Incident chronic kidney disease: trends in management and outcomes.

BACKGROUND: Management trends in early chronic kidney disease (CKD) and their associations with clinical outcomes have not previously been reported. METHODS: We evaluated incident (Stage G3A) CKD patients from an integrated health care system in 2004-06, 2007-09 and 2010-12 to determine adjusted trends in screening (urinary protein quantification), treatment [prescription for angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB), and statin] and nephrology referral. For the same time periods, adjusted rates for mortality, progression to Stage G4 CKD and hospitalization for myocardial infarction or heart failure were calculated and compared across time periods. RESULTS: There were 728, 788 and 956 patients with incident CKD in 2004-06, 2007-09 and 2010-12, respectively. Adjusted rates of proteinuria quantification (31, 39 and 51 screens/100 person-years), statin prescription (53, 63 and 64 prescriptions/100 person-years) and nephrology referral (2, 3 and 5 referrals/100 person-years) all increased over time (P for trend <0.001 in all cases). ACEI/ARB prescription rates did not change (88, 83 and 80 prescriptions/100 person-years, P = 0.68). Adjusted death rates (7, 5 and 6 deaths/100 person-years), CKD progression (9, 10 and 7 progressors/100 person-years) and cardiovascular hospitalization (10, 8 and 9 hospitalizations per 100/person-years) did not change (P for trend >0.4 in all cases). CONCLUSION: In this integrated health care system, management of incident CKD over the past decade has intensified.

The history and evolution of circulatory shock.

This article reviews the development of early ideas regarding the origins and pathogenesis of shock. The early history of shock is related primarily to traumatic shock. More recent history centers on differentiation of clinical syndromes and individual characteristics. Definitions, classification systems, pathogenic theories, and treatments have evolved. Progress has been aided by constant development of improved assessment technologies. Today, shock is not a single syndrome and the definition of shock no longer is descriptive in nature. The most accepted current definition involves an oxygen supply/demand imbalance that can have various causes-hypovolemia, cardiac dysfunction, vascular failure, or obstructive processes.

A history of pulmonary embolism and deep venous thrombosis.

Although enormous progress has been made in understanding the physiology of pulmonary embolism, developing new diagnostic modalities and strategies, and constant refinement in the use of heparin therapy and thrombolytic therapy, venous thromboembolism remains a common and lethal process. As the history of this disease illustrates, advances continue to be made and it is anticipated that with newer diagnostic studies and anticoagulants under development, diagnosis and treatment of pulmonary embolism will continue to improve.

Paradoxical air embolism successfully treated with hyperbaric oxygen.

The use of the central venous catheter may be complicated by air embolism when central venous pressure is subatmospheric and the catheter is open to the surrounding air. Paradoxical air embolus occurs when the gas bubbles are able to traverse a right to left shunt, gaining access to the systemic arterial circulation causing ischemic symptoms in end organs. In this article, a case of a patient with an unknown patent foramen ovale through which air entered the arterial circulation resulting in obtundation and stroke after inadvertent manipulation of a Hickman catheter is presented. The physiology, clinical manifestations, and management strategies are also discussed.