Patient-nephrologist prognostic awareness and discordance in end stage renal disease on renal replacement therapy.

PURPOSE: The 1-year mortality rate of patients with end-stage renal disease (ESRD) on renal replacement therapy (RRT) is 20-25% comparable to many cancers. Studies have shown that cancer patients commonly overestimate their likelihood of survival relative to their physicians. It is unclear if this translates into other terminal illnesses. METHODS: Adult and elderly patients with ESRD on RRT without cognitive defect were interviewed to evaluate their prognostic estimates at 1 and 5 years. Past medical history and demographic data was abstracted from their medical charts. Each patient's proper nephrologist was then interviewed regarding his proper prognostic estimate for this patient. Both the patient and the nephrologist's estimates were compared and a difference of greater than 20% was defined as the threshold for prognostic concordance. RESULTS: 77% of patients were found to be in prognostic discordance with their nephrologists. This group was older, had more comorbidities, a lower albumin level and a poorer prognosis. The majority of patients were in disagreement with their nephrologists regarding whether a discussion about prognosis had taken place. The choice of end of life care for 55% of patients was focused on relieving pain and discomfort. CONCLUSION: Communication of prognosis and discussions related to life expectancy and end of life care are lacking in the routine care of ESRD patients. ESRD patients therefore tend to overestimate their prognosis which might lead to overutilization of invasive procedures with increased acute healthcare costs as well as a delay in instigation of palliative or hospice measures.

Achromobacter xylosoxidans/denitrificans bacteremia and subsequent fatal Escherichia coli/Streptococcus anginosus pleural empyema.

Achromobacter xylosoxidans, a gram-negative bacillus with low virulence has rarely been reported to cause clinically significant infections. We report an unusual case of MDR Achromobacter xylosoxidans/denitrificans bacteremia from a peripherally inserted central catheter (PICC) and subsequent fatal pleural empyema due to MDR Escherichia coli and Streptococcus anginosus. A 44-year-old male presented to the hospital with chief complaints of chest tightness associated with a productive cough. He was found to have pleural empyema secondary to MDR E. coli and S. anginous. Three months prior to current presentation, he had a history of MDR A. xylosoxidans originating from a PICC. The patient expired even after appropriate management. Thoracic empyema continues to cause significant morbidity and mortality despite the improvement of antimicrobial therapy and the existence of multiple options for drainage of the infected pleural space. The bacteriology of thoracic empyema has been changing since the introduction of antibiotics. Typical antibiotics used to treat these MDR pathogens have become obsolete. Therefore, physicians should be aggressive in their diagnostic approach to pleural empyema, since the isolation of MDR aerobic gram-negative bacilli or multiple pathogens from the pleural fluid is associated with a poor prognosis and indicates a need for more aggressive antimicrobial chemotherapy. Also, the association of indwelling medical devices and MDR Achromobacter bacteremia should be known.

Spontaneous subcutaneous emphysema of the scalp following hair coloring/treatment.

Subcutaneous emphysema of the scalp is a process often attributed to secondary factors such as trauma, infection, or a myriad of iatrogenic etiologies. Here, we are presenting a case report of an adult patient with spontaneous subcutaneous emphysema of the scalp following a hair coloring/treatment. We performed an extensive review of literature on this topic, however, could not find a single case with similar presentation of subcutaneous emphysema. This case demonstrates an unreported etiology for this diagnosis and is thus being reported for its uniqueness and to raise clinical awareness.