: The Sagittal Vertical Axis C7 decreased during growth and was significantly smaller in adults (20-34 yr) (Pr>0.99). Thoracic kyphosis and lumbar lordosis increased during growth and were larger in adults (Pr<0.025). Lordosis increased mainly in the cranial arch (Pr<0.025). PI and pelvic tilt increased during growth and were larger in adults (Pr<0.025). In children and adolescents, PI<45° represented the largest proportion, significantly larger compared with adults (Pr>0.99). Proportions of Roussouly Types 1 and 2 were similar throughout ages. Types 3 and 4 were rarer during the prepubertal period (Pr<0.025). The proportion of Type 3A was significantly higher in children and adolescents (Pr>0.99). Linear regression showed that Type 4 had the largest PI increase with age, with significantly higher curve slope compared with other types (Pr>0.9999). Types 3, 3A and 2 had similar slopes and lowest PI increase with age. CONCLUSION: Global and spinopelvic alignment changed during childhood and adolescence, leading to different kyphosis and lordosis distribution compared with adults. Growth-related PI increase influenced Roussouly types with typical predominance of Type 3A in the pediatric population and larger PI increase in Type 4. LEVEL OF EVIDENCE: Level III.

Fatigue in Multiple Sclerosis: A Review of the Exploratory and Therapeutic Potential of Non-Invasive Brain Stimulation.

Fatigue is the most commonly reported symptom in patients with multiple sclerosis (MS). It is a worrisome, frequent, and debilitating manifestation that could occur at any time during the course of MS and in all its subtypes. It could engender professional, familial, and socioeconomic consequences and could severely compromise the patients' quality of life. Clinically, the symptom exhibits motor, cognitive, and psychosocial facets. It is also important to differentiate between perceived or subjective self-reported fatigue and fatigability which is an objective measure of decrement in the performance of cognitive or motor tasks. The pathophysiology of MS fatigue is complex, and its management remains a challenge, despite the existing body of literature on this matter. Hence, unraveling its neural mechanisms and developing treatment options that target the latter might constitute a promising field to explore. A PubMed/Medline/Scopus search was conducted to perform this review which aims (a) to reappraise the available electrophysiological studies that explored fatigue in patients with MS with a particular focus on corticospinal excitability measures obtained using transcranial magnetic stimulation and (b) to assess the potential utility of employing neuromodulation (i.e., non-invasive brain stimulation techniques) in this context. A special focus will be put on the role of transcranial direct current stimulation and transcranial magnetic stimulation. We have provided some suggestions that will help overcome the current limitations in upcoming research.

Variation of Global Sagittal Alignment Parameters According to Gender, Pelvic Incidence, and Age.

STUDY DESIGN: Retrospective cross-sectional study. OBJECTIVE: The aim was to describe existing global sagittal alignment parameters across ages and to analyze differences according to gender and pelvic incidence (PI). SUMMARY OF BACKGROUND DATA: Variability with age has been reported. It remains unclear how gender and spinopelvic morphology could additionally influence global alignment parameters. MATERIALS AND METHODS: Radiographs of 2599 individuals (5-93 y) were analyzed. Translation parameters were: Sagittal Vertical Axis (SVA)-C7, SVA-C2, SVA-Center Acoustic Meatus (CAM), C7/Sacrofemoral Distance (SFD) ratio. Inclination parameters were: C7-Vertical Tilt (VT), T1-VT and T9-VT, Odontoid-Hip Axis (OD-HA), OD-CAM. Pelvic compensation parameters were: T1-Pelvic Angle (TPA), Global Tilt (GT), Spino-Sacral Angle (SSA). Global sagittal alignment (GSA) was considered among formulae. The distribution of parameters was analyzed using a Bayesian inference. Correlations with spinopelvic parameters were investigated. RESULTS: SVA-C7, SVA-C2, SVA-CAM were larger in males and high PI, and increased significantly after 50 years (Pr>0.9999). C7/SFD decreased during growth and was larger in low PI (Pr=0.951). There was no correlation with spinopelvic parameters. Age-related variations of inclination parameters were nonsignificant. T1-VT and T9-VT increased with PI and were significantly larger in high PI (Pr>0.95). C7-VT was significantly larger in low PI (Pr>0.9999). OD-HA and OD-CAM were constant and increased after 80 years. TPA and GT increased with PI (Pr>0.9999) and age after 35 years (Pr>0.9999). SSA decreased nonsignificantly after 50 years. TPA correlated with PI (ρ=0.6130) and pelvic tilt (PT) (ρ=0.8375). GT correlated with PI (ρ=0.5961) and PT (ρ=0.8996). SSA correlated with sacral slope (ρ=0.9026). GSA was larger in high PI (Pr>0.9999) and increased after 35 years (Pr>0.9999). GSA correlated with PT (ρ=0.7732). CONCLUSION: Translation parameters increase with age, more prominently in males and high PI. Variations of inclination parameters are smaller. Pelvic compensation parameters and GSA increase with age and are closely related to PT and spinopelvic morphology. LEVEL OF EVIDENCE: Level III.

Anemia of chronic kidney disease: Will new agents deliver on their promise?

Anemia is a well-known complication of chronic kidney disease, and its treatment remains a challenge. Although erythropoiesis-stimulating agents (ESAs) raise hemoglobin levels, their benefits appear to be limited to decreasing the number of blood transfusions needed and perhaps improving quality of life. The newly developed prolyl hydroxylase inhibitors (PHIs)-agents that increase endogenous erythropoietin production-promise to improve outcomes for patients with anemia of chronic kidney disease. Randomized controlled trials have found these drugs to be at least as effective as ESAs, and the drugs are used in other countries. However, PHIs have yet to be approved in the United States.

Ten Years After SINS: Role of Surgery and Radiotherapy in the Management of Patients With Vertebral Metastases.

The objective of the different types of treatments for a spinal metastasis is to provide the best oncological and functional result with the least aggressive side effects. Initially created in 2010 to help clinicians in the management of vertebral metastases, the Spine Instability Neoplastic Score (SINS) has quickly found its place in the decision making and the treatment of patients with metastatic spinal disease. Here we conduct a review of the literature describing the different changes that occurred with the SINS score in the last ten years. After a brief presentation of the spinal metastases' distribution, with or without spinal cord compression, we present the utility of SINS in the radiological diagnosis and extension of the disease, in addition to its limits, especially for scores ranging between 7 and 12. We take this opportunity to expose the latest advances in surgery and radiotherapy concerning spinal metastases, as well as in palliative care and pain control. We also discuss the reliability of SINS amongst radiologists, radiation oncologists, spine surgeons and spine surgery trainees. Finally, we will present the new SINS-derived predictive scores, biomarkers and artificial intelligence algorithms that allow a multidisciplinary approach for the management of spinal metastases.

Spinal meningiomas, from biology to management - A literature review.

Meningiomas arise from arachnoidal cap cells of the meninges, constituting the most common type of central nervous system tumors, and are considered benign tumors in most cases. Their incidence increases with age, and they mainly affect females, constituting 25-46% of primary spinal tumors. Spinal meningiomas could be detected incidentally or be unraveled by various neurological symptoms (e.g., back pain, sphincter dysfunction, sensorimotor deficits). The gold standard diagnostic modality for spinal meningiomas is Magnetic resonance imaging (MRI) which permits their classification into four categories based on their radiological appearance. According to the World Health Organization (WHO) classification, the majority of spinal meningiomas are grade 1. Nevertheless, they can be of higher grade (grades 2 and 3) with atypical or malignant histology and a more aggressive course. To date, surgery is the best treatment where the big majority of meningiomas can be cured. Advances in surgical techniques (ultrasonic dissection, microsurgery, intraoperative monitoring) increase the complete resection rate. Operated patients have a satisfactory prognosis, even in those with poor preoperative neurological status. Adjuvant therapy has a growing role in treating spinal meningiomas, mainly in the case of subtotal resection and tumor recurrence. The current paper reviews the fundamental epidemiological and clinical aspects of spinal meningiomas, their histological and genetic characteristics, and their management, including the various surgical novelties and techniques.

May Measurement Month 2019: an analysis of blood pressure screening results from the Democratic Republic of the Congo.

Hypertension, the foremost cause of global morbi-mortality, is linked with a high mortality from numerous cardiovascular endpoints. The May Measurement Month (MMM) campaign is an annual initiative of the International Society of Hypertension (ISH) to collect information on blood pressure (BP) and other risk factors for cardiovascular disease (CVD) in adults. MMM2019 in the Democratic Republic of the Congo (DRC) was an opportunistic cross-sectional survey of volunteers aged ≥18 years that took place in Kinshasa and Mbuji-Mayi after the training of observers to familiarize with the ISH ad hoc methods. We screened 29 857 individuals (mean age: 40 years; 40% female). Hypertension was present in 7624 (25.5%) individuals. Of them, 2520 (33.1%) were aware, 1768 (23.2%) on treatment with 910 (51.5%) controlled BP (systolic BP <140 mmHg and/or diastolic BP <90 mmHg). Of all hypertensives screened, 11.9% had controlled BP. Of all respondents, 16.7% had participated in MMM18 and 60.5% did not have their BP verified during the last year. Fasting, pregnancy, and underweight status were linked with lower BP levels whilst smoking, drinking, antihypertensive medication, previous stroke, diabetes as well as being overweight/obese were associated with higher BP levels. Our results reflect the high rate of hypertension in the DRC with low levels of awareness, treatment, and control. A nationally representative sample is required to establish the nationwide hypertension prevalence.

Proton-pump inhibitor vs. H2-receptor blocker use and overall risk of CKD progression.

BACKGROUND: The relationship between proton-pump inhibitor (PPI) use and chronic kidney disease (CKD) progression remains controversial. Specifically, there is a lack of data evaluating renal outcomes in established CKD patients. The aim of our study is to determine the risk of progression to end-stage kidney disease (ESKD) or death amongst CKD patients on PPI, histamine-2 receptor blocker (H2B), or no anti-acid therapy. METHODS: Using our CKD registry, we evaluated the relationship between PPI and H2B use and outcomes amongst patients with CKD (eGFR < 60), with at least 2 PCP visits in the year prior. A Cox proportional hazards model was used to evaluate the relationship between medication groups and overall mortality, while competing risks regression models were used to determine the risk of ESKD with death as a competing risk. RESULTS: 25,455 patients met inclusion criteria and were stratified according to medication group: no antacid therapy (15,961), PPI use (8646), or H2B use (848). At 4 years, the cumulative incidence of ESKD with death as a competing risk was 2.0% (95% CI: 1.7, 2.4), 1.5% (0.8, 2.8), and 1.6%(1.4, 1.9) among PPI, H2B, and no medication respectively (P = 0.22). The cumulative incidence of death with ESKD as a competing risk was 17.6% (95% CI: 16.6, 18.6), 16.7% (13.7, 19.8), and 17.3% (16.6, 18.0) (P = 0.71). CONCLUSIONS: Use of PPI in a CKD population was not associated with increased mortality or progression to ESKD when compared to H2 blocker and to no acid suppressing therapy.

"What do you think about nephrology?" A national survey of internal medicine residents.

BACKGROUND: Interest in nephrology has been declining among internal medicine residents but the reasons behind this observation are not well characterized. Our objective was to evaluate factors influencing residents' choice of subspecialty. METHODS: This is a mixed-method QUAL-QUAN design study that used the results of our previously published qualitative analysis on residents' perception of nephrology to create and pilot a questionnaire of 60 questions. The final questionnaire was distributed to 26 programs across the United States and a total of 1992 residents. We calculated response rates and tabulated participant characteristics and percentage of participant responses. We categorized choice of fellowship into 2 medical categories (Highly Sought After vs. Less Sought After) and fitted a logistic regression model of choosing a highly vs. less sought after fellowship. RESULTS: Four hundred fifteen out of 1992 (21%) US residents responded to the survey. Of the 268 residents planning to pursue fellowship training, 67 (25%) selected a less sought after fellowship. Female sex was associated with significantly higher odds of selecting a less sought after fellowship (OR = 2.64, 95% CI: 1.47, 4.74). Major factors deterring residents from pursuing nephrology were perception of inadequate financial compensation, broad scope of clinical practice and complexity of patient population. We observed a decline in exposure to nephrology during the clinical years of medical school with only 35.4% of respondents rotating in nephrology versus 76.8% in residency. The quality of nephrology education was rated less positively during clinical medical school years (median of 50 on a 0-100 point scale) compared to the pre-clinical years (median 60) and residency (median 75). CONCLUSION: Our study attempts to explain the declining interest in nephrology. Results suggest potential targets for improvement: diversified trainee exposure, sub-specialization of nephrology, and increased involvement of nephrologists in the education of trainees.

Analysis of blood pressure and selected cardiovascular risk factors in the Democratic Republic of the Congo: the May Measurement Month 2018 results.

Hypertension (HT) is the largest contributor to cardiovascular disease mortality and is characterized by high prevalence and low awareness, treatment, and control rates in sub-Saharan Africa. May Measurement Month (MMM) is an international campaign intended to increase awareness of high blood pressure (BP) among the population and advocate for its importance to the health authorities. This study aimed to increase awareness of raised BP in a country where its nationwide prevalence is yet unestablished. Investigators trained and tested how to use the campaign materials, collected participants' demographic data, lifestyle habits, and obtained from each one three BP measurements. Hypertension was defined as a BP ≥140/90 mmHg, or use of antihypertensive medication. Of the 18 719 screened (mean age 41 years; 61.4% men), 26.1% were found to be hypertensive of whom 46.3% were aware of their condition and 29.6% were taking antihypertensive medication. The control rate of HT was 43.0% in those on medication and 12.7% among all hypertensive respondents. Comorbidities found were-diabetes (3.3%), overweight/obesity (35.5%); and a previous stroke and a previous myocardial infarction were reported by 1.2% and 2.0%, respectively. Imputed age- and sex-standardized BP was higher in treated hypertensive individuals (135/85 mmHg) than those not treated (124/78 mmHg). Based on linear regression models adjusted for age and sex (and an interaction) and antihypertensive medication, stroke survivors, those who drank once or more per week (vs. never/rarely), and overweight/obese participants were associated with higher BP. MMM18 results in the Democratic Republic of the Congo corroborated the high prevalence of HT in Kinshasa screenees with low rates of treatment and control. Extension of the MMM campaign to other parts of the country is advisable.

Correction to: Serum magnesium, mortality and disease progression in chronic kidney disease.

Following publication of the original article [1], we have been notified that the name of one author was spelled incorrectly as Georges N. Na khoul, when the correct spelling is Georges N. Nakhoul.

Serum magnesium, mortality and disease progression in chronic kidney disease.

INTRODUCTION: Magnesium disorders are commonly encountered in chronic kidney disease (CKD) and are typically a consequence of decreased kidney function or frequently prescribed medications such as diuretics and proton pump inhibitors. While hypomagnesemia has been linked with increased mortality, the association between elevated magnesium levels and mortality is not clearly defined. Additionally, associations between magnesium disorders, type of death, and CKD progression have not been reported. Therefore, we studied the associations between magnesium levels, CKD progression, mortality, and cause specific deaths in patients with CKD. METHODS: Using the Cleveland Clinic CKD registry, we identified 10,568 patients with estimated Glomerular Filtration Rate (eGFR) between 15 and 59 ml/min/1.73 m2 in this range for a minimum of 3 months with a measured magnesium level. We categorized subjects into 3 groups based on these magnesium levels (≤ 1.7, 1.7-2.6 and > 2.6 mg/dl) and applied cox regression modeling and competing risk models to identify associations with overall and cause-specific mortality. We also evaluated the association between magnesium level and slope of eGFR using mixed models. RESULTS: During a median follow-up of 3.7 years, 4656 (44%) patients died. After adjusting for relevant covariates, a magnesium level < 1.7 mg/dl (vs. 1.7-2.6 mg/dl) was associated with higher overall mortality (HR = 1.14, 95% CI: 1.04, 1.24), and with higher sub-distribution hazards for non-cardiovascular non-malignancy mortality (HR = 1.29, 95% CI: 1.12, 1.49). Magnesium levels > 2.6 mg/dl (vs. 1.7-2.6 mg/dl) was associated with a higher risk of all-cause death only (HR = 1.23, 95% CI: 1.03, 1.48). We found similar results when evaluating magnesium as a continuous measure. There were no significant differences in the slope of eGFR across all three magnesium groups (p = 0.10). CONCLUSIONS: In patients with CKD stage 3 and 4, hypomagnesemia was associated with higher all-cause and non-cardiovascular non-malignancy mortality. Hypermagnesemia was associated with higher all-cause mortality. Neither hypo nor hypermagnesemia were associated with an increased risk of CKD progression.