Vaccination for Patients Receiving Dialysis.

Vaccinating patients receiving dialysis may prevent morbidity and mortality in this vulnerable population. The National Forum of End-Stage Renal Disease Networks (the Forum) published a revised vaccination toolkit in 2021 to update evidence and recommendations on vaccination for patients receiving dialysis. Significant changes in the last 10 years include more data supporting the use of a high-dose influenza vaccine, the introduction of the Heplisav-B vaccine for hepatitis B, and changes in pneumococcal vaccines, including the approval of the PCV15 and PCV20 to replace the PCV13 and PPSV23 vaccines. Additional key items include the introduction of vaccines against severe acute respiratory syndrome coronavirus 2, the virus that causes coronavirus disease 2019 (COVID-19), and a new vaccine to prevent respiratory syncytial virus disease. Historically, influenza and pneumococcal vaccinations were routinely administered by dialysis facilities, and because of possible risks of hematogenous spread of hepatitis B, dialysis providers often have detailed hepatitis B vaccine protocols. In March 2021, COVID-19 vaccines were made available for dialysis facilities to administer, although with the end of the public health emergency, vaccine policies by dialysis facilities against COVID-19 remains uncertain. The respiratory syncytial virus vaccine was authorized in 2023, and how dialysis facilities will approach this vaccine also remains uncertain. This review summarizes the Forum's vaccination toolkit and discusses the role of the dialysis facility in vaccinating patients to reduce the risk of severe infections.

Clinical utility of gene-expression profiling for tumor-site origin in patients with metastatic or poorly differentiated cancer: impact on diagnosis, treatment, and survival.

PURPOSE: The primary tissue-site origin in over 4% of cancers remains uncertain despite thorough clinicopathological evaluation. This study assessed the effect of a Food and Drug Administration-cleared 2,000- gene-expression-profiling (GEP) test on primary tissue-site working diagnoses and management for metastatic and poorly differentiated cancers. METHODS: Clinical information was collected from physicians ordering the GEP test for patients with difficult to diagnose cancers. Endpoints included diagnostic procedures, physicians' working diagnoses and treatment recommendations before and after GEP result availability, and physician reports of the test's usefulness for clinical decision making. Patient date of death was obtained, with a minimum of one year follow-up from date of biopsy. RESULTS: Sixty-five physicians participated in the study (n=107 patients). Before GEP, patients underwent 3.2 investigations on average (e.g., radiology, endoscopy). Ten immunohistochemistry tests were used per biopsy (SD 5.2). After GEP testing, physicians changed the primary working diagnosis for 50% of patients (95% CI: 43%,58%) and management for 65% of patients (95% CI: 58%,73%). With GEP results, the recommendation for guideline-consistent chemotherapy increased from 42% to 65% of patients, and the recommendation for non-guideline-consistent regimens declined from 28% to 13%. At last follow-up, 69 patients had died, and median survival was 14.0 months (95% CI: 10.2,18.6). Thirty-three percent of patients were alive at 2 years. CONCLUSION: In patients with difficult-to-diagnose cancers, GEP changed the working diagnosis and management for the majority of patients. Patients for whom the GEP test was ordered had longer median survival than that historically reported for patients enrolled in treatment trials for cancer of unknown primary.

Is specific gravity a good estimate of urine osmolality?

CONTEXT: Urine specific gravity (USG) is often used by clinicians to estimate urine osmolality. USG is measured either by refractometry or by reagent strip. OBJECTIVE: We studied the correlation of USG obtained by either method with a concurrently obtained osmolality. DESIGN: Using our laboratory's records, we retrospectively gathered data on 504 urine specimens on patients on whom a simultaneously drawn USG and an osmolality were available. Out of these, 253 USG's were measured by automated refractometry and 251 USG's were measured by reagent strip. Urinalysis data on these subjects were used to determine the correlation between USG and osmolality, adjusting for other variables that may impact the relationship. The other variables considered were pH, protein, glucose, ketones, nitrates, bilirubin, urobilinogen, hemoglobin, and leukocyte esterase. The relationships were analyzed by linear regression. RESULTS: This study demonstrated that USG obtained by both reagent strip and refractometry had a correlation of approximately 0.75 with urine osmolality. The variables affecting the correlation included pH, ketones, bilirubin, urobilinogen, glucose, and protein for the reagent strip and ketones, bilirubin, and hemoglobin for the refractometry method. At a pH of 7 and with an USG of 1.010 predicted osmolality is approximately 300 mosm/kg/H(2)O for either method. For an increase in SG of 0.010, predicted osmolality increases by 182 mosm/kg/H(2) O for the reagent strip and 203 mosm/kg/H(2)O for refractometry. Pathological urines had significantly poorer correlation between USG and osmolality than "clean" urines. CONCLUSION: In pathological urines, direct measurement of urine osmolality should be used.

Acid-base effects on intestinal Cl- absorption and vesicular trafficking.

In rat ileum and colon, apical membrane Cl(-)/HCO(3)(-) exchange and net Cl(-) absorption are stimulated by increases in Pco(2) or [HCO(3)(-)]. Because changes in Pco(2) stimulate colonic Na(+) absorption, in part, by modulating vesicular trafficking of the Na(+)/H(+) exchanger type 3 isoform to and from the apical membrane, we examined whether changes in Pco(2) affect net Cl(-) absorption by modulating vesicular trafficking of the Cl(-)/HCO(3)(-) exchanger anion exchanger (AE)1. Cl(-) transport across rat distal ileum and colon was measured in the Ussing chamber, and apical membrane protein biotinylation of these segments and Western blots of recovered proteins were performed. In colonic epithelial apical membranes, AE1 protein content was greater at Pco(2) 70 mmHg than at Pco(2) 21 mmHg but was not affected by pH changes in the absence of CO(2). AE1 was internalized when Pco(2) was reduced and exocytosed when Pco(2) was increased, and both mucosal wortmannin and methazolamide inhibited exocytosis. Wortmannin also inhibited the increase in colonic Cl(-) absorption caused by an increase in Pco(2). Increases in Pco(2) stimulated ileal Cl(-) absorption, but wortmannin was without effect. Ileal epithelial apical membrane AE1 content was not affected by Pco(2). We conclude that CO(2) modulation of colonic, but not ileal, Cl(-) absorption involves effects on vesicular trafficking of AE1.