Cardiac surgery-associated acute kidney injury.

Cardiac surgery-associated acute kidney injury (CSA-AKI) is a common and serious postoperative complication of cardiac surgery requiring cardiopulmonary bypass (CPB), and it is the second most common cause of AKI in the intensive care unit. Although the complication has been associated with the use of CPB, the etiology is likely multifactorial and related to intraoperative and early postoperative management including pharmacologic therapy. To date, very little evidence from randomized trials supporting specific interventions to protect from or prevent AKI in broad cardiac surgery populations has been found. The definition of AKI employed by investigators influences not only the incidence of CSA-AKI, but also the identification of risk variables. The advent of novel biomarkers of kidney injury has the potential to facilitate the subclinical diagnosis of CSA-AKI, the assessment of its severity and prognosis, and the early institution of interventions to prevent or reduce kidney damage. Further studies are needed to determine how to optimize cardiac surgical procedures, CPB parameters, and intraoperative and early postoperative blood pressure and renal blood flow to reduce the risk of CSA-AKI. No pharmacologic strategy has demonstrated clear efficacy in the prevention of CSA-AKI; however, some agents, such as the natriuretic peptide nesiritide and the dopamine agonist fenoldopam, have shown promising results in renoprotection. It remains unclear whether CSA-AKI patients can benefit from the early institution of such pharmacologic agents or the early initiation of renal replacement therapy.

Economic evaluation of intravenous iodinated contrast media in Italy.

BACKGROUND: Contrast-induced acute kidney injury (CI-AKI) is defined as a deterioration in renal function after administration of radiologic iodinated contrast media (CM). Iodixanol, showed a lower CI-AKI incidence than low-osmolar contrast media (LOCM). A cost-effectiveness analysis was performed comparing iodixanol and LOCM in intravenous (IV) setting in Italy. METHODS: A Markov model was developed. Patients moved across four health states: CI-AKI free, CI-AKI, myocardial infarction, and death. The simulation horizon was lifetime with 1-month cycles. Costs and outcomes were discounted at 3.5 percent rate. CI-AKI incidence was considered from published literature across different definitions. Cost-effectiveness of iodixanol was assessed in terms of incremental cost per life-year gained. Net monetary benefit (NMB) was also calculated. Both deterministic and probabilistic sensitivity analyses were performed. RESULTS: Base-case results showed an average survival increase of 0.51 life-years and a savings of €7.25 for iodixanol versus LOCM. The cost-effectiveness of iodixanol was confirmed when other scenarios were explored, such as varying CI-AKI definition, sub-populations with specified risk factors, CM hospital bids prices, and inclusion of adverse drug reactions of allergic nature. An NMB ranging between €6,007.25 and €30,007.25 was calculated. CONCLUSION: Base-case results show that IV iodixanol is cost-effective compared with LOCM in the Italian clinical setting of a hospital computed tomography radiology practice. However, some caution is due, mainly linked to inherent limitations of the modeling technique and to the lack of agreement on CI-AKI incidence data in the clinical literature.

Effect of percutaneous ventricular assist devices on renal function.

Ventricular assist devices (VADs) are used to improve the systemic circulation and to decrease ventricular loading in patients with hemodynamic instability that is refractory to pharmacologic therapies. During an acute critical event, percutaneous devices are preferred because of their rapid deployment, since implantable devices require more extensive procedures. Implantable devices are used for patients with established end-stage heart failure as a bridge to heart transplantation, recovery or destination therapy. This report reviews mechanical principles and clinical studies regarding percutaneous VAD to address their potential renal effects. Since the focus of this study is set on devices that are dedicated to cardiac support only, extracorporeal membrane oxygenation systems are not included.

Students' engagement and perceptions of small group tutorial classes among undergraduate medical students.

INTRODUCTION: Small group teaching is an educational strategy that may be used to facilitate learning. Tutorials enable an adult approach toward learning where students take responsibility for their own learning. We aimed to investigate the students' engagement and perceptions of small group tutorial classes among undergraduate medical students. METHODS: A cross­sectional, descriptive survey was conducted at the Subbaiah Institute of Medical Sciences, where we collected the data from 300 undergraduate students using convenience sampling method. A self­administered questionnaire consisting of 22 items which was piloted on 20 students, and six experienced medical educators were consulted for face validation. The internal consistency of the questionnaire measured by Cronbach's alpha reliability test was 0.80. It was used to measure the students' perception on the effectiveness of tutorials with regard to learning experience, teamwork, confidence, communication skills, and role of the teacher. Statistical analyses included mean and standard deviation for the description of each item, t-test to compare the mean scores for gender and class year, and one­way analysis of variance between groups for age group comparisons using SPSS version 24 software. RESULTS: Students' overall perceptions of small group teaching effectiveness showed that tutorials were beneficial to their learning process (mean: 3.61±0.50). The majority of the students have positive perceptions toward small group effectiveness, particularly in learning experience (mean: 3.72±0.68) and teamwork (mean: 3.36±0.59). A significant difference was found between year 1 and year 2 students with regards to learning experience (p<0.001), teamwork (p<0.05), communication skills (p<0.05), and the role of the tutor (p<0.001). Additionally, the mean scores, measuring overall effectiveness of tutorials, for the 2nd year students were significantly higher than that for the 1st year students (3.70± .41 and 3.50 ±0.57, (p<0.001). CONCLUSIONS: The data of this study show that tutorial is an effective small group teaching method for medical students compared to large group teaching.

Computer-aided diagnosis of cirrhosis and hepatocellular carcinoma using multi-phase abdomen CT.

PURPOSE: High mortality rate due to liver cirrhosis has been reported over the globe in the previous years. Early detection of cirrhosis may help in controlling the disease progression toward hepatocellular carcinoma (HCC). The lack of trained CT radiologists and increased patient population delays the diagnosis and further management. This study proposes a computer-aided diagnosis system for detecting cirrhosis and HCC in a very efficient and less time-consuming approach. METHODS: Contrast-enhanced CT dataset of 40 patients (n = 40; M:F = 5:3; age = 25-55 years) with three groups of subjects: healthy (n = 14), cirrhosis (n = 12) and cirrhosis with HCC (n = 14), were retrospectively analyzed in this study. A novel method for the automatic 3D segmentation of liver using modified region-growing segmentation technique was developed and compared with the state-of-the-art deep learning-based technique. Further, histogram parameters were calculated from segmented CT liver volume for classification between healthy and diseased (cirrhosis and HCC) liver using logistic regression. Multi-phase analysis of CT images was performed to extract 24 temporal features for detecting cirrhosis and HCC liver using support vector machine (SVM). RESULTS: The proposed method produced improved 3D segmentation with Dice coefficient 90% for healthy liver, 86% for cirrhosis and 81% for HCC subjects compared to the deep learning algorithm (healthy: 82%; cirrhosis: 78%; HCC: 70%). Standard deviation and kurtosis were found to be statistically different (p < 0.05) among healthy and diseased liver, and using logistic regression, classification accuracy obtained was 92.5%. For detecting cirrhosis and HCC liver, SVM with RBF kernel obtained highest slice-wise and patient-wise prediction accuracy of 86.9% (precision = 0.93, recall = 0.7) and 80% (precision = 0.86, recall = 0.75), respectively, than that of linear kernel (slice-wise: accuracy = 85.4%, precision = 0.92, recall = 0.67; patient-wise: accuracy = 73.33%, precision = 0.75, recall = 0.75). CONCLUSIONS: The proposed computer-aided diagnosis system for detecting cirrhosis and hepatocellular carcinoma (HCC) showed promising results and can be used as effective screening tool in medical image analysis.

Controlling Lipids AIDS in the Prevention of Type 2 Diabetes, Hypertension, and Cardiovascular Diseases.

BACKGROUND: Abnormal lipid profiles are a characteristic feature of persons with chronic conditions in which the diabetic populations are recognized as the dominant group, regardless of gender and ethnicity worldwide. This study was conducted to identify and evaluate the abnormalities of serum lipid profiles in both nondiabetic and diabetic persons. METHODS: This study was a case-control investigation conducted between 2013 and 2015. The study enrolled 266 patients from the North Central and South West Regional Health Authorities of Trinidad. Of the 266 patients recruited, 126 were diabetic and 140 were nondiabetic. RESULTS: Our study observed that dyslipidemia was present among the nondiabetic populations as the nondiabetics had 55 women and 20 men with high cholesterol, 22 women and 14 men with high triglyceride (TG), 30 women and 25 men with low high-density lipoprotein cholesterol (HDL-C), 42 women and 21 men with high low-density level-cholesterol (LDL-C), 13 women and 8 men with high very low-density lipoprotein (VLDL), and also 30 women and 11 men with body mass index (BMI) over 30 kg/m2. We also observed that diabetic women had significantly lower TGs (P = 0.019) and higher HDL-C (P = 0.001) and LDL (P = 0.003) when compared with the diabetic men. In addition, the nondiabetic females also had higher HDL-C (P = 0.045) when compared to their male counterparts. Both diabetic and nondiabetic women exhibited significantly higher BMI of P = 0.000. A negative correlation was obtained among TGs and HDL (r = -0.356, n = 83, P = 0.001) and a positive correlation was observed among LDL and HDL (r = 0.230, n = 86, P = 0.035). CONCLUSIONS: This study observed the incidences in the abnormalities of serum lipid profiles in both nondiabetic and diabetic persons. It also presents the high occurrence of nondiabetic women with dyslipidemia as they presented with high cholesterol, high TG, low HDL-C, and high VLD-L with BMI over 30 kg/m2.

Cardiac surgery-associated acute kidney injury.

Cardiac surgery-associated acute kidney injury (CSA-AKI) is a common and serious postoperative complication of cardiac surgery requiring cardiopulmonary bypass (CPB), and it is the second most common cause of AKI in the intensive care unit. Although the complication has been associated with the use of CPB, the etiology is likely multifactorial and related to intraoperative and early postoperative management including pharmacologic therapy. To date, very little evidence from randomized trials supporting specific interventions to protect from or prevent AKI in broad cardiac surgery populations has been found. The definition of AKI employed by investigators influences not only the incidence of CSA-AKI, but also the identification of risk variables. The advent of novel biomarkers of kidney injury has the potential to facilitate the subclinical diagnosis of CSA-AKI, the assessment of its severity and prognosis, and the early institution of interventions to prevent or reduce kidney damage. Further studies are needed to determine how to optimize cardiac surgical procedures, CPB parameters, and intraoperative and early postoperative blood pressure and renal blood flow to reduce the risk of CSA-AKI. No pharmacologic strategy has demonstrated clear efficacy in the prevention of CSA-AKI; however, some agents, such as the natriuretic peptide nesiritide and the dopamine agonist fenoldopam, have shown promising results in renoprotection. It remains unclear whether CSA-AKI patients can benefit from the early institution of such pharmacologic agents or the early initiation of renal replacement therapy.

Remote monitoring of peritoneal dialysis in special locations.

Peritoneal dialysis (PD) as a therapy with all its advantages has not grown as would have been expected except in certain pockets, notably in Asia. In our opinion, from patient and their family interviews, a perception among prospective PD patients of inaccessibility to the referral PD Unit (RPU), usually for patients from rural areas in far flung places, inaccessible due to difficult terrain or long distances, play a strong role against the choice of PD as their modality choice for end-stage renal disease. We decided to address this issue by adopting novel initiatives such as easy access to the RPU through usage of internet and mobile phones from the patient homes especially in addressing the more clinically relevant infectious complications such as peritonitis and exit site infections with immediate treatment management responses from the RPU. In addition, we found that inherently the rural PD patients had several advantages over their urban counterparts and also over their hemodialysis (HD) counterparts in many socioeconomic, emotional support and nutritional parameters. We enhanced these advantages with an intensive home visit program. This two pronged approach has paid dividends in that our rural PD patients do as well, if not better than the urban PD and the HD patients, contrary to prevailing international experience.