The Nutritional Risk Index as a Predictor of 90-Day Dialysis Dependence After Acute Renal Failure: A Pilot Study.

OBJECTIVE: Return of sufficient renal function to discontinue dialysis following acute renal failure is an important clinical and patient-oriented outcome. Our study sought to develop a model using the Nutritional Risk Index (NRI) to predict 90-day dialysis dependence. METHODS: We retrospectively analyzed 77 patients with acute renal failure admitted to a single university medical center's intensive care units between January 2015 and January 2019 with the need for continuous renal replacement therapy. We assessed the predictive ability of the NRI for 90-day dialysis dependence using age, serum total protein, number of vasopressor days, baseline predialysis estimated glomerular filtration rate (eGFR), and Sequential Organ Failure Assessment (SOFA) score as covariates. RESULTS: Of the analytic group, 20 (25.9%) had severe nutritional risk, and 16 (20.8%) recovered from acute renal failure at 90 days. The mean age was 57.1 years. The clinical model comprising the NRI, age, serum total protein, number of vasopressor days, SOFA score, and baseline predialysis eGFR had an area under the curve (AUC) of 0.89 (95% confidence interval [CI], 0.81-0.97), sensitivity 56.3%, and specificity 95%. Exclusion of baseline predialysis eGFR and SOFA score did not significantly decrease model discrimination, AUC 0.87 (95% CI, 0.78-0.97). The AUC was least when serum total protein was dropped from the final model, 0.79 (95% CI, 0.66-0.92). CONCLUSIONS: The NRI when used together with other clinical parameters, including serum total protein, may improve the accuracy of predicting renal recovery and independence from dialysis at 90 days.

Lack of an Association Between Household Air Pollution Exposure and Previous Pulmonary Tuberculosis.

CONTEXT: Observational studies investigating household air pollution (HAP) exposure to biomass fuel smoke as a risk factor for pulmonary tuberculosis have reported inconsistent results. OBJECTIVE: To evaluate the association between HAP exposure and the prevalence of self-reported previous pulmonary tuberculosis. DESIGN: We analyzed pooled data including 12,592 individuals from five population-based studies conducted in Latin America, East Africa, and Southeast Asia from 2010 to 2015. We used multivariable logistic regression to model the association between HAP exposure and self-reported previous pulmonary tuberculosis adjusted for age, sex, tobacco smoking, body mass index, secondary education, site and country of residence. RESULTS: Mean age was 54.6 years (range of mean age across settings 43.8-59.6 years) and 48.6% were women (range of % women 38.3-54.5%). The proportion of participants reporting HAP exposure was 38.8% (range in % HAP exposure 0.48-99.4%). Prevalence of previous pulmonary tuberculosis was 2.7% (range of prevalence 0.6-6.9%). While participants with previous pulmonary tuberculosis had a lower pre-bronchodilator FEV1 (mean - 0.7 SDs, 95% CI - 0.92 to - 0.57), FVC (- 0.52 SDs, 95% CI - 0.69 to - 0.33) and FEV1/FVC (- 0.59 SDs, 95% CI - 0.76 to - 0.43) as compared to those who did not, we did not find an association between HAP exposure and previous pulmonary tuberculosis (adjusted odds ratio = 0.86; 95% CI 0.56-1.32). CONCLUSIONS: There was no association between HAP exposure and self-reported previous pulmonary tuberculosis in five population-based studies conducted worldwide.

"Allow Natural Death" versus "Do Not Resuscitate": What Do Patients with Advanced Cancer Choose?

BACKGROUND: Many patients with advanced cancer at our hospital request full resuscitative efforts at the end of life. We assessed the knowledge and attitudes of these patients towards end-of-life (EOL) care, and their preferences about "Do Not Resuscitate" (DNR), "Allow Natural Death" (AND), and "full code" orders. METHODS: The first 100 consenting adult patients with advanced cancer were surveyed regarding their diagnosis, prognosis, and attitudes about critical care and resuscitation. They were then presented with hypothetical scenarios in which a decision on their code status had to be made if they had one year, six months, or one month left to live. Half were given a choice between being "full code" and "DNR," and half could choose between "full code" and "AND." RESULTS: All 93 of the participants who completed the survey were considered by their attending physician to have a terminal illness, but only 42% of these interviewees believed they were terminally ill. In addition, only 25% of participants thought that their primary oncologist knew their EOL wishes. Participants were equally likely to choose either of the "no code" options in all hypothetical scenarios (p>0.54), regardless of age, sex, race, type of cancer, education, or income level. A similar proportion of patients who had a living will chose "AND" and "DNR" orders instead of "full code" in all the scenarios (47%-74% and 63%-71%). In contrast, among patients who did not have a living will, 52% chose "DNR," while 19% opted for "AND." CONCLUSIONS: We hypothesized that "AND" orders may be more acceptable to patients with advanced cancer, but there was no statistically significant difference in acceptability between "AND" and "DNR" orders.

Pancreatic cysts: a systematic approach and second look.

BACKGROUND: Pancreatic cysts are relatively rare, but constitute an important disease entity that poses a challenge with clinical, radiological, and pathological differential diagnosis. METHODS: New attention has been drawn to pancreatic cysts given their potential cure rates with resection. However, preoperative distinction between neoplastic and benign lesions needs further study for effective strategies in identification and management. The role and safety of cystic fluid analysis remains to be clarified in this context. RESULTS: The presence of mural nodules is a significant indicator for malignancy; however, size as a reliable predictor remains controversial. Specific criteria are required with particular focus on the histologic subtype of pancreatic lesions. CONCLUSION: We review recent developments in the understanding and management of cystic lesions of the pancreas.