Conservative Kidney Management: When, Why, and For Whom?

Deciding between dialysis and conservative kidney management (CKM) in an elderly or seriously ill person with kidney failure is complex and requires shared decision making. Patients and families look to their nephrologist to provide an individualized recommendation that aligns with patient-centered goals. For a balanced and considered decision to be made, dialysis should not be the default and nephrologists need to be familiar with relevant prognostic information including survival, symptom burden, functional trajectory, and quality of life with dialysis and with CKM. CKM is a holistic, proactive, and multidisciplinary treatment for kidney failure. For some elderly comorbid patients, CKM improves symptom burden and aligns with quality-of-life goals, with modest or no loss of longevity. CKM can be provided by a nephrologist alone but ideally is managed through partnership with a dedicated supportive or palliative care service embedded within the nephrology practice. Treatment decisions are best discussed early in the disease trajectory and occur over many consultations, and nephrologists should be upskilled in communication to better support patients and families in these important conversations. Nephrologists should remain actively involved in their patients' care through to end-of-life care.

Survival of Older Patients With Advanced CKD Managed Without Dialysis: A Narrative Review.

Shared decision making is important when deciding the appropriateness of dialysis for any individual, particularly for older patients with advanced chronic kidney disease who have high mortality. Emerging evidence suggests that patients with advanced age, high comorbidity burden, and poor functional status may not have any survival advantage on dialysis compared with those on a conservative kidney management pathway. The purpose of this narrative review is to summarize the existing studies on the survival of older patients with stage 4 or 5 chronic kidney disease managed with or without dialysis and to evaluate the factors that may influence mortality in an effort to assist clinicians with shared decision making. Median survival estimates of conservative kidney management patients are widely varied, ranging from 1-45 months with 1-year survival rates of 29%-82%, making it challenging to provide consistent advice to patients. In existing cohort studies, the selected group of patients on dialysis generally survives longer than the conservative kidney management cohort. However, in patients with advanced age (aged ≥80 years), high comorbidity burden, and poor functional status, the survival benefit conferred by dialysis is no longer present. There is an overall paucity of data, and the variability in outcomes reflect the heterogeneity of the existing studies; further prospective studies are urgently needed.

Microguided endodontics: Accuracy evaluation for access through intraroot fibre-post.

In this work, we intended to assess the reliability of guided endodontic technique to remove a bonded fibre-post when there are artefacts in the cone-beam computed tomography (CBCT) images caused by composite dental materials. We mounted natural posterior teeth on ten simulated models. Forty fibre-post and composite-core restorations were inserted in the teeth. We merged a pre-operative CBCT and optical surface scan on the BlueskyplanTM software to digitally design and subsequently 3D-printed the guides. Two operators initiated endodontic access into the fibre-post restorations using the template to guide the drill. Post-operative CBCT was taken and merged onto the pre-operative plan to measure the deviations at the coronal and apical segments. The mean deviation between the planned and actual drill paths were, respectively, of 0.39 ± 0.14 mm coronally and 0.40 ± 0.19 mm apically. Microguided endodontics is a predictable and accurate method to remove fibre-post restorations efficiently.

The Legal Doctrine of Informed Consent and Renal Dialysis - Do Patients Really Consent?

A doctor has a legal duty to secure the informed consent of a patient prior to performing a medical or surgical procedure. The elements of the legal doctrine of informed consent include capacity, voluntariness and the provision and understanding of relevant information. This article examines the doctrine in the context of renal dialysis. Dialysis is a complex therapy that impacts upon quality of life and has limited survival advantage in some patients. It is likely that informed consent is often not fully integrated into the care of patients commencing dialysis. The article analyses the common law doctrine of informed consent as it relates to dialysis and presents the findings of a retrospective study of the adequacy of the consent process based on interviews with dialysis patients who commenced dialysis in the previous 12 months. It concludes with recommendations for improvement in practice.

Incidence of tension pneumothorax in police officers feloniously killed in the line of duty: a ten-year retrospective analysis.

BACKGROUND: According to US military data, tension pneumothorax (TPx) is the second leading cause of possibly preventable combat death after isolated extremity hemorrhage. The purpose of this study was to determine whether TPx similarly represents a significant cause of possibly preventable death in police officers. METHODS: FBI data for the years 1998 through 2007 were reviewed. Cases were included if officers were on-duty at the time of fatal injury, and died within one hour from time of wounding from penetrating torso trauma. After case identification, letters were sent to the departments of victim officers requesting autopsy reports. RESULTS: One hundred and eight victim officers met inclusion criteria. Four charts were excluded due to inability to re-identify officers. Departmental response rate was 83.7%. Autopsy reports were provided for 60 officers (57.7%). All officers died from gunshot wounds. No coroner specifically identified TPx as either a direct cause of death or a contributing factor (95% CI, 0.00%-5.96%). CONCLUSION: In contrast to the military experience, TPx appears to be a rare cause of possibly preventable death in police officers. Further study of non-fatal "near miss" events will be required to determine the actual need for law enforcement-specific medical training in the recognition and management of TPx.

How to attract a nephrology trainee: quantitative questionnaire results.

AIM: Global health workforce shortages are being experienced across many specialties. Australia faces a nephrology workforce shortage coupled with increased demand for nephrology services. This study examines issues impacting on the choice of nephrology as a career and identifies factors that can be modified to improve trainee recruitment. This study provides evidence to inform those seeking to address nephrology, and by extrapolation, other specialty workforce shortages. METHODS: In Australia in 2005, a mailed self-administered questionnaire was sent to all basic physician trainees eligible for the clinical component of the Royal Australasian College of Physicians' examination. Trainees were asked about the main influences on career choice; including perceived motivators and detractors surrounding a career in nephrology. RESULTS: Of the 531 doctors surveyed, 222 (42%) responded. Younger respondents and those with previous nephrology experience were more likely to consider nephrology. Perceptions deterring respondents from considering nephrology included inflexible work hours, an absence of positive role models, the perceived restriction of the subspecialty to a hospital-based practice and poor remuneration relative to other specialties. CONCLUSION: Exposure to a nephrology term in early postgraduate years is an important factor in a decision to undertake nephrology training. During these rotations; trainees need to experience positive role modelling. Effective trainee recruitment strategies should utilize the positive influence of role models, and must consider restructuring workforce and training activities to improve work hour flexibility and remuneration. Negative perceptions, acting as barriers to the pursuit of a career in nephrology, must be addressed and any misinformation corrected.