COVID-19 in patients undergoing chronic kidney replacement therapy and kidney transplant recipients in Scotland: findings and experience from the Scottish renal registry.

BACKGROUND: Infection with the severe acute respiratory coronavirus 2 (SARS-CoV-2) has led to a worldwide pandemic with coronavirus disease 2019 (COVID-19), the disease caused by SARS-CoV-2, overwhelming healthcare systems globally. Preliminary reports suggest a high incidence of infection and mortality with SARS-CoV-2 in patients receiving kidney replacement therapy (KRT). The aims of this study are to report characteristics, rates and outcomes of all patients affected by infection with SARS-CoV-2 undergoing KRT in Scotland. METHODS: Study design was an observational cohort study. Data were linked between the Scottish Renal Registry, Health Protection Scotland and the Scottish Intensive Care Society Audit Group national data sets using a unique patient identifier (Community Health Index (CHI)) for each individual by the Public Health and Intelligence unit of Public Health, Scotland. Descriptive statistics and survival analyses were performed. RESULTS: During the period 1st March 2020 to 31st May 2020, 110 patients receiving KRT tested positive for SARS-CoV-2 amounting to 2% of the prevalent KRT population. Of those affected, 86 were receiving haemodialysis or peritoneal dialysis and 24 had a renal transplant. Patients who tested positive were older and more likely to reside in more deprived postcodes. Mortality was high at 26.7% in the dialysis patients and 29.2% in the transplant patients. CONCLUSION: The rate of detected SARS-CoV-2 in people receiving KRT in Scotland was relatively low but with a high mortality for those demonstrating infection. Although impossible to confirm, it appears that the measures taken within dialysis units coupled with the national shielding policy, have been effective in protecting this population from infection.

Factors influencing withdrawal from dialysis: a national registry study.

BACKGROUND: Dialysis withdrawal is the third most common cause of death in patients receiving dialysis for established renal failure (ERF) in Scotland. We describe incidence, risk factors and themes influencing decision-making in a national renal registry. METHODS: Details of deaths in those receiving renal replacement therapy (RRT) for ERF in Scotland are reported to the Scottish Renal Registry via a unique mortality report. We extracted patient demographics and comorbidity, cause and location of death, duration of RRT and pertinent free text comments from 1 January 2008 to 31 December 2014. Withdrawal incidence was calculated and logistic regression used to identify significantly influential variables. Themes emerging from clinician comments were tabulated for descriptive purposes. RESULTS: There were 2596 deaths; median age at death was 68 [interquartile range (IQR) 58, 76] years, 41.5% were female. Median duration on RRT was 1110 (IQR 417, 2151) days. Dialysis withdrawal was the primary cause of death in 497 (19.1%) patients and withdrawal contributed to death in a further 442 cases (17.0%). The incidence was 41 episodes per 1000 patient-years. Regression analysis revealed increasing age, female sex and prior cerebrovascular disease were associated with dialysis withdrawal as a primary cause of death. Conversely, interstitial renal disease, angiographically proven ischaemic heart disease, valvular heart disease and malignancy were negatively associated. Analysis of free text comments revealed common themes, portraying an image of physical and psychological decline accelerated by acute illnesses. CONCLUSIONS: Death following dialysis withdrawal is common. Factors important to physical independence-prior cerebrovascular disease and increasing age-are associated with withdrawal. When combined with clinician comments this study provides an insight into the clinical decline affecting patients and the complexity of this decision. Early recognition of those likely to withdraw may improve end of life care.

Preventive effect of nasal filters on allergic rhinitis: A randomized, double-blind, placebo-controlled crossover park study.

BACKGROUND: A recently reported small, out-of-season environmental exposure unit study found nasal filters to be efficacious in preventing seasonal allergic rhinitis (AR). However, nasal filters still need to show efficacy in a natural setting in a regular pollen season. OBJECTIVE: We sought to evaluate the efficacy of nasal filters (Rhinix; Rhinix ApS, Aarhus, Denmark) for the prevention of symptoms related to seasonal AR. METHODS: The trial was a single-center, randomized (1:1), double-blind, placebo-controlled crossover clinical trial (NCT02108574) conducted over 2 days in the main grass pollen season in June 2014 in Aarhus, Denmark, on 65 adults with proven grass allergy. A total nasal symptom score (TNSS) consisting of blocked nose, runny nose, nasal itching, and sneezing was used to evaluate symptoms. The difference in daily∑ TNSS (the sum of 13 ratings) was the primary outcome measure. The difference in maximum TNSS (highest score, 13 ratings) was also evaluated. RESULTS: The nasal filters significantly reduced daily∑ TNSSs (P = .03) and maximum TNSSs (P = .03) compared with placebo. Median relative reductions were 40% for daily∑ TNSSs (P = .02), 43% for maximum TNSSs (P = .004), 83% for daily∑ sneezing (P = .001), 75% for daily∑ watery eyes (P = .02), and 53% for daily∑ runny nose (P = .005) when compared with placebo. The nasal filters were well tolerated, and no serious adverse events were recorded. CONCLUSION: Statistically significant and clinically relevant reductions were achieved for the primary outcome measure of daily∑ TNSS, for maximum TNSS and for a subset of individual symptoms. The results support the preventive role of nasal filters for managing seasonal AR.

Relative efficiencies of the Burkard 7-Day, Rotorod and Burkard Personal Samplers for Poaceae and Urticaceae pollen under field conditions.

INTRODUCTION: In aerobiological studies it is often necessary to compare concentration data recorded with different models of sampling instrument. Sampler efficiency typically varies from device to device, and depends on the target aerosol and local atmospheric conditions. To account for these differences inter-sampler correction factors may be applied, however for many pollen samplers and pollen taxa such correction factors do not exist and cannot be derived from existing published work. MATERIALS AND METHODS: In this study, the relative efficiencies of the Burkard 7-Day Recording Volumetric Spore Trap, the Sampling Technologies Rotorod Model 20, and the Burkard Personal Volumetric Air Sampler were evaluated for Urticaceae and Poaceae pollen under field conditions. The influence of wind speed and relative humidity on these efficiency relationships was also assessed. Data for the two pollen taxa were collected during 2010 and 2011-2012, respectively. RESULTS: The three devices were found to record significantly different concentrations for both pollen taxa, with the exception of the 7-Day and Rotorod samplers for Poaceae pollen. Under the range of conditions present during the study, wind speed was found to only have a significant impact on inter-sampler relationships involving the vertically-orientated Burkard Personal sampler, while no interaction between relative efficiency and relative humidity was observed. CONCLUSIONS: Data collected with the three models of sampler should only be compared once the appropriate correction has been made, with wind speed taken into account where appropriate.

Do urban canyons influence street level grass pollen concentrations?

In epidemiological studies, outdoor exposure to pollen is typically estimated using rooftop monitoring station data, whilst exposure overwhelmingly occurs at street level. In this study the relationship between street level and roof level grass pollen concentrations was investigated for city centre street canyon environments in Aarhus, Denmark, and London, UK, during the grass pollen seasons of 2010 and 2011 respectively. For the period mid-day to late evening, street level concentrations in both cities tended to be lower than roof-level concentrations, though this difference was found to be statistically significant only in London. The ratio of street/roof level concentrations was compared with temperature, relative humidity, wind speed and direction, and solar radiation. Results indicated that the concentration ratio responds to wind direction with respect to relative canyon orientation and local source distribution. In the London study, an increase in relative humidity was linked to a significant decrease in street/roof level concentration ratio, and a possible causative mechanism involving moisture mediated pollen grain buoyancy is proposed. Relationships with the other weather variables were not found to be significant in either location. These results suggest a tendency for monitoring station data to overestimate exposure in the canyon environment.

How safe is renal replacement therapy? A national study of mortality and adverse events contributing to the death of renal replacement therapy recipients.

BACKGROUND: Patients receiving treatment with renal replacement therapy (RRT) have high mortality, and ensuring patient safety in this population is difficult. We aimed to estimate the incidence and nature of medical adverse events contributing to the death of patients being treated with RRT. METHODS: This population registry-based retrospective case review study included all patients being treated with RRT for established renal failure in Scotland and who died between 1 January 2008 and 30 June 2011. Deaths were reviewed by consultant nephrologists using a structured questionnaire to identify factors contributing to death occurring in both the inpatient and outpatient setting. Reviewers were able to use any information source deemed relevant, including paper and electronic clinical records, mortality and morbidity meetings and procurator fiscal (Scottish coroner) investigations. Deaths occurring in 2008 and 2009 where avoidable factors were identified that may have or did lead to death of a patient were subject to further review and root cause analysis, in order to identify recurrent themes. RESULTS: Of 1551 deaths in the study period, 1357 were reviewed (87.5%). Cumulative RRT exposure in the cohort was 2.78 million person-days. RRT complications were the primary cause of death in 28 (2.1%). Health-care-associated infection had contributed to 9.6% of all deaths. In 3.5% of deaths, factors were identified which may have or did contribute to death. These were both organizational and human error related and were largely due to five main causes: management of hyperkalaemia, prescribing, out of hours care, infection and haemodialysis vascular access. CONCLUSIONS: Adverse events contributing to death in RRT recipients mainly relate to the everyday management of common medical problems and not the technical aspects of RRT. Efforts to avoid harm in this population should address these ubiquitous causes of harm.

Personal exposure to grass pollen: relating inhaled dose to background concentration.

BACKGROUND: Very few studies on human exposure to allergenic pollen have been conducted using direct methods, with background concentrations measured at city center monitoring stations typically taken as a proxy for exposure despite the inhomogeneous nature of atmospheric pollen concentrations. A 2003 World Health Organization report highlighted the need for an improved understanding of the relation between monitoring station data and actual exposure. OBJECTIVE: To investigate the relation between grass pollen dose and background concentrations measured at a monitoring station, to assess the fidelity of monitoring station data as a qualitative proxy for dose, and to evaluate the ratio of dose rate to background concentration. METHODS: Grass pollen dose data were collected in Aarhus, Denmark, in an area where grass pollen sources were prevalent, using Nasal Air Samplers. Sample collection lasted for approximately 25 to 30 minutes and was performed at 2-hour intervals from noon to midevening under moderate exercise by 2 individuals. RESULTS: A median ratio of dose rate to background concentration of 0.018 was recorded, with higher ratio values frequently occurring at 12 to 2 PM, the time of day when grass species likely to be present in the area are expected to flower. From 4 to 8 PM, dose rate and background concentration data were found to be strongly and significantly correlated (rs = 0.81). Averaged dose rate and background concentration data showed opposing temporal trends. CONCLUSION: Where local emissions are not a factor, background concentration data constitute a good quantitative proxy for inhaled dose. The present ratio of dose rate to background concentration may aid the study of dose-response relations.

Buttonhole needling of ateriovenous fistulae: a randomized controlled trial.

Buttonhole needling of arteriovenous fistulae (AVFs) was first described 30 years ago, but little evidence has been reported to show how it might differ from the standard rope-ladder technique. We carried out a randomized control trial comparing these two techniques. All suitable patients within the region were considered for recruitment. Patients were then randomized to continue with traditional rope-ladder needling or changed to buttonhole needling. A mean of 13.7 (median, 11) sharp needles were required to create a track. Nine of 22 patients in the buttonhole group reduced or stopped local anesthetic (LA) for needle insertion compared with one of 25 in the traditional group. The diameter of the buttonhole AVFs remained unchanged, whereas the control group increased in size by 30% +/- 7% (p < 0.01), equivalent to an absolute increase of 5 mm. There was no difference in bleeding times, but there was a preference for the buttonhole technique with 21 of the 22 patients and 15 of 23 nurses preferring buttonhole needling. Buttonhole needling is preferred by both patients and staff, reduces discomfort during needling and reduces AVF enlargement. There is a low level of complication.

Salivary type tumors seen in consultation.

The aim of this study is to characterize personal consultation practice in salivary pathology and to identify most common diagnostic challenges. Seven hundred sixty consultation requests were prospectively indexed over 12 months, and 205 cases of salivary type tumors were identified. The following data were recorded: anatomic site, patients' age and gender, geographic origin of cases, diagnoses by submitting pathologist and consultant, and turn-around time. Final diagnosis was offered by submitting pathologist in 77 of 205 cases (37.5%). The definitive diagnosis was provided to contributors in 188 of 205 cases (91.7%); diagnostic limitations and potential adequacy issues were addressed in 17 remaining cases. The average turn-around time was 4.4 days. The three most common diagnostic problems were acinic cell carcinoma, epithelial myoepithelial carcinoma, and adenoid cystic carcinoma. Pathologists' adherence to recommendations by Association of Directors of Anatomic and Surgical Pathology regarding consultation practice is described.

Cystic parathyroid lesions: functional and nonfunctional parathyroid cysts.

HYPOTHESIS: Functional parathyroid cysts (FPCs) and nonfunctional parathyroid cysts (NPCs) are 2 distinct clinical and histologic entities. DESIGN: Review of prospective clinical database records. SETTING: Tertiary academic center. PATIENTS: Patients enrolled in a prospective surgical database between January 1, 1990, and May 31, 2007. INTERVENTION: Cervical exploration for primary hyperparathyroidism or cervical mass. MAIN OUTCOME MEASURES: Age, sex, morbidity, imaging results, pathologic findings, cyst characteristics (size, location, and fluid), and perioperative calcium and parathyroid hormone levels. RESULTS: Cystic parathyroid lesions were found in 48 of 1769 patients (3%) studied. Functional parathyroid cysts were more common than NPCs, arising in 41 of 48 patients (85%), and showed no predisposition for sex or embryologic origin. Single-photon emission computed tomographic imaging failed to localize FPCs in 12 of 37 patients (32%). The fluid in FPCs was clear or colorless in 9 of 15 characterized specimens (60%). Rupture of cystic parathyroid lesions during resection was associated with prolonged elevation of intraoperative parathyroid hormone levels (P =.045). Cystic parathyroid lesions weighing 4 g or more were associated with the development of postoperative symptomatic hypocalcemia (P =.03). Functional parathyroid cysts occurred exclusively in adenomas with cystic change, whereas NPCs (with 1 exception) were without associated adenoma on final histologic examination. CONCLUSIONS: Cystic parathyroid lesions often contain turbid or colored fluid, and FPCs are more common than NPCs. Neck cysts of uncertain origin should be diagnostically aspirated for parathyroid hormone content. During resection, cyst rupture should be avoided, and patients with large cysts should be managed expectantly to forestall the development of symptomatic hypocalcemia. Functional parathyroid cysts and NPCs are likely 2 separate clinical and histologic entities.

Diffuse filiform polyposis with unique histology mimicking familial adenomatous polyposis in a patient without inflammatory bowel disease.

Filiform polyposis is an uncommon entity that is most often encountered in the colon of patients with a history of inflammatory bowel disease (IBD). Filiform polyposis is characterized by a large number of "wormlike" polyps lined by histologically normal colonic mucosa. These polyps can mimic adenomatous polyps. Only rare cases without a history or evidence of IBD have been reported. Neuromuscular and vascular hamartoma of the small bowel is a rare, focal disorder characterized by disorganized smooth muscle fascicles throughout the submucosa accompanied by fibrosis, nerve fibers, ganglion cells, and vessels. To our knowledge, there is only one report of this lesion in the large bowel (cecum), where it presented as a mass. Here we report the case of a 50-year-old man with no known history or symptoms of IBD presenting with filiform polyposis involving the entire colon, clinically mimicking familial adenomatous polyposis, and showing histologic features similar to neuromuscular and vascular hamartoma of the small bowel.

Multimodality treatment in a case of primary cardiac lymphoma.

Primary cardiac lymphoma(PCL) is an exceptionally rare entity associated with a poor progonosis. The patient in this report underwent successful surgical resection of a PCL. We now describe her multimodality treatment including autologous stem cell transplantation which resulted in a 22 month survival.