Coronary Artery Disease, Cardiac Arrest, and Shared Decision Making in a Recreational Athlete.

A highly active 59-year-old-man with a history of cardiac arrest and myocardial infarction presented for exercise recommendations. Multimodality risk stratification led to ventricular fibrillation cardiac arrest at the completion of a maximal effort cardiopulmonary exercise test. Using shared decision making, the safety and feasibility of returning to exercise were discussed. (Level of Difficulty: Intermediate.).

Noninvasive Vocal Biomarker is Associated With Severe Acute Respiratory Syndrome Coronavirus 2 Infection.

OBJECTIVE: To investigate the association of voice analysis with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. PATIENTS AND METHODS: A vocal biomarker, a unitless scalar with a value between 0 and 1, was developed based on 434 voice samples. The biomarker training was followed by a prospective, multicenter, observational study. All subjects were tested for SARS-CoV-2, had their voice recorded to a smartphone application, and gave their informed consent to participate in the study. The association of SARS-CoV-2 infection with the vocal biomarker was evaluated. RESULTS: The final study population included 80 subjects with a median age of 29 [range, 23 to 36] years, of whom 68% were men. Forty patients were positive for SARS-CoV-2. Infected patients were 12 times more likely to report at least one symptom (odds ratio, 11.8; P<.001). The vocal biomarker was significantly higher among infected patients (OR, 0.11; 95% CI, 0.06 to 0.17 vs OR, 0.19; 95% CI, 0.12 to 0.3; P=.001). The area under the receiver operating characteristic curve evaluating the association of the vocal biomarker with SARS-CoV-2 status was 72%. With a biomarker threshold of 0.115, the results translated to a sensitivity and specificity of 85% (95% CI, 70% to 94%) and 53% (95% CI, 36% to 69%), respectively. When added to a self-reported symptom classifier, the area under the curve significantly improved from 0.775 to 0.85. CONCLUSION: Voice analysis is associated with SARS-CoV-2 status and holds the potential to improve the accuracy of self-reported symptom-based screening tools. This pilot study suggests a possible role for vocal biomarkers in screening for SARS-CoV-2-infected subjects.

What Do We Know about Opioids and the Kidney?

Evidence suggests a link between opioid use and kidney disease. This review summarizes the known renal manifestations of opioid use including its role in acute and chronic kidney injury. Both the direct and indirect effects of the drug, and the context which leads to the development of renal failure, are explored. While commonly used safely for pain control and anesthesia in those with kidney disease, the concerns with respect to side effects and toxicity of opioids are addressed. This is especially relevant with the worldwide increase in the use of opioids for medical and recreational use.

Metabolic profiling of a chronic kidney disease cohort reveals metabolic phenotype more likely to benefit from a probiotic.

SCOPE: Persistent reduction in Glomerular Filtration Rate (GFR) is a hallmark of Chronic Kidney Disease (CKD) and is associated with an elevation of Blood Urea Nitrogen (BUN). This metabolomics pilot study sought to identify metabolites that differentiated patients with CKD whose BUN decreased on a probiotic and possible mechanisms. METHODS AND RESULTS: Metabolomics was used to analyze baseline plasma samples previously diagnosed with CKD Stage III-IV. Patients had participated in a dose escalation study of the probiotic Renadyl™. A total of 24 samples were categorized depending on whether BUN increased or decreased from baseline after 4 months of probiotic use. Multivariate analysis was used to analyze the data and determine the metabolites that best differentiated the phenotypic groups. The sixteen patients who had a decrease in BUN were not significantly different based on demographic and clinical measures from those whose BUN increased or did not change with the exception of age. Eleven of the fourteen metabolites that differentiated the groups were known to be modulated by gut microflora, which may eventually provide a mechanistic link between probiotic and outcomes. CONCLUSIONS: Metabolomics revealed metabolites at baseline that may predict individuals with CKD that would most benefit from a probiotics.

Fourth-Year Medical Student Charting of Older Persons' Cognitive and Functional Status.

BACKGROUND AND OBJECTIVES: Functional and cognitive impairment correlates with medical outcomes in older persons, yet documentation in the medical record is often inadequate. The purpose of this pilot study was to evaluate fourth year (M4) medical students' charting performance of cognition and functional status in older persons during non-geriatric clerkships using an audit tool. METHODS: The research assistants used a chart abstracting tool to retrospectively review patients' charts. The abstracting tool contained keywords and phrases to prompt the research assistants to look for any documentation of patient status in four domains: (1) delirium or acute confusional state, (2) chronic cognitive impairment, (3) activities of daily living, and (4) instrumental activities of daily living. The threshold was any mention of keywords in these domains. RESULTS: On non-geriatrics M4 clerkships in the hospital, students documented acute cognitive status (ACS) and presence or absence of chronic cognitive impairment (CCI) in 57% and 68% of cases respectively, with physicians and/or nurses doing it more often at 63% and 84%. Both students and other care providers documented ACS and CCI in the same charts 41% and 59% of the time, respectively. Students documented activities of daily living (ADLs) and instrumental activities of daily living (IADLs) 31% and 3% respectively, physicians and/or nurses 59% and 0%. CONCLUSIONS: Documentation of cognitive status in hospital charts for students and physicians was somewhat higher than in the literature. This may be because geriatrics is integrated into our 4-year curriculum. Documentation by both students and physicians was better for ADLs than IADLs and poor for IADLs overall.

Randomized controlled trial of strain-specific probiotic formulation (Renadyl) in dialysis patients.

BACKGROUND: Primary goal of this randomized, double-blind, placebo-controlled crossover study of Renadyl in end-stage renal disease patients was to assess the safety and efficacy of Renadyl measured through improvement in quality of life or reduction in levels of known uremic toxins. Secondary goal was to investigate the effects on several biomarkers of inflammation and oxidative stress. METHODS: Two 2-month treatment periods separated by 2-month washout and crossover, with physical examinations, venous blood testing, and quality of life questionnaires completed at each visit. Data were analyzed with SAS V9.2. RESULTS: 22 subjects (79%) completed the study. Observed trends were as follows (none reaching statistical significance): decline in WBC count (-0.51 × 10(9)/L, P = 0.057) and reductions in levels of C-reactive protein (-8.61 mg/L, P = 0.071) and total indoxyl glucuronide (-0.11 mg%, P = 0.058). No statistically significant changes were observed in other uremic toxin levels or measures of QOL. CONCLUSIONS: Renadyl appeared to be safe to administer to ESRD patients on hemodialysis. Stability in QOL assessment is an encouraging result for a patient cohort in such advanced stage of kidney disease. Efficacy could not be confirmed definitively, primarily due to small sample size and low statistical power-further studies are warranted.

Chronic kidney disease in the elderly: evaluation and management.

Chronic kidney disease (CKD) is a very common clinical problem in elderly patients and is associated with increased morbidity and mortality. As life expectancy continues to improve worldwide, there is a rising prevalence of comorbidities and risk factors such as hypertension and diabetes predisposing to a high burden of CKD in this population. The body of knowledge on the approach to elderly patient with CKD is still evolving. Thus, this review seeks to explore the epidemiology and to discuss current understanding of challenges in the diagnosis and management of elderly patients CKD.

Renal function status.

OBJECTIVE: The objective of this article is to review and evaluate the various parameters used in determining renal status. CONCLUSION: The physiologic determination of renal status is the measured glomerular filtration rate (mGFR). Serum creatinine, blood urea nitrogen, cystatin C, and estimated GFR (eGFR), based on serum creatinine have failed to replace mGFR. All physicians should be aware of limitations of substituted mGFR.

Peritoneal dialysis should not be the first choice for renal replacement therapy in the elderly.

Based on our review, it appears fair to infer that substantive differences in long-term outcome with PD compared with in-center HD have not been documented. PD may offer a slight advantage in younger, nondiabetic patients in the early phase of renal replacement therapy. Nevertheless, PD is not an advantageous option for that large cohort of the dialysis population in the United States comprised of elderly patients with diabetes.

A step toward solving the long-term care dilemma for living kidney donors.

Living kidney donor transplantation, universally recognized as the best current option in care for patients with end-stage renal disease, has shown a static growth in application in the United States despite continued expansion of the prevalent number of patients sustained by dialysis. Whether insurance providers' deficient payment to transplantation facilities for long-term costs generated by living kidney donors contributes to the problem was examined by the facility. Precise focus on all coding and billing for services rendered during care beyond 6 months effectively increased reimbursement from insurance providers for a living kidney donor from 47% to 85% of the amount billed. Although the sample of 82 donors was small and predominantly white (81.7%), it seems reasonable to suggest that centers with a low rate of payment consider an examination of their own billing and coding practices. The extent of donor resistance to participate in a continuing posttransplantation relationship with the transplantation center previously linked to financial issues borne by the donor remains unaddressed and could be explored in a subsequent study.

Initial description of cerebral oximetry measurement in heart failure patients.

Cerebral oximetry is a noninvasive technology using near-infrared spectroscopy (NIRS) to monitor regional cerebral tissue oxygen saturation (SctO(2)). NIRS has been widely used for assessing cerebral tissue oxygenation in a variety of populations including the fields of neonatology, anesthesiology, neurology, and cardiac surgery.However, little information has been reported on cerebral oximetry in heart failure (HF) patients. In this observational study, we enrolled 30 patients (15 men) aged 23 to 82 years (mean 67 years) with stage C HF. All patients had New York Heart Association (NYHA) functional class I to III. All patients were on stable HF medical therapy. SctO(2) measurements were recorded from the left and right forehead simultaneously, using FORE-SIGHT cerebral oximeter (CAS Medical Systems Inc, Branford, CT). Feasible associations with SctO(2) risk factors, known to correlate with HF, were recorded. The mean SctO(2) value was 67.4% (range, 47.6%-76.3%), while the mean peripheral tissue saturation (SpO(2)) was 97% (range, 92%-100%). The mean difference between cerebral and peripheral tissue oxygenation (SpO(2)-SctO(2)) was 29.2% (range, 19.2%-51.4%). There was also a significant positive correlation between SctO(2) and mean arterial blood pressure (0.55, P<.01). Statistically significant lower SctO(2) values were observed in patients with diabetes (P=.026; confidence interval [CI], 0.006-0.090) and in patients with dyslipidemia (P=.007; CI, 0.018-0.103). In this initial description of SctO(2) in patients with stage C HF, we noted a wide range of SctO(2) measurements. For most patients, there was a profound SpO(2)-SctO(2) difference, despite near-normal peripheral oxygen saturations. The authors suggest that SctO(2) is a potentially important biomarker to measure in HF patients and may be a useful marker of target organ perfusion.

Obstructed or malpositioned urethral catheter induced acute kidney injury.

Unanticipated renal failure may be induced by an obstructed urethral catheter that was a component of complex management or difficult insertion. Two patients with new-onset uremia due to obstructed urethral catheters evinced rapid return of renal function when their blocked catheters were replaced.