Cardiovascular implantable electronic device leads in CKD and ESRD patients: review and recommendations for practice.

Cardiovascular implantable electronic devices (CIEDs) are frequently utilized for management of cardiac dysrhythmias in patients with chronic kidney disease or end-stage renal disease receiving hemodialysis. The survival benefit from use of implantable cardioverter defibrillators in patients with CKD or ESRD is not as clear as in the general population, particularly when used for primary prevention of sudden cardiac death. Transvenous CIED leads are associated with central vein stenosis resulting in significant adverse consequences for existing or future arteriovenous access. Venous hypertension from CIED lead-related central vein stenosis is a challenging clinical problem and may require repeated percutaneous interventions, replacement of the CIED, or creation of alternative arteriovenous access. Infections associated with transvenous CIED leads are more frequent and associated with worse outcomes in patients with renal disease. Epicardial CIED leads or other nontransvenous devices may reduce complications of both central venous stenosis and endovascular infection in these vulnerable patients. Consensus recommendations are offered for avoidance and management of complications arising from the use of CIEDs and arteriovenous hemodialysis access.

Homomorphic-Encrypted Volume Rendering.

Computationally demanding tasks are typically calculated in dedicated data centers, and real-time visualizations also follow this trend. Some rendering tasks, however, require the highest level of confidentiality so that no other party, besides the owner, can read or see the sensitive data. Here we present a direct volume rendering approach that performs volume rendering directly on encrypted volume data by using the homomorphic Paillier encryption algorithm. This approach ensures that the volume data and rendered image are uninterpretable to the rendering server. Our volume rendering pipeline introduces novel approaches for encrypted-data compositing, interpolation, and opacity modulation, as well as simple transfer function design, where each of these routines maintains the highest level of privacy. We present performance and memory overhead analysis that is associated with our privacy-preserving scheme. Our approach is open and secure by design, as opposed to secure through obscurity. Owners of the data only have to keep their secure key confidential to guarantee the privacy of their volume data and the rendered images. Our work is, to our knowledge, the first privacy-preserving remote volume-rendering approach that does not require that any server involved be trustworthy; even in cases when the server is compromised, no sensitive data will be leaked to a foreign party.

Intravascular ultrasound imaging for the optimization of dialysis access interventions.

Intravascular ultrasound allows for detailed imaging of the dialysis access anatomy. Accurate visualization and precise measurements of the anatomy can be obtained using intravascular ultrasound, while limiting contrast usage and radiation exposure. Intravascular ultrasound allows for a true appreciation of stenosis morphology and can further guide endovascular management decisions, with a particular benefit in management of central venous lesions. Here, we describe a series of cases that together highlight the advantages of using intravascular ultrasound in the evaluation and management of dialysis access care.

Advances in Endovascular Salvage.

Endovascular salvage plays an important role in dialysis access care. Angioplasty using standard high- and ultrahigh-pressure balloon is the mainstay of therapy, while the use of cutting balloons and balloons designed to deliver pharmacologically active agents to the site of recurrent stenosis is demonstrating improved performance for specific targets that have to be further defined. Stents and stent grafts are additional tools for use at access segments predisposed for inward remodeling such as the cephalic arch or basilic swing point. The juxta-anastomotic segment has particular relevance in maturation of autogenous accesses as well as maintenance of access flow volume. Depending on the location of the access in the forearm or upper arm, and which artery is feeding into the access vein, any type of balloon angioplasty and stent or stent graft placement may be used to establish and maintain patency. Successful management of dialysis access options relies on preservation of venous real estate during the chronic kidney disease phase of kidney disease as well as on knowledgeable evaluation of arm veins and the access by physical examination, bed side ultrasound, and angiographic studies.

The seismic analyzer: interpreting and illustrating 2D seismic data.

We present a toolbox for quickly interpreting and illustrating 2D slices of seismic volumetric reflection data. Searching for oil and gas involves creating a structural overview of seismic reflection data to identify hydrocarbon reservoirs. We improve the search of seismic structures by precalculating the horizon structures of the seismic data prior to interpretation. We improve the annotation of seismic structures by applying novel illustrative rendering algorithms tailored to seismic data, such as deformed texturing and line and texture transfer functions. The illustrative rendering results in multi-attribute and scale invariant visualizations where features are represented clearly in both highly zoomed in and zoomed out views. Thumbnail views in combination with interactive appearance control allows for a quick overview of the data before detailed interpretation takes place. These techniques help reduce the work of seismic illustrators and interpreters.

Principles of treating enlarging pseudoaneurysm in a dialysis arteriovenous graft.

The arteriovenous graft (AVG) is one of the major types of permanent vascular access used to provide hemodialysis. Complications encountered with AVG use include stenosis, infection, thrombosis, and pseudoaneurysm formation. Venous outflow stenosis along with frequent needle cannulation at the same site can lead to breakdown of the graft material, resulting in pseudoaneurysm formation. In the following case, we illustrate common management principles used to treat pseudoaneurysms. While stent-grafts have been utilized for pseudoaneurysm repair, stent-graft usage is not always optimal. Surgical management may be an ideal choice of treatment. The role of educating the dialysis staff and patients is essential to identify and minimize the risk of pseudoaneurysm formation.

A virtual reality solution for evaluation of radiotherapy plans.

This report presents a VR system for evaluation of treatment plans used in radiotherapy (RT), developed to improve the understanding of the spatial relationships between the patient anatomy and the calculated dose distribution. The VR system offers visualization through interactive volume rendering of RT dose distribution and computed tomography (CT) and surface and line rendering of RT structures such as target volumes and organs at risk. The VR system has been installed and networked in a hospital room used for the daily RT conferences, making stereoscopic viewing of treatment planning data for clinical cases possible.

Barriers to successful care for chronic kidney disease.

BACKGROUND: The National Kidney Foundation has formulated clinical practice guidelines for patients with chronic kidney disease (K/DOQI). However, little is know about how many patients actually achieve these goals in a dedicated clinic for chronic kidney disease. METHODS: We performed a cross-sectional analysis of 198 patients with an estimated glomerular filtration rate of less than 30 ml/min/1.73 m2 and determined whether K/DOQI goals were met for calcium, phosphate, calcium-phosphate product, parathyroid hormone, albumin, bicarbonate, hemoglobin, lipids, and blood pressure. RESULTS: We found that only a small number of patients achieved K/DOQI targets. Recent referral to the nephrologist, failure to attend scheduled clinic appointments, African American ethnicity, diabetes, and advanced renal failure were significant predictors of low achievement of K/DOQI goals. CONCLUSION: We conclude that raising awareness of chronic kidney disease and K/DOQI goals among primary care providers, early referral to a nephrologist, the exploration of socioeconomic barriers and cultural differences, and both patient and physician education are critical to improve CKD care in patients with Stage 4 and 5 CKD.