Coupling Sr-Nd-Hf Isotope Ratios and Elemental Analysis to Accurately Quantify North African Dust Contributions to PM2.5 in a Complex Urban Atmosphere by Reducing Mineral Dust Collinearity.

Tracking Saharan-Sahelian dust across the globe is essential to elucidate its effects on Earth's climate, radiation budget, hydrologic cycle, nutrient cycling, and also human health when it seasonally enters populated/industrialized regions of Africa, Europe, and North America. However, the elemental composition of mineral dust arising locally from construction activities and aeolian soil resuspension overlaps with African dust. Therefore, we derived a novel "isotope-resolved chemical mass balance" (IRCMB) method by employing radiogenic strontium, neodymium, and hafnium isotopes to accurately differentiate and quantitatively apportion collinear proximal and synoptic-scale crustal and anthropogenic mineral dust sources. IRCMB was applied to two air masses that transported African dust to Barbados and Texas to track particulate matter (PM) spikes at both locations. During Saharan-Sahelian intrusions, the radiogenic content of urban PM2.5 increased with respect to 87Sr/86Sr and 176Hf/177Hf but decreased in terms of 143Nd/144Nd, demonstrating the ability of these isotopes to sensitively track African dust intrusions even in complex metropolitan atmospheres. The principal aerosol strontium, neodymium, and hafnium end members were concrete dust and soil, soil and motor vehicles, and motor vehicles and North African dust, respectively. IRCMB separated and quantified local soil and distal crustal dust even when PM2.5 concentrations were low, opening a promising source apportionment avenue for urbanized/industrialized atmospheres.

Pharmacogenomics of Hypertension in CKD: The CKD-PGX Study.

Background: Patients with CKD often have uncontrolled hypertension despite polypharmacy. Pharmacogenomic drug-gene interactions (DGIs) may affect the metabolism or efficacy of antihypertensive agents. We report changes in hypertension control after providing a panel of 11 pharmacogenomic predictors of antihypertensive response. Methods: A prospective cohort with CKD and hypertension was followed to assess feasibility of pharmacogenomic testing implementation, self-reported provider utilization, and BP control. The analysis population included 382 subjects with hypertension who were genotyped for cross-sectional assessment of DGIs, and 335 subjects followed for 1 year to assess systolic BP (SBP) and diastolic BP (DBP). Results: Most participants (58%) with uncontrolled hypertension had a DGI reducing the efficacy of one or more antihypertensive agents. Subjects with a DGI had 1.85-fold (95% CI, 1.2- to 2.8-fold) higher odds of uncontrolled hypertension, as compared with those without a DGI, adjusted for race, health system (safety-net hospital versus other locations), and advanced CKD (eGFR <30 ml/min). CYP2C9-reduced metabolism genotypes were associated with losartan response and uncontrolled hypertension (odds ratio [OR], 5.2; 95% CI, 1.9 to 14.7). CYP2D6-intermediate or -poor metabolizers had less frequent uncontrolled hypertension compared with normal metabolizers taking metoprolol or carvedilol (OR, 0.55; 95% CI, 0.3 to 0.95). In 335 subjects completing 1-year follow-up, SBP (-4.0 mm Hg; 95% CI, 1.6 to 6.5 mm Hg) and DBP (-3.3 mm Hg; 95% CI, 2.0 to 4.6 mm Hg) were improved. No significant difference in SBP or DBP change were found between individuals with and without a DGI. Conclusions: There is a potential role for the addition of pharmacogenomic testing to optimize antihypertensive regimens in patients with CKD.

Sr-Nd-Hf isotopic analysis of reference materials and natural and anthropogenic particulate matter sources: Implications for accurately tracing North African dust in complex urban atmospheres.

We present novel chemical separation protocols for isotopic analysis of low mass aliquots (0.3 mg and 25 mg) of several reference materials and real-world samples of relevance to urban airborne particulate matter (PM) investigations. A high-yielding gravity flow column chromatography scheme was developed for facile and quantitative separation of Sr, Nd, and Hf prior to multi collector - inductively coupled plasma - mass spectrometry (MC-ICP-MS). Because we are interested in isolating and accurately quantitating individual anthropogenic and natural aerosol sources in complex industrial/metropolitan atmospheric environments, laboratory protocols were optimized using National Institute of Standards and Technology Standard Reference Material (SRM) 1648a (urban atmospheric PM), SRM 1633b (coal fly ash), and European Commission standards BCR-723 (vehicular road dust), and BCR-2 (basalt rock standard). Sr, Nd, and Hf procedural blanks from column chromatography were low (averaging only 37 pg, 17 pg, 11 pg, respectively) and recoveries were high (averaging 95%, 82%, and 92%, respectively). A volume-adjustment protocol was established using isotope reference solutions SRM 987 (SrCO3), JNdi (Nd2O3), and in-house Hf standards to dilute the dried samples prior to MC-ICP-MS based on projected uncertainties for low sample masses. 87Sr/86Sr, 143Nd/144Nd, and 176Hf/177Hf isotopic ratios in SRM 1648a, BCR-723, and SRM 1633b are reported for the first time that can serve as provisional reference values. The novel method was used to characterize isotopic ratios and elemental abundances in two anthropogenic urban aerosol sources, namely motor vehicles and petroleum refining using airborne fine PM collected in a vehicular tunnel and fluidized-bed catalytic cracking catalysts, respectively. Two other important mineral-rich urban PM sources, namely soil (i.e., resuspended crustal material) and concrete/cement dust (i.e., construction activity) were also characterized. These are the first isotopic measurements in these environmental compartments and were compared with literature data for long-range transported North African dust, which is a prominent summertime PM source in urban regions in southeastern United States. We demonstrate the capability of coupled Sr-Nd-Hf isotopes to uniquely trace different mineral dust sources with overlapping elemental composition (Sahara-Sahel region, local soil, and concrete/cement) and accurately isolate various urban PM sources demonstrating the superiority of isotopic markers over elemental tracers.

Reconciling the Current Status of Home Hemodialysis With the 2019 Executive Order-Realistic or Obtainable?

The Advancing American Kidney Health Initiative places financial incentives largely aimed at nephrologists and dialysis providers, but including other health care providers, in an attempt to improve clinical outcomes and lower costs in the chronic kidney disease population. Both peritoneal and home hemodialysis utilization will need to be markedly increased to achieve these policy goals. This article looks at some of the concerns that may stand in the way of achieving those goals.

Perceptions of Home Dialysis Training and Experience Among US Nephrology Fellows.

RATIONALE & OBJECTIVE: Prior research suggests a lack of confidence among graduating US nephrology trainees in implementing both peritoneal dialysis (PD) and home hemodialysis (HHD). Gaps in fellowship training may represent an obstacle to achieving the Advancing American Kidney Health Initiative's goal of increasing the use of home dialysis. We sought to identify the strengths of and limitations in home dialysis training. DESIGN: A cross-sectional study surveying nephrology trainees regarding their confidence with home dialysis management and perceptions of home dialysis educational resources provided by their training program. SETTING & PARTICIPANTS: A paper survey was distributed to 110 nephrology trainees with at least 1 year of nephrology fellowship training who attended any 1 of 3 home dialysis conferences. ANALYTICAL APPROACH: Data were summarized as percentages. χ2, Fisher exact, and Kruskal-Wallis rank sum tests were used for statistical analysis. OUTCOME: Self-perception of readiness to manage PD and HHD patients. RESULTS: 76 of 110 (66%) attendees completed the survey. Most respondents were moderately confident regarding principles of PD. However, only 3% had initiated patients on "urgent-start PD" and 11% observed a PD catheter insertion. The level of confidence for HHD was low. Most trainees attended a home dialysis continuity clinic with mentorship from faculty. LIMITATIONS: A small number of participants and the inability to verify respondent-provided data for the number of PD and HHD patients seen and clinics attended. Potential lack of generalizability owing to inclusion of only trainees who attended a home dialysis conference. CONCLUSIONS: Nephrology trainees perceive low and moderate levels of preparedness for managing HHD and PD, respectively. Educational innovation and optimization of resources at both the institutional and national levels may improve confidence and promote public policy goals regarding home dialysis therapies.

Apical Sparing Pattern of Longitudinal Strain and Positive Bone Scintigraphy in Metastatic Myocardial Calcification.

An apical sparing pattern of longitudinal strain and positive radionuclide bone scintigraphy are believed to be specific for the diagnosis of transthyretin cardiac amyloidosis. We report on a young woman with apical sparing of longitudinal strain and positive bone scintigraphy who was found to have metastatic myocardial calcification at autopsy. (Level of Difficulty: Intermediate.).

A Systematic Approach To Promoting Home Hemodialysis during End Stage Kidney Disease.

Home dialysis has garnered much attention since the advent of the Advancing American Kidney Health initiative. For many patients and nephrologists, home dialysis and peritoneal dialysis are synonymous. However, home hemodialysis (HHD) should not be forgotten. Since 2004, HHD has grown more rapidly than other dialytic modalities. The cardinal feature of HHD is customizability of treatment intensity, which can be titrated to address the vexing problems of volume and pressure loading during interdialytic gaps and ultrafiltration intensity during each hemodialysis session. Growing HHD utilization requires commitment to introducing patients to the modality throughout the course of ESKD. In this article, we describe a set of strategies for introducing HHD concepts and equipment. First, patients initiating dialysis may attend a transitional care unit, which offers an educational program about all dialytic modalities during 3-5 weeks of in-facility hemodialysis, possibly using HHD equipment. Second, prevalent patients on hemodialysis may participate in "trial-run" programs, which allow patients to experience increased treatment frequency and HHD equipment for several weeks, but without the overt commitment of initiating HHD training. In both models, perceived barriers to HHD-including fear of equipment, anxiety about self-cannulation, catheter dependence, and the absence of a care partner-can be addressed in a supportive setting. Third, patients on peritoneal dialysis who are nearing a transition to hemodialysis may be encouraged to consider a home-to-home transition (i.e., from peritoneal dialysis to HHD). Taken together, these strategies represent a systematic approach to growing HHD utilization in multiple phenotypes of patients on dialysis. With the feature of facilitating intensive hemodialysis, HHD can be a key not only to satiating demand for home dialysis, but also to improving the health of patients on dialysis.

Thermodynamic Integration and Steppingstone Sampling Methods for Estimating Bayes Factors: A Tutorial.

One of the more principled methods of performing model selection is via Bayes factors. However, calculating Bayes factors requires marginal likelihoods, which are integrals over the entire parameter space, making estimation of Bayes factors for models with more than a few parameters a significant computational challenge. Here, we provide a tutorial review of two Monte Carlo techniques rarely used in psychology that efficiently compute marginal likelihoods: thermodynamic integration (Friel & Pettitt, 2008; Lartillot & Philippe, 2006) and steppingstone sampling (Xie, Lewis, Fan, Kuo, & Chen, 2011). The methods are general and can be easily implemented in existing MCMC code; we provide both the details for implementation and associated R code for the interested reader. While Bayesian toolkits implementing standard statistical analyses (e.g., JASP Team, 2017; Morey & Rouder, 2015) often compute Bayes factors for the researcher, those using Bayesian approaches to evaluate cognitive models are usually left to compute Bayes factors for themselves. Here, we provide examples of the methods by computing marginal likelihoods for a moderately complex model of choice response time, the Linear Ballistic Accumulator model (Brown & Heathcote, 2008), and compare them to findings of Evans and Brown (2017), who used a brute force technique. We then present a derivation of TI and SS within a hierarchical framework, provide results of a model recovery case study using hierarchical models, and show an application to empirical data. A companion R package is available at the Open Science Framework: https://osf.io/jpnb4.

Choosing Home Hemodialysis: A Critical Review of Patient Outcomes.

BACKGROUND/AIM: Home hemodialysis (HHD) has been associated with improved clinical outcomes vs. in-center HD (ICHD). The prevalence of HHD in the United States is still very low at 1.8%. This critical review compares HHD and ICHD outcomes for survival, hospitalization, cardiovascular (CV), nutrition, and quality of life (QoL). METHODS: Of 545 publications identified, 44 were not selected after applying exclusion criteria. A systematic review of the identified publications was conducted to compare HHD to ICHD outcomes for survival, hospitalization, CV outcomes, nutrition, and QoL. RESULTS: Regarding mortality, 10 of 13 trials reported 13-52% reduction; three trials found no differences. According to 6 studies, blood pressure and left ventricular size measurements were generally lower in HHD patients compared to similar measurements in ICHD patients. Regarding nutritional status, conflicting results were reported (8 studies); some found improved muscle mass, total protein, and body mass index in HHD vs. ICHD patients, while others found no significant differences. There were no significant differences in the rate of hospitalization between HHD and ICHD in the 6 articles reviewed. Seven studies on QoL demonstrated positive trends in HHD vs. ICHD populations. CONCLUSIONS: Despite limitations in the current data, 66% of the publications reviewed (29/44) demonstrated improved clinical outcomes in patients who chose HHD. These include improved survival, CV, nutritional, and QoL parameters. Even though HHD may not be preferred in all patients, a review of the literature suggests that HHD should be provided as a modality choice for substantially more than the current 1.8% of HHD patients in the United States.

Paricalcitol and cinacalcet have disparate actions on parathyroid oxyphil cell content in patients with chronic kidney disease.

The parathyroid oxyphil cell content increases in patients with chronic kidney disease (CKD), and even more in patients treated with the calcimimetic cinacalcet and/or calcitriol for hyperparathyroidism. Oxyphil cells have significantly more calcium-sensing receptors than chief cells, suggesting that the calcium-sensing receptor and calcimimetics are involved in the transdifferentiation of a chief cell to an oxyphil cell type. Here, we compared the effect of the vitamin D analog paricalcitol (a less calcemic analog of calcitriol) and/or cinacalcet on the oxyphil cell content in patients with CKD to further investigate the genesis of these cells. Parathyroid tissue from four normal individuals and 27 patients with CKD who underwent parathyroidectomy for secondary hyperparathyroidism were analyzed. Prior to parathyroidectomy, patients had received the following treatment: seven with no treatment, seven with cinacalcet only, eight with paricalcitol only, or cinacalcet plus paricalcitol in five. Oxyphilic areas of parathyroid tissue, reported as the mean percent of total tissue area per patient, were normal, 1.03; no treatment, 5.3; cinacalcet, 26.7 (significant vs. no treatment); paricalcitol, 6.9 (significant vs. cinacalcet; not significant vs. no treatment); and cinacalcet plus paricalcitol, 12.7. Cinacalcet treatment leads to a significant increase in parathyroid oxyphil cell content but paricalcitol does not, reinforcing a role for the calcium-sensing receptor activation in the transdifferentiation of chief-to-oxyphil cell type. Thus, two conventional treatments for hyperparathyroidism have disparate effects on parathyroid composition, and perhaps function. This finding is provocative and may be useful when evaluating future drugs for hyperparathyroidism.

Bayesian inference with Stan: A tutorial on adding custom distributions.

When evaluating cognitive models based on fits to observed data (or, really, any model that has free parameters), parameter estimation is critically important. Traditional techniques like hill climbing by minimizing or maximizing a fit statistic often result in point estimates. Bayesian approaches instead estimate parameters as posterior probability distributions, and thus naturally account for the uncertainty associated with parameter estimation; Bayesian approaches also offer powerful and principled methods for model comparison. Although software applications such as WinBUGS (Lunn, Thomas, Best, & Spiegelhalter, Statistics and Computing, 10, 325-337, 2000) and JAGS (Plummer, 2003) provide "turnkey"-style packages for Bayesian inference, they can be inefficient when dealing with models whose parameters are correlated, which is often the case for cognitive models, and they can impose significant technical barriers to adding custom distributions, which is often necessary when implementing cognitive models within a Bayesian framework. A recently developed software package called Stan (Stan Development Team, 2015) can solve both problems, as well as provide a turnkey solution to Bayesian inference. We present a tutorial on how to use Stan and how to add custom distributions to it, with an example using the linear ballistic accumulator model (Brown & Heathcote, Cognitive Psychology, 57, 153-178. doi: 10.1016/j.cogpsych.2007.12.002 , 2008).

Cytomegalovirus-induced thrombotic microangiopathy after renal transplant successfully treated with eculizumab: case report and review of the literature.

De novo thrombotic microangiopathy (TMA) after renal transplant is rare. Cytomegalovirus (CMV)-related post-transplant TMA has only been reported in 6 cases. We report an unusual case of a 75-year-old woman who developed de novo TMA in association with CMV viremia. The recurrence of TMA with CMV viremia, the resolution with treatment for CMV, and the lack of correlation with a calcineurin inhibitor (CNI) in our case support CMV as the cause of the TMA. What is unique is that the use of eculizumab without plasmapheresis led to prompt improvement in renal function. After a failure to identify a genetic cause for TMA and the clear association with CMV, eculizumab was discontinued. This case provides insight into the pathogenesis and novel treatment of de novo TMA, highlights the beneficial effects of complement inhibitors in this disease, and shows that they can be safely discontinued once the inciting etiology is addressed.

Mesenchymal Stromal Cells Improve Renovascular Function in Polycystic Kidney Disease.

Polycystic kidney disease (PKD) is a common cause of end-stage renal failure, for which there is no accepted treatment. Progenitor and stem cells have been shown to restore renal function in a model of renovascular disease, a disease that shares many features with PKD. The objective of this study was to examine the potential of adult stem cells to restore renal structure and function in PKD. Bone marrow-derived mesenchymal stromal cells (MSCs, 2.5 × 10(5)) were intrarenally infused in 6-week-old PCK rats. At 10 weeks of age, PCK rats had an increase in systolic blood pressure (SBP) versus controls (126.22 ± 2.74 vs. 116.45 ± 3.53 mmHg, p < 0.05) and decreased creatinine clearance (3.76 ± 0.31 vs. 6.10 ± 0.48 µl/min/g, p < 0.01), which were improved in PKD animals that received MSCs (SBP: 114.67 ± 1.34 mmHg, and creatinine clearance: 4.82 ± 0.24 µl/min/g, p = 0.001 and p = 0.003 vs. PKD, respectively). MSCs preserved vascular density and glomeruli diameter, measured using microcomputed tomography. PCK animals had increased urine osmolality (843.9 ± 54.95 vs. 605.6 ± 45.34 mOsm, p < 0.01 vs. control), which was improved after MSC infusion and not different from control (723.75 ± 56.6 mOsm, p = 0.13 vs. control). Furthermore, MSCs reduced fibrosis and preserved the expression of proangiogenic molecules, while cyst size and number were unaltered by MSCs. Delivery of exogenous MSCs improved vascular density and renal function in PCK animals, and the benefit was observed up to 4 weeks after a single infusion. Cell-based therapy constitutes a novel approach in PKD.

A cognitive model for aggregating people's rankings.

We develop a cognitive modeling approach, motivated by classic theories of knowledge representation and judgment from psychology, for combining people's rankings of items. The model makes simple assumptions about how individual differences in knowledge lead to observed ranking data in behavioral tasks. We implement the cognitive model as a Bayesian graphical model, and use computational sampling to infer an aggregate ranking and measures of the individual expertise. Applications of the model to 23 data sets, dealing with general knowledge and prediction tasks, show that the model performs well in producing an aggregate ranking that is often close to the ground truth and, as in the "wisdom of the crowd" effect, usually performs better than most of individuals. We also present some evidence that the model outperforms the traditional statistical Borda count method, and that the model is able to infer people's relative expertise surprisingly well without knowing the ground truth. We discuss the advantages of the cognitive modeling approach to combining ranking data, and in wisdom of the crowd research generally, as well as highlighting a number of potential directions for future model development.

Symptomatic hyperammonemia after lung transplantation: lessons learnt.

Hyperammonemia, post-orthotopic lung transplantation, is a rare but mostly fatal complication. Various therapies, including those to decrease ammonia generation, increase nitrogen excretion, and several dialytic methods for removing ammonia have been tried. We describe three lung transplant recipients who developed acute hyperammonemia early after transplantation. Two of the three patients survived after a multidisciplinary approach including discontinuation of drugs, which impair urea cycle, aggressive ammonia reduction with prolonged daily intermittent hemodialysis (HD), and overnight slow low-efficiency dialysis in conjunction with early weaning of steroids and other therapeutic measures. Our experience suggests that early initiation of dialysis, high dialysis dose, increased frequency, and HD preferably to less efficient modalities increases survival in these patients.

Polycystic kidneys have decreased vascular density: a micro-CT study.

OBJECTIVE: Polycystic kidney disease (PKD) is a common cause of end-stage renal failure and many of these patients suffer vascular dysfunction and hypertension. It remains unclear whether PKD is associated with abnormal microvascular structure. Thus, this study examined the renovascular structure in PKD. METHODS: PKD rats (PCK model) and controls were studied at 10 weeks of age, and mean arterial pressure (MAP), renal blood flow, and creatinine clearance were measured. Microvascular architecture and cyst number and volume were assessed using micro-computed tomography, and angiogenic pathways evaluated. RESULTS: Compared with controls, PKD animals had an increase in MAP (126.4 ± 4.0 vs. 126.2 ± 2.7 mmHg) and decreased clearance of creatinine (0.39 ± 0.09 vs. 0.30 ± 0.05 mL/min), associated with a decrease in microvascular density, both in the cortex (256 ± 22 vs. 136 ± 20 vessels per cm2) and medullar (114 ± 14 vs. 50 ± 9 vessels/cm2) and an increase in the average diameter of glomeruli (104.14 ± 2.94 vs. 125.76 ± 9.06 mm). PKD animals had increased fibrosis (2.2 ± 0.2 fold vs. control) and a decrease in the cortical expression in hypoxia inducible factor 1-α and vascular endothelial growth factor. CONCLUSIONS: PKD animals have impaired renal vascular architecture, which can have significant functional consequences. The PKD microvasculature could represent a therapeutic target to decrease the impact of this disease.

Brain-derived neurotrophic factor in cigarette smoke-induced airway hyperreactivity.

Enhanced airway smooth muscle (ASM) contractility contributes to increased resistance to airflow in diseases such as bronchitis and asthma that occur in passive smokers exposed to secondhand smoke. Little information exists on the cellular mechanisms underlying such airway hyperreactivity. Sputum samples of patients with chronic sinusitis, bronchitis, and asthma show increased concentrations of growth factors called neurotrophins, including brain-derived growth factor (BDNF), but their physiological significance remains unknown. In human ASM, we tested the hypothesis that BDNF contributes to increased contractility with cigarette smoke exposure. The exposure of ASM to 1% or 2% cigarette smoke extract (CSE) for 24 hours increased intracellular calcium ([Ca(2+)](i)) responses to histamine, and further potentiated the enhancing effects of a range of BDNF concentrations on such histamine responses. CSE exposure increased the expression of the both high-affinity and low-affinity neurotrophin receptors tropomyosin-related kinase (Trk)-B and p75 pan-neurotrophin receptor, respectively. Quantitative ELISA showed that CSE increased BDNF secretion by human ASM cells. BDNF small interfering (si)RNA and/or the chelation of extracellular BDNF, using TrkB-fragment crystallizable, blunted the effects of CSE on [Ca(2+)](i) responses as well as the CSE enhancement of cell proliferation, whereas TrkB siRNA blunted the effects of CSE on ASM contractility. These data suggest that cigarette smoke is a potent inducer of BDNF and TrkB expression and signaling in ASM, which then contribute to cigarette smoke-induced airway hyperresponsiveness.