Public and patient perspectives on the use of clinical and administrative health data to identify and contact people at risk of future illness-The case of chronic kidney disease.

For decades, researchers have used linkable administrative health data for evaluating the health care system, subject to local privacy legislation. In Ontario, Canada, the relevant privacy legislation permits some organizations (prescribed entities) to conduct this kind of research but is silent on their ability to identify and contact individuals in those datasets. Following consultation with the Office of the Information and Privacy Commissioner of Ontario, we developed a pilot study to identify and contact by mail a sample of people at high risk for kidney failure within the next 2 years, based on laboratory and administrative data from provincial datasets held by ICES, to ensure they receive needed kidney care. Before proceeding, we conducted six focus groups to understand the acceptability to the public and people living with chronic kidney disease of direct mail outreach to people at high risk of developing kidney failure. While virtually all participants indicated they would likely participate in the study, most felt strongly that the message should come directly from their primary care provider or whoever ordered the laboratory tests, rather than from an unknown organization. If this is not possible, they felt the health care provider should be made aware of the concern related to their kidney health. Most agreed that, if health authorities could identify people at high risk of a treatable life-threatening illness if caught early enough, there is a social responsibility to notify people. While privacy laws allow for free flow of health information among health care providers who provide direct clinical care, the proposed case-finding and outreach falls outside that model. Enabling this kind of information flow will require greater clarity in existing laws or revisions to these laws. This also requires adequate notification and culture change for health care providers and the public around information uses and flows.

Predictors of Delayed Diagnosis of Pediatric CNS Tumors in the Emergency Department.

OBJECTIVE: Central nervous system (CNS) tumor diagnoses are frequently delayed in children, which may lead to adverse outcomes and undue burdens on families. Examination of factors associated with delayed emergency department (ED) diagnosis could identify approaches to reduce delays. STUDY DESIGN: We performed a case-control study using data from 2014 to 2017 for 6 states. We included children aged 6 months to 17 years with a first diagnosis of CNS tumor in the ED. Cases had a delayed diagnosis, defined as 1 or more ED visits in the 140 days preceding tumor diagnosis (the mean prediagnostic symptomatic interval for pediatric CNS tumors in the United States). Controls had no such preceding visit. RESULTS: We included 2828 children (2139 controls, 76%; 689 cases, 24%). Among cases, 68% had 1 preceding ED visit, 21% had 2, and 11% had 3 or more. Significant predictors of delayed diagnosis included presence of a complex chronic condition (adjusted odds ratio [aOR], 9.73; 95% confidence interval [CI], 6.67-14.20), rural hospital location (aOR, 6.37; 95% CI, 1.80-22.54), nonteaching hospital status (aOR, 3.05, compared with teaching hospitals; 95% CI, 1.94-4.80), age younger than 5 years (aOR, 1.57; 95% CI, 1.16-2.12), public insurance (aOR, 1.49, compared with private; 95% CI, 1.16-1.92), and Black race (aOR, 1.42, compared with White; 95% CI, 1.01-1.98). CONCLUSIONS: Delayed ED diagnosis of pediatric CNS tumors is common and frequently requires multiple ED encounters. Prevention of delays should focus on careful evaluation of young or chronically ill children, mitigating disparities for Black and publicly insured children, and improving pediatric readiness in rural and nonteaching EDs.

Rapid Cycle Deliberate Practice Improves Retention of Pediatric Resuscitation Skills Compared With Postsimulation Debriefing.

INTRODUCTION: Rapid cycle deliberate practice (RCDP) for teaching team-based resuscitation is associated with similar improvements in immediate performance as compared with postsimulation debriefing (PSD). Limited studies compare skill retention between these 2 modalities. Our objective was to compare retention of team leader performance in residents trained with RCDP versus PSD. METHODS: This was a cluster-randomized trial comparing RCDP and PSD from January 2018 to April 2019. Pediatric and emergency medicine residents participated in simulation-based pediatric resuscitation education, and teams were randomized to undergo either RCDP or PSD. Each participant's team leader performance was assessed 1 to 12 months after training via a simulated cardiac arrest. The primary outcome was time to defibrillation. Secondary outcomes included overall team leader performance and time to chest compressions. RESULTS: Thirty-two residents (90.6% pediatrics, 9.4% emergency medicine) met inclusion criteria (16 RCDP, 16 PSD). Of the 32 residents, 40% returned in 1 to 3 months, 25% 3 to 6 months, 16% 6 to 9 months, and 19% 10 to 12 months. Participants in RCDP had more than 5 times the odds of achieving defibrillation versus those in the PSD group (odds ratio = 5.57, 95% confidence interval = 1.13-27.52, P = 0.04). The RCDP group had a higher mean Resident Team Leader Evaluation score (0.54 ± 0.19) than the PSD group (0.34 ± 0.16, P < 0.001). CONCLUSIONS: This study shows significant differences in subsequent performance in the team leader trained with RCDP and suggests that RCDP may improve retention of pediatric resuscitation skills compared with PSD. Future studies should focus on best applications for RCDP with attention to knowledge and skill decay.

Rapid-cycle deliberate practice improves time to defibrillation and reduces workload: A randomized controlled trial of simulation-based education.

BACKGROUND: The optimal structure of simulation to train teams to perform pediatric advanced life support (PALS) requires further research. Most simulation is structured with an uninterrupted scenario with postsimulation debriefing (PSD). Rapid-cycle deliberate practice (RCDP) is structured with a series of simulations with microdebriefing quickly switching within action targeting specific performance goals. OBJECTIVE: The objective was to compare team performance immediately after training, as well as learner workload, for teams trained using either PSD or RCDP. METHODS: In 2018-2019, a total of 41 interprofessional teams of 210 residents and nurses were recruited from 250 eligible participants (84%) and randomized into either arm (RCDP or PSD) teaching the same objectives of resuscitation of a patient in PEA arrest, in the same time frame. The structure of the simulation varied. Demographic surveys were collected before training, the National Aeronautics and Space Administration-Task Load Index (NASA-TLX) was administered immediately after training to assess workload during training and performance was assessed immediately after training using a pulseless ventricular tachycardia arrest with the primary outcome being time to defibrillation. RESULTS: Thirty-nine teams participated over a 16-month time span. Performance of teams randomized to RCDP showed significantly better time to defibrillation, 100 s (95% confidence interval [CI] = 90-111), compared to PSD groups, 163 s (95% CI = 120-201). The workload of the groups also showed a lower total NASA-TLX score for the RCDP groups. CONCLUSIONS: For team-based time-sensitive training of PALS, RCDP outperformed PSD. This may be due to a reduction in the workload faced by teams during training.

Evolving Medical Imaging Techniques for the Assessment of Delayed Graft Function: A Narrative Review.

PURPOSE OF REVIEW: Delayed graft function (DGF) is a significant complication that contributes to poorer graft function and shortened graft survival. In this review, we sought to evaluate the current and emerging role of medical imaging modalities in the assessment of DGF and how it may guide clinical management. SOURCES OF INFORMATION: PubMed, Google Scholar, and ClinicalTrial.gov up until February 2021. METHODS: This narrative review first examined the pathophysiology of DGF and current clinical management. We then summarized relevant studies that utilized medical imaging to assess posttransplant renal complications, namely, DGF. We focused our attention on noninvasive, evolving imaging modalities with the greatest potential for clinical translation, including contrast-enhanced ultrasound (CEUS) and multiparametric magnetic resonance imaging (MRI). KEY FINDINGS: A kidney biopsy in the setting of DGF can be used to assess the degree of ischemic renal injury and to rule out acute rejection. Biopsies are accompanied by complications and may be limited by sampling bias. Early studies on CEUS and MRI have shown their potential to distinguish between the 2 most common causes of DGF (acute tubular necrosis and acute rejection), but they have generally included only small numbers of patients and have not kept pace with more recent technical advances of these imaging modalities. There remains unharnessed potential with CEUS and MRI, and more robust clinical studies are needed to better evaluate their role in the current era. LIMITATIONS: The adaptation of emerging approaches for imaging DGF will depend on additional clinical trials to study the feasibility and diagnostic test characteristics of a given modality. This is limited by access to devices, technical competence, and the need for interdisciplinary collaborations to ensure that such studies are well designed to appropriately inform clinical decision-making.

MOTIF DE LA REVUE: La reprise retardée de la fonction du greffon (RRFG) est une complication importante susceptible d'affecter négativement la fonction du greffon et de réduire sa survie. Dans cette revue, nous cherchions à évaluer le rôle actuel et grandissant des modalités d'imagerie médicale dans l'évaluation de la RRFG et la façon dont cela pourrait orienter la prise en charge clinique. SOURCES: PubMed, Google Scholar et ClinicalTrial.gov jusqu'à février 2021. MÉTHODOLOGIE: Notre revue narrative portait d'abord sur la physiopathologie de la RRFG et la prise en charge clinique actuelle. Nous avons par la suite résumé les études pertinentes ayant utilisé l'imagerie médicale pour évaluer les complications rénales post- transplantation, notamment la RRFG. Nous avons concentré notre attention sur les modalités d'imagerie non effractives et évolutives présentant le plus grand potentiel d'application clinique, notamment l'échographie de contraste (CEUS) et l'imagerie par résonance magnétique (IRM) multiparamétrique. PRINCIPAUX RÉSULTATS: Dans les cas de RRFG, une biopsie du rein peut être utilisée pour évaluer l'ampleur des lésions rénales ischémiques et pour exclure le rejet aigu. Les biopsies s'accompagnent de complications et pourraient être limitées par des biais d'échantillonnage. Des études préliminaires examinant les CEUS et l'IRM ont montré que ces modalités permettaient une distinction entre les deux causes les plus fréquentes de la RRFG (nécrose tubulaire aiguë et rejet aigu), mais ces études portaient généralement sur de petits nombres de patients et n'avaient pas suivi les plus récents progrès techniques de ces modalités d'imagerie. Il subsiste un potentiel non exploité avec les CEUS et l'IRM. Des études cliniques plus robustes sont nécessaires pour mieux évaluer leur rôle à l'heure actuelle. LIMITES: L'adaptation des approches émergentes pour l'imagerie en contexte de RRFG dépendra d'essais cliniques supplémentaires qui examineront la faisabilité et les caractéristiques des tests diagnostiques d'une modalité donnée. Cela est limité par l'accès aux appareils, la compétence technique et la nécessité de collaborations interdisciplinaires afin de s'assurer que ces études sont bien conçues et qu'elles puissent éclairer adéquatement la prise de décisions cliniques.

Workload of learners during simulated paediatric cardiopulmonary resuscitation.

Introduction: Learner workload during simulated team-based resuscitations is not well understood. In this descriptive study, we measured the workload of learners in different team roles during simulated paediatric cardiopulmonary resuscitation. Methods: Paediatric emergency nurses and paediatric and emergency medicine residents formed teams of four to eight and randomised into roles to participate in simulation-based, paediatric resuscitation. Participant workload was measured using the NASA Task Load Index, which provides an average workload score (from 0 to 100) across six subscores: mental demand, physical demand, temporal demand, performance, frustration and mental effort. Workload is considered low if less than 40, moderate if between 40 and 60 and high if greater than 60. Results: There were 210 participants representing 40 simulation teams. 138 residents (66%) and 72 nurses (34%) participated. Team lead reported the highest workload at 65.2±10.0 (p=0.001), while the airway reported the lowest at 53.9±10.8 (p=0.001); team lead had higher scores for all subscores except physical demand. Team lead reported the highest mental demand (p<0.001), while airway reported the lowest. Cardiopulmonary resuscitation coach and first responder reported the highest physical demands (p<0.001), while team lead and nurse recorder reported the lowest (p<0.001). Conclusions: Workload for learners in paediatric simulated resuscitation teams was moderate to high and varied significantly based on team role. Composition of workload varied significantly by team role. Measuring learner workload during simulated resuscitations allows improved processes and choreography to optimise workload distribution.

Video-Based Telemedicine for Kidney Disease Care: A Scoping Review.

BACKGROUND AND OBJECTIVES: Video-based telemedicine provides an alternative health care delivery model for patients with CKD. The objective was to provide an overview of the available evidence on the implementation and outcomes of adopting video-based telemedicine in nephrology. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and CINAHL were searched in December 2019 and again in January 2021 for studies using video-based telemedicine for adults across the spectrum of kidney disease. Study types included peer-reviewed clinical trials, observational studies, and descriptive studies available in full text. Search results were independently screened by two authors, who then independently reviewed and extracted data from the eligible studies. Results were synthesized in tabular format, summarizing study characteristics by area within nephrology; the video-based interventions used; and clinical, health care utilization, and patient-reported outcomes. RESULTS: After reviewing 1870 unique citations, 24 studies were included (four randomized controlled trials, six cohort studies, five pre-post intervention studies, seven case series, and two qualitative studies). Video-based technology was used to facilitate care across all stages of CKD. Although earlier studies used a range of institution-specific technologies that linked main hospital sites to more remote health care locations, more recent studies used technology platforms that allowed patients to receive care in a location of their choice. Video-based care was well received, with the studies reporting high patient satisfaction and acceptable clinical outcomes. CONCLUSIONS: Video-based telemedicine is being used for kidney care and has evolved to be less reliant on specialized telemedicine equipment. As its use continues to grow, further primary studies and systematic reviews of outcomes associated with the latest innovations to video-based care in nephrology can address knowledge gaps, such as approaches to sustainable integration and minimization of barriers to access.

DAMPAned Methotrexate: A Case Report and Review of the Management of Acute Methotrexate Toxicity.

RATIONALE: Consensus guidelines on the management of methotrexate-induced nephrotoxicity using glucarpidase (Voraxaze) may be relatively unfamiliar to the nephrology community. PRESENTING CONCERNS OF THE PATIENT: A 61-year-old man with intravascular large B-cell lymphoma was admitted for cycle #1 of high-dose methotrexate (HDMTX) following 2 cycles of R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) chemotherapy. On admission, he was clinically euvolemic and had a creatinine clearance of 98 mL/min. He received standard HDMTX toxicity prophylaxis with volume expansion, urinary alkalinization, and leucovorin rescue. DIAGNOSES: Despite prophylactic efforts, he developed a severe acute kidney injury, creatinine 63 to 226 µmol/L (2.56 mg/dL), following HDMTX, impaired methotrexate clearance, and neurotoxicity manifested by status epilepticus. INTERVENTIONS: He was given glucarpidase to convert extracellular methotrexate into its inactive metabolites, glutamate and DAMPA (4-deoxy-4-amino-N 10-methylpteroic acid) at 52 hours post-HDMTX. Cross-reactivity between commercial methotrexate immunoassays with DAMPA led to falsely elevated methotrexate concentrations for much longer than expected based on the current guideline (5 days instead of <48 hours). This required ongoing monitoring of methotrexate concentration by mass spectrometry. OUTCOMES: The patient remained nonoliguric and did not develop acute indications for dialysis. Serum creatinine peaked at 608 µmol/L (6.88 mg/dL) 6 days after HDMTX. He ultimately had a full renal and neurologic recovery. LESSONS LEARNED: Glucarpidase is an effective option for nonrenal elimination of methotrexate-induced nephrotoxicity. Timing of methotrexate concentration monitoring to assess for toxicity, how to access the drug, and the need for ongoing monitoring by mass spectrometry beyond the guideline recommendation are highlighted for centers where HDMTX therapy may be used.

JUSTIFICATION: Les lignes directrices consensuelles sur la prise en charge de la néphrotoxicité induite par le méthotrexate par l'administration de glucarpidase (VoraxazeMD) sont possiblement mal connues en néphrologie. PRÉSENTATION DU CAS: Nous présentons le cas d'un patient de 61 ans atteint d'un lymphome intravasculaire à grandes cellules B qui avait été admis pour un cycle de traitement à dose élevée de méthotrexate (HDMTX) après deux cycles de chimiothérapie par R-CHOP. À l'admission, le patient était cliniquement euvolémique et présentait une clairance de la créatinine à 98 mL/min. Le patient a reçu la prophylaxie standard pour une toxicité à HDMTX avec expansion volumique, alcalinisation urinaire et sauvetage par leucovorine. DIAGNOSTIC: Malgré les mesures prophylactiques, l'état du patient a évolué vers une grave insuffisance rénale aigüe (créatinine initiale de 63 à 226 µmol/L [2,56 mg/dL]) après le traitement au HDMTX, de même qu'une altération de la clairance du méthotrexate et une neurotoxicité manifestée par un status epilepticus. INTERVENTIONS: Le patient a reçu du glucarpidase pour convertir le méthotrexate extracellulaire en ses métabolites inactifs, le glutamate et le DAMPA (acide 4-déoxy-4-amino-N 10-méthylptéroïque) 52 heures après le traitement au HDMTX. La réactivité croisée entre les immunoessais commerciaux au méthotrexate et le DAMPA a entraîné des concentrations faussement élevées de méthotrexate pour beaucoup plus longtemps que prévu selon la recommandation actuelle (5 jours plutôt que < 48 heures). Cette situation a nécessité une surveillance continue de la concentration du méthotrexate par spectrométrie de masse. RÉSULTATS: Le patient est demeuré non oligurique et n'a pas nécessité de dialyse. Le taux de créatinine sérique a culminé à 608 µmol/L (6,88 mg/dL) six jours après l'administration de HDMTX. Les fonctions rénale et neurologique du patient se sont finalement rétablies complètement. LEÇONS TIRÉES: La glucarpidase est une option efficace pour éliminer de façon non rénale la néphrotoxicité induite par le méthotrexate. Le moment de mesurer la concentration de méthotrexate pour évaluer la toxicité, la façon d'accéder au médicament et la nécessité d'une surveillance continue par spectrométrie de masse au-delà de la recommandation actuelle sont clarifiés pour les centres où un traitement par HDMTX pourrait être administré.

Treatment options for isolated iliac artery aneurysms and their impact on aortic diameter after treatment

PURPOSE: Isolated iliac artery aneurysm (IIAA) is uncommon. It is frequently treated by endovascular aneurysm repair (EVAR). This study was to evaluate treatment results of IIAA and survey aortic diameter after EVAR. METHODS: Patients treated for IIAA in Seoul St. Mary's Hospital and Bundang Seoul National University from 2005 to April 2016 were retrospectively enrolled. The inclusion criteria of IIAA was >30 mm of iliac artery aneurysm without abdominal aortic aneurysm, which was treated by open surgical repair (OSR) or EVAR. Patients' clinical characteristics, treatment results, and mortality were obtained from electronic medical records. Diameters of aorta and iliac arteries were measured periodically with scheduled interval based on CT scans. RESULTS: Forty-nine patients (40 males; mean age, 71.9 ± 11.1 years) were enrolled. Five ruptured IIAAs were treated with EVAR (n = 1) or hybrid methods (n = 4). The diameter of ruptured IIAAs was 65 ± 31.4 mm, which was not significantly different from that of elective (44.3 ± 17.0 mm). Forty-four elective IIAA underwent 9 OSR, 31 EVARs, and 3 hybrid treatments (15 bifurcated and 12 straight stent-grafts). Treatment success rate was 93.8% without hospital mortality. There were 4 type I endoleak, 1 type II endoleak, and 1 type III endoleak without aneurysm-related mortality during follow-up. However, the aortic diameter was increased over time though there was no change or decrease in common iliac artery's diameter. CONCLUSION: Treatment of IIAA included various endovascular modalities as well as open surgery. Regular surveillance is still needed due to aortic dilatation after its treatment.

Is the Kidney Donor Risk Index a Useful Tool in Non-US Patients?

BACKGROUND: Deceased donor kidney allocation in the United States is guided by the Kidney Donor Risk Index (KDRI). The generalizability of the KDRI beyond the United States has not been widely studied. OBJECTIVE: To assess the generalizability of the KDRI in a cohort of non-US (Canadian) deceased donor kidney transplant recipients. DESIGN: Population-based retrospective cohort study. SETTING: Ontario, Canada. PATIENTS: Recipients of deceased donor kidneys from January 1, 2005, to March 31, 2011. METHODS: Using administrative data, we analyzed a cohort of deceased donor kidney recipients in Ontario, Canada. The Kaplan-Meier method and Cox proportional hazards models were used to assess the relationship between KDRI and the outcomes of graft loss and death. KDRI was modeled continuously and categorically. The ability of models with KDRI to predict recipient outcomes beyond donor age was also explored. Model discrimination was assessed using c-statistics, evaluated at 5 years of follow-up. RESULTS: A total of 1299 consecutive deceased donor kidney transplant recipients were included. The median follow-up was 5.5 years. Mean donor age increased from 27 to 64 years across ascending KDRI quintiles. The adjusted relative hazards (95% confidence interval) for total graft loss from Q2 to Q5 (referent = Q1) were 1.27 (0.89-1.80), 1.58 (1.13-2.22), 1.43 (1.01-2.02), and 2.15 (1.54-2.99), respectively. Increased relative hazards across KDRI quintiles were also observed for death-censored graft loss, but not death with graft function. All-cause mortality was increased for the highest KDRI quintile only. In this cohort, a model with KDRI performed better than a model with donor age alone (P = .009). LIMITATIONS: Large health care databases may have precluded the complete capture of covariate data. CONCLUSIONS: In conclusion, the KDRI is generalizable to Canadian patients in Ontario and may help inform risk assessment beyond donor age. The performance of KDRI in other non-US settings, and the need for additional model refinement, warrants further study.

CONTEXTE: Aux États-Unis, l'attribution des reins provenant de donneurs décédés est guidée par l'indice Kidney Donor Risk Index (KDRI). La généralisation de cet indice hors des États-Unis a toutefois été peu étudiée. OBJECTIF DE L'ÉTUDE: Déterminer s'il est possible de généraliser l'indice KDRI à une cohorte canadienne de receveurs d'un rein provenant d'un donneur décédé. TYPE D'ÉTUDE: Il s'agit d'une étude de cohorte rétrospective. CADRE: La province de l'Ontario, au Canada. SUJETS: Les patients ayant reçu un rein provenant d'un donneur décédé entre le 1er janvier 2005 et le 31 mars 2011. MÉTHODOLOGIE: À l'aide des données administratives provinciales de l'Ontario (Canada), nous avons analysé une cohorte de receveurs d'un rein provenant d'un donneur décédé. Des modèles des risques proportionnels de Cox et la méthode de Kaplan-Meier ont été employés pour quantifier la relation entre l'indice KDRI et le risque de perte du greffon ou de décès du patient. L'indice KDRI a été modélisé de façon continue et par quintiles. On a également étudié la validité prédictive des modèles employant l'indice KDRI concernant les résultats du receveur au-delà d'une prédiction basée uniquement sur l'âge du donneur. Le pouvoir discriminant des modèles a été analysé par la surface sous la courbe à cinq ans post-intervention. RÉSULTATS: Un total de 1 299 receveurs d'une greffe de rein provenant d'un donneur décédé ont été inclus dans l'étude. La durée médiane du suivi s'établissait à 5,5 ans. L'âge moyen des donneurs passait de 27 ans au quintile inférieur à 64 ans au quintile supérieur. Le risque relatif corrigé (IC 95 %) de perte totale du greffon du Q2 au Q5 (référence = Q1) s'établissait respectivement à 1,27 (0,89; 1,80), 1,58 (1,13; 2,22), 1,43 (1,01; 2,02), et 2,15 (1,54; 2,99). Une augmentation du risque relatif a également été observée pour tous les quintiles dans les cas de perte du greffon censurée au décès du patient, mais pas dans les cas de décès du patient dont le greffon était toujours fonctionnel. Le taux de mortalité toutes causes confondues s'est accru dans le quintile supérieur seulement. Au sein de cette cohorte, le modèle basé sur l'indice KDRI a mieux prédit l'issue des patients que le modèle basé uniquement l'âge du donneur (p=0,009). LIMITES DE L'ÉTUDE: Vu la grande taille des bases de données en santé, il est possible que la saisie des covariables soit incomplète. CONCLUSION: L'indice KDRI est généralisable aux patients ontariens et pourrait contribuer à éclairer l'évaluation des risques plus efficacement qu'en ne considérant que l'âge du donneur. La valeur prédictive de l'indice KDRI hors des États-Unis et la nécessité de perfectionner le modèle justifient des études plus approfondies.

Validation of Living Donor Nephrectomy Codes.

BACKGROUND: Use of administrative data for outcomes assessment in living kidney donors is increasing given the rarity of complications and challenges with loss to follow-up. OBJECTIVE: To assess the validity of living donor nephrectomy in health care administrative databases compared with the reference standard of manual chart review. DESIGN: Retrospective cohort study. SETTING: 5 major transplant centers in Ontario, Canada. PATIENTS: Living kidney donors between 2003 and 2010. MEASUREMENTS: Sensitivity and positive predictive value (PPV). METHODS: Using administrative databases, we conducted a retrospective study to determine the validity of diagnostic and procedural codes for living donor nephrectomies. The reference standard was living donor nephrectomies identified through the province's tissue and organ procurement agency, with verification by manual chart review. Operating characteristics (sensitivity and PPV) of various algorithms using diagnostic, procedural, and physician billing codes were calculated. RESULTS: During the study period, there were a total of 1199 living donor nephrectomies. Overall, the best algorithm for identifying living kidney donors was the presence of 1 diagnostic code for kidney donor (ICD-10 Z52.4) and 1 procedural code for kidney procurement/excision (1PC58, 1PC89, 1PC91). Compared with the reference standard, this algorithm had a sensitivity of 97% and a PPV of 90%. The diagnostic and procedural codes performed better than the physician billing codes (sensitivity 60%, PPV 78%). LIMITATIONS: The donor chart review and validation study was performed in Ontario and may not be generalizable to other regions. CONCLUSIONS: An algorithm consisting of 1 diagnostic and 1 procedural code can be reliably used to conduct health services research that requires the accurate determination of living kidney donors at the population level.

CONTEXTE: Les professionnels de la santé se fient de plus en plus aux données administratives pour évaluer l'issue de l'opération chez les donneurs de rein vivants, étant donné la rareté des complications et les défis posés par la perte des patients au cours du suivi. OBJECTIF: Nous souhaitions évaluer la validité des données de néphrectomies sur donneur vivant rapportées dans les bases de données administratives en santé comparativement à la norme de référence qui consiste à consigner les données manuellement dans les dossiers médicaux. TYPE D'ÉTUDE: Il s'agit d'une étude de cohorte rétrospective. CADRE DE L'ÉTUDE: L'étude a été menée dans l'un des cinq principaux centres de transplantation d'Ontario, au Canada. PARTICIPANTS: La cohorte était composée de donneurs de rein vivants dont la néphrectomie a eu lieu entre 2003 et 2010. MESURES: Sensibilité et valeur prédictive positive (VPP). MÉTHODOLOGIE: Dans le cadre d'une étude rétrospective menée à l'aide de bases de données administratives, nous avons examiné la validité des codes de diagnostic et des codes d'intervention dans les cas de néphrectomie sur donneur vivant. Les données de l'organisme ontarien d'approvisionnement en organes, vérifiées manuellement par analyse des dossiers médicaux, ont servi de norme de référence. On a déterminé les paramètres fonctionnels (la sensibilité et la VPP) de plusieurs algorithmes basés sur les codes de diagnostic, les codes d'intervention et les codes de facturation. RÉSULTATS: Il y a eu 1 199 néphrectomies sur donneur vivant pendant la période couverte par l'étude. Globalement, le meilleur algorithme de repérage des donneurs de rein vivants combinait i) un code de diagnostic attribué à un donneur de rein (ICD-10 Z52.4) et ii) un code d'intervention attribué à l'ablation ou au prélèvement rénal (1PC58, 1PC89, 1PC91). En comparaison avec la norme de référence, cet algorithme présente une sensibilité de 97 % et une VPP de 90 %. Les codes de diagnostic et d'intervention se sont avérés de meilleurs indicateurs que les codes de facturation du médecin (sensibilité de 60 %; VPP de 78 %). LIMITES DE L'ÉTUDE: L'examen des dossiers médicaux des donneurs et l'étude de validation ayant été menés en Ontario, ses conclusions peuvent ne pas être transposables à d'autres régions. CONCLUSION: Un algorithme combinant un code de diagnostic et un code d'intervention s'est avéré fiable pour le dénombrement des donneurs de rein vivants dans la population générale en contexte de recherche en santé.

A Prospective Study on Nutritional Status and Nutrient Intake of Hemodialysis Patients Based on Coexistence of Diabetes

It is well known that malnutrition is a predictor of mortality in hemodialysis patients. The number of diabetic nephropathy patients is increasing rapidly. This study aimed to investigate nutritional status and nutrient intake according to the presence of diabetes among hemodialysis patients. The nutritional intake and general characteristics of outpatients at Ajou University Hospital (24 with diabetes and 30 without diabetes) were investigated between July and September 2015. Patients' general data were collected, and nutritional status by Patient-Generated Subjective Global Assessment (PG-SGA) was evaluated. Nutrient intakes were assessed according to 3-day food records. There was no significant difference regarding body weight between the two groups. However, the non-diabetic group showed a better nutritional status by Patient-Generated Subjective Global Assessment (PG-SGA) (5.2±4.4 vs. 8.0±4.3 score, non-diabetics vs. diabetics, P<0.05). There was no difference in daily calorie intake (1,473.9±370.5 vs. 1,503.8±397.5 kcal) and protein intake (60.3±19.7 vs. 65.6±20.5 g) in those with diabetes. Intakes of vegetables protein, sodium, potassium, vitamin C, folic acid and fiber were significantly higher in the diabetic group compared to those of the non-diabetic group. There was no difference in daily nutrient intake between the hemodialysis weekday and weekend groups. The non-diabetic group had higher calorie and sodium intakes per meal in the hemodialysis weekday group, but the difference was not significant. Based on these results, intervention should be performed to improve nutritional status in consideration of diabetes and dietary patterns.

The Canadian experience using the expanded criteria donor classification for allocating deceased donor kidneys for transplantation.

BACKGROUND: Although the outcomes of transplantation with expanded criteria donor (ECD) kidneys are inferior to non-ECD transplants in the USA, the impact of the ECD classification on Canadian kidney transplant recipients is not known. OBJECTIVES: The objective of the study was to assess the performance of the US-derived ECD classification among deceased donor kidney transplant recipients in a Canadian setting. DESIGN: This study was a population-based cohort study. SETTING: The study was conducted in all adult kidney transplant centers in the province of Ontario. PATIENTS: The patients were incident-deceased donor kidney transplant recipients from January 1, 2005 to March 31, 2011. MEASUREMENTS: Study subjects were identified through the Trillium Gift of Life Network and linked to healthcare databases in Ontario. ECD status was based on age, hypertension, kidney function, and stroke-related death. Outcomes of interest included graft loss, death, and delayed graft function. METHODS: The Kaplan-Meier product limit method was used to graphically assess time to graft loss or death. Multivariable Cox proportional hazards models were used to assess graft loss or death as a function of ECD status. Multivariable logistic regression models were fitted for the outcome of delayed graft function. RESULTS: Of 1422 deceased donor kidney transplants, 325 (23 %) were from ECDs. The median donor age was 63 vs. 42 years for ECD vs. non-ECD, respectively. The 5-year cumulative incidence of total graft loss was 29.2 % in ECD and 20.7 % in non-ECD kidney transplants. The relative hazards for total graft loss (HR 1.48 [95 % CI, 1.10; 2.00]) and death-censored graft loss (HR 1.80 [95 % CI, 1.19, 2.71]) were increased in ECD vs. non-ECD transplants. Increased relative risks were also observed for death and delayed graft function, albeit not statistically significant. LIMITATIONS: Although comprehensive in coverage and outcome ascertainment, the available details on covariate data may be limited in large healthcare databases. CONCLUSIONS: The ECD classification identifies kidneys at increased risk for graft loss in Canadian patients. The performance of more granular measures of donor risk (e.g., Kidney Donor Risk Index) and its impact on organ allocation/utilization in Canadian patients requires further study.

MISE EN CONTEXTE: Aux États-Unis, le classement des donneurs répondant à des critères élargis (classement DCE) a déjà permis d'établir que l'issue favorable d'une greffe de rein provenant d'un tel donneur était inférieure aux résultats obtenus avec des reins provenant de donneurs ne faisant pas partie de ce classement. Toutefois, nous ne connaissons toujours pas les répercussions d'un tel classement sur les receveurs d'une greffe de rein au Canada. OBJECTIFS DE L'ÉTUDE: L'étude visait à évaluer, dans le contexte canadien, l'efficacité de la mise en application du classement DCE américain pour les receveurs de greffe du rein provenant de donneurs décédés. CADRE ET TYPE D'ÉTUDE: L'étude de type cohorte représentative de la population s'est tenue au sein de tous les centres de transplantation rénale pour adultes de l'Ontario. PATIENTS: L'étude s'est tenue en répertoriant tous les patients qui ont reçu une greffe de rein provenant de donneurs décédés d'un accident vasculaire cérébral (AVC) entre le 1er janvier 2005 et le 31 mars 2011. MESURES: Les sujets susceptibles de pouvoir participer à l'étude ont été repérés grâce au Réseau Trillium pour le don de vie et reliés aux bases de données du système de santé de l'Ontario. Le statut du donneur au classement DCE a été établi en fonction de son âge, de la présence ou non d'un historique d'hypertension artérielle, de sa fonction rénale et du fait que la mort cérébrale soit conséquente d'un AVC. Les événements indésirables retenus pour le suivi incluaient la perte du greffon, le décès du receveur ou un retard dans la reprise de la fonction du greffon après la transplantation. MÉTHODOLOGIE: La méthode de Kaplan-Meier a été employée pour représenter graphiquement le temps entre la transplantation et la perte du greffon ou le décès. Le modèle de régression de Cox à variables multiples a été utilisé pour évaluer ces deux mêmes critères en fonction du statut du donneur au classement DCE. Enfin, on a eu recours à des modèles de régression logistique à variables multiples pour ajuster les résultats dans les cas de retard de la fonction du greffon après l'intervention chirurgicale. RÉSULTATS: Parmi les 1422 donneurs décédés répertoriés pour la période couverte par l'étude, on a dénombré 325 (23 %) donneurs répondant à des critères élargis (DCE). Leur âge médian se situait à 63 ans contre 42 ans dans le cas des donneurs non classés DCE. L'incidence cumulative de la perte totale du greffon après cinq ans était de 29,2 % pour les reins provenant de DCE alors qu'elle n'était que de 20,7 % pour les reins de donneurs non classés DCE. Le risque relatif (RR) de perte totale du greffon chez les receveurs survivants (RR 1,48 [95 % IC : 1,10, 2,00]) et chez les receveurs décédés en cours d'étude (RR 1,80 [95 % IC : 1,19, 2,71]) était plus élévé lorsque le greffon provenait de DCE que de donneurs non classés DCE. On a également noté une augmentation du risque relatif de décès du receveur ainsi que du retard de reprise de fonction du greffon, quoique ces données n'aient pas atteint un degré acceptable de signification statistique. LIMITES DE L'ÉTUDE: Malgré le fait que l'étude soit complète en ce qui concerne la couverture des événements indésirables et des résultats obtenus, il reste que les détails relatifs aux données covariables sont parfois limités dans les grandes bases de données des systèmes de santé. CONCLUSION: L'étude a démontré que le classement DCE permettait de recenser les reins disponibles pour transplantation présentant un risque élevé de perte du greffon chez les patients canadiens. Une analyse plus approfondie présentant une meilleure distribution statistique des risques pour le donneur en se référant notamment au Kidney Donor Risk Index (KDRI), et de leurs répercussions engendrées sur l'attribution ou l'utilisation des organes chez les patients canadiens s'avère essentielle.

Conformational states of syntaxin-1 govern the necessity of N-peptide binding in exocytosis of PC12 cells and Caenorhabditis elegans.

Syntaxin-1 is the central SNARE protein for neuronal exocytosis. It interacts with Munc18-1 through its cytoplasmic domains, including the N-terminal peptide (N-peptide). Here we examine the role of the N-peptide binding in two conformational states ("closed" vs. "open") of syntaxin-1 using PC12 cells and Caenorhabditis elegans. We show that expression of "closed" syntaxin-1A carrying N-terminal single point mutations (D3R, L8A) that perturb interaction with the hydrophobic pocket of Munc18-1 rescues impaired secretion in syntaxin-1-depleted PC12 cells and the lethality and lethargy of unc-64 (C. elegans orthologue of syntaxin-1)-null mutants. Conversely, expression of the "open" syntaxin-1A harboring the same mutations fails to rescue the impairments. Biochemically, the L8A mutation alone slightly weakens the binding between "closed" syntaxin-1A and Munc18-1, whereas the same mutation in the "open" syntaxin-1A disrupts it. Our results reveal a striking interplay between the syntaxin-1 N-peptide and the conformational state of the protein. We propose that the N-peptide plays a critical role in intracellular trafficking of syntaxin-1, which is dependent on the conformational state of this protein. Surprisingly, however, the N-peptide binding mode seems dispensable for SNARE-mediated exocytosis per se, as long as the protein is trafficked to the plasma membrane.

Experience with Elizabethkingia meningoseptica Infection in Adult Patients at a Tertiary Hospital / 대한중환자의학회지

BACKGROUND: Few reports have documented the clinical characteristics and treatment outcomes of adult patients with Elizabethkingia meningoseptica infection. METHODS: Medical records of patients over 18 years of age and suspected of having an E. meningoseptica infection from March 1, 2006 to February 28, 2013 were reviewed retrospectively. Their clinical characteristics, antimicrobial susceptibility results, and treatment outcomes were analyzed. RESULTS: E. meningoseptica was isolated from 30 patients. Median age was 68.5 years, and infections were more frequent in males (17, 56.7%). The most common isolation source was sputum (23, 76.7%), and pneumonia was the most common condition (21, 70%) after excluding two cases of colonization. This bacterium was most susceptible to minocycline (27, 90%) and fluoroquinolones, including levofloxacin (20, 66.7%) and ciprofloxacin (18, 60%). The mortality rate due directly to E. meningoseptica infection was 20% (6/30), and uncontrolled pneumonia was the only cause of death. After isolating E. meningoseptica, the numbers of patients with pneumonia (9/9, 100% vs. 12/21, 57.1%), history of hemodialysis (5/9, 55.6% vs. 3/21, 14.3%), tracheostomy (8/9, 88.9 vs. 10/21, 47.6%), and median Charlson comorbidity index score (6 [range, 3-9] vs. 4 [range, 0-9]) were significantly higher in non-survivors than those in survivors (p < 0.05, for each). However, only 12 (40%) patients received appropriate antibiotics. CONCLUSIONS: E. meningoseptica infection most commonly presented as pneumonia in adults with severe underlying diseases. Despite the high mortality rate, the rate of appropriate antibiotic use was notably low.

Lack of associations between tumor necrosis factor-alpha genetic polymorphism -308G/A and antituberculous drug-induced maculopapular eruption

PURPOSE: Adverse cutaneous reactions to antituberculous drugs (ATD), such as maculopapular eruption (MPE), are the most common causes of discontinuation of scheduled treatment of tuberculosis. We previously reported that tumor necrosis factor (TNF)-alpha genetic polymorphism -308G/A is significantly associated with ATD-induced hepatitis. This study aimed to investigate associations between TNF-alpha -308G/A and ATD-induced MPE. METHODS: Patients with ATD-induced MPE and controls without any adverse reactions to ATD were recruited from the database of the Adverse Drug Reaction Pharmacogenomic Research Group database of Korea. We compared the genotype frequency of TNF-alpha-308G/A between patients with ATD-induced MPE and ATD-tolerant controls. RESULTS: A total of 69 patients with ATD-induced MPE and 229 control subjects were enrolled for this study. There were no significant differences in genotype frequency between the patients and the controls, suggesting lack of associations between TNF-alpha-308G/A and ATD-induced MPE. CONCLUSION: The TNF-alpha genetic polymorphism -308G/A may not be related to the development of ATD-induced MPE, in contrast to ATD-induced hepatitis. These findings suggest that associations between TNF-alpha-308G/A and ATD-induced adverse reactions can be phenotype-specific.

Clinical Characteristics of Defectors from North Korea Visiting a Single Tertiary Hospital in South Korea / 대한내과학회지

BACKGROUND/AIMS: There are increasing numbers of North Korean defectors, and their health status differs from that of the South Korean population. This study was performed to investigate the clinical characteristics of North Korean defectors visiting a single tertiary hospital in South Korea. METHODS: The medical records of North Korean defectors who visited Dankook University Hospital, Cheonan, South Korea from 1 February 2006 to 30 April 2014 were retrospectively reviewed. Their comorbidities, main reasons for the visit, and most common diseases were investigated. RESULTS: A total of 169 North Korean defectors (163 females, 6 males) visited our hospital. Sixty-eight patients (40.24%) had comorbidities, the most common of which was tuberculosis (13.60%), followed by chronic hepatitis B (10.06%) and chronic hepatitis C (9.47%). North Korean refugees visited the department of ophthalmology (15.71%) most frequently, followed by gastroenterology (15.18%). Cataracts, chronic hepatitis C, chronic hepatitis B, and pulmonary tuberculosis were the most common reasons for the hospital visit. Chronic hepatitis B and chronic hepatitis C were diagnosed in 19.32% and 17.58% of the patients, respectively. Sixteen patients (9.47%) were diagnosed with tuberculosis, and eight of these patients showed multidrug resistance. Of all 169 patients, 17 underwent colonofibroscopy or stool examination, and parasites (Trichuris trichiura, n = 6; Clonorchis sinensis, n = 1) were found in 7 patients (41.18%). CONCLUSIONS: Most North Korean defectors who visited this tertiary hospital in South Korea were female, and they mainly visited the departments of ophthalmology, gastroenterology, and pulmonology. Compared with South Koreans, they showed high rates of chronic hepatitis B, chronic hepatitis C, pulmonary tuberculosis with multidrug resistance, and parasite infection.