Policy and Payment Decisions on Peritoneal Dialysis in the United States: A Review.

End-stage kidney disease (ESKD) accounts for a sizable proportion of Medicare spending. Peritoneal dialysis remains an underutilized treatment modality for ESKD despite its quality of life and cost-saving benefits. Medicare policy on reimbursements and patient eligibility for dialysis coverage has been amended numerous times since its inception in 1972. Over the last two decades, Medicare policy on ESKD reimbursements has evolved from a primarily fee-for-service model to a prospective payment system, and within the past few years, it has begun including more experimental payment structures. While prior work has explored the evolution of Medicare's ESKD policy as a whole, we specifically outline the impact of Medicare policy changes on peritoneal dialysis reimbursement rates, uptake by physicians and dialysis facilities, and accessibility to patients. This narrative review offers historical insights, an overview of modern ESKD policy, actionable strategies, and policy opportunities to increase the accessibility of this treatment modality.

The power of three: Atrial rate limit power-on-reset - A non-electromagnetic cause of pacemaker-induced extracardiac stimulation.

BACKGROUND: Power-on reset (PoR) is most commonly due to electromagnetic interference. Full PoR results in a switch to an inhibited mode (VVI) pacing and resets pacing outputs to maximal unipolar settings, leading to extracardiac stimulation. METHODS: We present a case of PoR occurrence in the absence of electromagnetic interference, resulting in pectoral stimulation triggered by violation of the atrial rate limit. CONCLUSIONS: It is useful for clinicians to recognizethe occurrence of PoR in the setting of atrial limit violation andthe appropriate management in such circumstances.

Impact of COVID-19 on maintenance peritoneal dialysis patients and providers: A review.

The COVID-19 pandemic exerted complex pressures on the nephrology community. Despite multiple prior reviews on acute peritoneal dialysis during the pandemic, the effects of COVID-19 on maintenance peritoneal dialysis patients remain underexamined. This review synthesizes and reports findings from 29 total cases of chronic peritoneal dialysis patients with COVID-19, encompassing 3 case reports, 13 case series, and 13 cohort studies. When available, data for patients with COVID-19 on maintenance hemodialysis are also discussed. Finally, we present a chronological timeline of evidence regarding the presence of SARS-CoV-2 in spent peritoneal dialysate and explore trends in telehealth as they relate to peritoneal dialysis patients during the pandemic. We conclude that the COVID-19 pandemic has underscored the efficacy, flexibility, and utility of peritoneal dialysis.

Hospitalization in maintenance peritoneal dialysis: a review.

Although hemodialysis continues to be the dominant form of dialysis in the United States, peritoneal dialysis rates continue to rise both nationally and worldwide. Peritoneal dialysis offers patients increased flexibility due to the ability to dialyze at home, leading to potential quality of life benefits for patients. However, questions exist regarding clinical outcomes in patients on peritoneal dialysis and the literature has not recently been reviewed. This review examines hospitalizations within patients utilizing peritoneal dialysis, including comparison to other dialysis modalities. Much heterogeneity exists within the literature, often explained by patient population. Recent data show all-cause, cardiovascular, and infection-related hospitalizations to be high in patients on peritoneal dialysis, although data variation limits conclusions in comparison to other modalities. This review found there is insufficient evidence to suggest admission rates are different in peritoneal dialysis than in-center hemodialysis. While the rate is similar to infectious causes, most studies report cardiovascular complications to be the leading cause of hospitalization. Some evidence suggests that cardiovascular hospitalizations occur at a higher rate in peritoneal dialysis, but further studies are required. The infection-related hospitalization rate appears to be higher in peritoneal dialysis due to rates of peritonitis, but rates of life-threatening bacteremia are lower. Differences in reporting of hospital days vs. length of stay challenge the interpretability of length of stay data between modalities, but patients on PD may spend more days per year in the hospital. In summary, hospitalization is highly prevalent in patients on peritoneal dialysis and few definitive conclusions can be drawn in comparison to other dialysis modalities. In eligible patient populations who desire increased flexibility, peritoneal dialysis is a reasonable modality choice.

End-to-end artificial intelligence platform for the management of large vessel occlusions: A preliminary study.

OBJECTIVES: In this study, we developed a deep learning pipeline that detects large vessel occlusion (LVO) and predicts functional outcome based on computed tomography angiography (CTA) images to improve the management of the LVO patients. METHODS: A series identifier picked out 8650 LVO-protocoled studies from 2015 to 2019 at Rhode Island Hospital with an identified thin axial series that served as the data pool. Data were annotated into 2 classes: 1021 LVOs and 7629 normal. The Inception-V1 I3D architecture was applied for LVO detection. For outcome prediction, 323 patients undergoing thrombectomy were selected. A 3D convolution neural network (CNN) was used for outcome prediction (30-day mRS) with CTA volumes and embedded pre-treatment variables as inputs. RESULT: For LVO-detection model, CTAs from 8,650 patients (median age 68 years, interquartile range (IQR): 58-81; 3934 females) were analyzed. The cross-validated AUC for LVO vs. not was 0.74 (95% CI: 0.72-0.75). For the mRS classification model, CTAs from 323 patients (median age 75 years, IQR: 63-84; 164 females) were analyzed. The algorithm achieved a test AUC of 0.82 (95% CI: 0.79-0.84), sensitivity of 89%, and specificity 66%. The two models were then integrated with hospital infrastructure where CTA was collected in real-time and processed by the model. If LVO was detected, interventionists were notified and provided with predicted clinical outcome information. CONCLUSION: 3D CNNs based on CTA were effective in selecting LVO and predicting LVO mechanical thrombectomy short-term prognosis. End-to-end AI platform allows users to receive immediate prognosis prediction and facilitates clinical workflow.

A young man with irregularly irregular narrow complex tachycardia.

Pulmonary vein atrial tachycardia (PVAT) is a rare arrhythmia that accounts for 3% of all atrial tachycardia types. On electrocardiogram, fast PVATs may be misinterpreted as atrial fibrillation at first glance. We present a case of PVAT refractory to pharmacological intervention in a 31-year-old, requiring ablation to terminate the arrhythmia.

Spontaneous Termination of Ventricular Fibrillation: Is Organization Required?

Ventricular fibrillation is a life-threatening arrhythmia that can result in sudden cardiac death and almost always requires emergency electrical defibrillation. This paper presents a unique case of a 74-year-old woman with spontaneous termination of a 2-min 13-s ventricular fibrillation episode without organization before termination. (Level of Difficulty: Advanced.).

Rate of neuropathic progression in hereditary transthyretin amyloidosis with polyneuropathy and other peripheral neuropathies: a systematic review and meta-analysis.

BACKGROUND: We aimed to compare neuropathic progression rate between hereditary transthyretin amyloidosis with polyneuropathy (ATTRv-PN) and other peripheral neuropathies, including diabetic peripheral neuropathy (DPN) and Charcot-Marie-Tooth disease (CMT). METHODS: Literature searches identified studies reporting neuropathic progression, measured by Neuropathy Impairment Score (NIS) or NIS-Lower Limbs (NIS-LL). Our study also included unpublished data from a clinical registry of patients who were diagnosed with different peripheral neuropathies and seen at the Oregon Health & Science University (OHSU) during 2016-2020. Meta-analysis and meta-regression models examined and compared annual progression rates, calculated from extracted data, between studies of ATTRv-PN and other peripheral neuropathies. RESULTS: Data were synthesized from 15 studies in which NIS and/or NIS-LL total scores were assessed at least twice, with ≥12 weeks between assessments, among untreated patients with ATTRv-PN or other peripheral neuropathies. Meta-analysis models yielded that the annual progression rate in NIS total scores was significantly different from zero for studies in ATTRv-PN and CMT (11.77 and 1.41; both P < 0.001), but not DPN (- 1.96; P = 0.147). Meta-regression models showed significantly faster annual progression in studies in ATTRv-PN, which statistically exceeded that in other peripheral neuropathies by 12.45 points/year for NIS, and 6.96 for NIS-LL (both P < 0.001). CONCLUSIONS: Peripheral nervous function deteriorates more rapidly in patients with ATTRv-PN than for other peripheral neuropathies. These findings may improve understanding of the natural history of neuropathy in ATTRv-PN, facilitate early diagnosis, and guide the development of assessment tools and therapies specifically targeting neuropathic progression in this debilitating disease.

Screening for genetic mutations in patients with neuropathy without definite etiology is useful.

OBJECTIVE: To determine the clinical usefulness of systemic genetic testing in neuropathies without definite etiology. METHODS: We systematically performed genetic testing in all patients with neuropathy who did not have a definite etiology, seen at our neuromuscular clinic between 2017 and 2020. The testing consisted of an inherited neuropathy panel (72-81 genes), which used next-generation sequencing technology. RESULTS: We screened 200 patients. Pathogenic mutations were found in 30 (15%). PMP22, TTR and GJB1, accounted for 83.3% of positive mutations. The management was altered in four patients (2%). Two patients were found to have hereditary transthyretin amyloidosis and were started on TTR gene silencers. Two patients were being treated for demyelinating autoimmune neuropathy and were diagnosed with CMT1A and CMTX. CONCLUSION: Screening for genetic mutations in patients with neuropathy without a definite etiology is useful. While only a minority of patients with unsuspected inherited neuropathy tested positive, the findings altered management in some, improving morbidity and, perhaps, mortality.