Erythropoietin-Stimulating Agent Hyporesponsiveness in Patients Living with Chronic Kidney Disease

<b><i>Background:</i></b> Erythropoietin-stimulating agent (ESA) hyporesponsiveness is commonly observed in patients with anemia secondary to chronic kidney disease (CKD). Because of its complexity, a global consensus on how we should define ESA hyporesponsiveness remains unavailable. The reported prevalence and demographic information on ESA hyporesponsiveness within the CKD population are variable with no consensus definition. <b><i>Summary:</i></b> ESA hyporesponsiveness is defined as having no increase in hemoglobin concentration from baseline after the first month of treatment on appropriate weight-based dosing. The important factors associated with ESA hyporesponsiveness include absolute or functional iron deficiency, inflammation, and uremia. Hepcidin has been demonstrated to play an important role in this process. Mineral bone disease secondary to CKD and non-iron malnutrition among other factors are also associated with ESA hyporesponsiveness. There is continued debate toward determining a gold-standard treatment pathway to manage ESA hyporesponsiveness. The development of hypoxia-inducing factor-stabilizers brings new insights and opportunities in the management of ESA hyporesponsiveness. <b><i>Key Message:</i></b> Management of ESA hyporesponsiveness involves a comprehensive multidisciplinary team approach to address its risk factors. The progression of basic and clinical research on identifying risk factors and management of ESA hyporesponsiveness brings greater hope on finding solutions to eventually tackling one of the most difficult problems in the topic of anemia in CKD.

Introduction: From Autofiction to the Autofictional

The introduction takes as its starting point autofiction’s continuing resistance to a consensus definition and suggests that this has to do with the ad-hoc invention of the term but also with the fact that autofictional texts tend to challenge and transform generic conventions. The chapter proposes embracing the slipperiness of the concept by purposefully extending its scope to encompass a wide range of autofictional phenomena. These include the diverse affordances of the autofictional as an aesthetic strategy and a theoretical lens and the many shapes it can take as it interacts with different forms and media. The chapter discusses the heretofore geographically and linguistically limited focus of autofiction research and advocates a more global perspective, which promises to enrich our understanding of the autofictional.

Malnutrition assessment methods in adult patients with tuberculosis: a systematic review

ObjectivesMalnutrition is associated with a twofold higher risk of dying in patients with tuberculosis (TB) and considered an important potentially reversible risk factor for failure of TB treatment. The construct of malnutrition has three domains: intake or uptake of nutrition; body composition and physical and cognitive function. The objectives of this systematic review are to identify malnutrition assessment methods, and to quantify how malnutrition assessment methods capture the international consensus definition for malnutrition, in patients with TB.DesignDifferent assessment methods were identified. We determined the extent of capturing of the three domains of malnutrition, that is, intake or uptake of nutrition, body composition and physical and cognitive function.ResultsSeventeen malnutrition assessment methods were identified in 69 included studies. In 53/69 (77%) of studies, body mass index was used as the only malnutrition assessment method. Three out of 69 studies (4%) used a method that captured all three domains of malnutrition.ConclusionsOur study focused on published articles. Implementation of new criteria takes time, which may take longer than the period covered by this review. Most patients with TB are assessed for only one aspect of the conceptual definition of malnutrition. The use of international consensus criteria is recommended to establish uniform diagnostics and treatment of malnutrition.PROSPERO registration numberCRD42019122832.

EPIdemiology of Surgery-Associated Acute Kidney Injury (EPIS-AKI): study protocol for a multicentre, observational trial

IntroductionMore than 300 million surgical procedures are performed each year. Acute kidney injury (AKI) is a common complication after major surgery and is associated with adverse short-term and long-term outcomes. However, there is a large variation in the incidence of reported AKI rates. The establishment of an accurate epidemiology of surgery-associated AKI is important for healthcare policy, quality initiatives, clinical trials, as well as for improving guidelines. The objective of the Epidemiology of Surgery-associated Acute Kidney Injury (EPIS-AKI) trial is to prospectively evaluate the epidemiology of AKI after major surgery using the latest Kidney Disease: Improving Global Outcomes (KDIGO) consensus definition of AKI.Methods and analysisEPIS-AKI is an international prospective, observational, multicentre cohort study including 10 000 patients undergoing major surgery who are subsequently admitted to the ICU or a similar high dependency unit. The primary endpoint is the incidence of AKI within 72 hours after surgery according to the KDIGO criteria. Secondary endpoints include use of renal replacement therapy (RRT), mortality during ICU and hospital stay, length of ICU and hospital stay and major adverse kidney events (combined endpoint consisting of persistent renal dysfunction, RRT and mortality) at day 90. Further, we will evaluate preoperative and intraoperative risk factors affecting the incidence of postoperative AKI. In an add-on analysis, we will assess urinary biomarkers for early detection of AKI.Ethics and disseminationEPIS-AKI has been approved by the leading Ethics Committee of the Medical Council North Rhine-Westphalia, of the Westphalian Wilhelms-University Münster and the corresponding Ethics Committee at each participating site. Results will be disseminated widely and published in peer-reviewed journals, presented at conferences and used to design further AKI-related trials.Trial registration numberNCT04165369.

Primary plasma cell leukemia: consensus definition by the International Myeloma Working Group according to peripheral blood plasma cell percentage

Primary plasma cell leukemia (PCL) has a consistently ominous prognosis, even after progress in the last decades. PCL deserves a prompt identification to start the most effective treatment for this ultra-high-risk disease. The aim of this position paper is to revisit the diagnosis of PCL according to the presence of circulating plasma cells in patients otherwise meeting diagnostic criteria of multiple myeloma. We could identify two retrospective series where the question about what number of circulating plasma cells in peripheral blood should be used for defining PCL. The presence of ≥5% circulating plasma cells in patients with MM had a similar adverse prognostic impact as the previously defined PCL. Therefore, PCL should be defined by the presence of 5% or more circulating plasma cells in peripheral blood smears in patients otherwise diagnosed with symptomatic multiple myeloma.

Spirituality Training as an Essential Element of Person-Centered Care

Palliative Medicine, built on the biopsychosocial-spiritual model of care, has long recognized the critical role of spirituality in the care of patients with complex, serious, and chronic illnesses. We conducted focus groups to arrive at a consensus definition of “spiritual care.” Additionally, we collected and compared frameworks and models that recognize that providers cannot be made compassionate simply through the imposition of rules; methods were needed to achieve behavior change. The created curricula covered the definitions of spiritual care, self-awareness, cultural sensitivity, assessment, and skills. As part of ongoing curriculum development processes, training included evaluation tools to accompany competency standards. Results demonstrated improvements in self- reported abilities to (a) establish appropriate boundaries with patients; (b) apply the concept of compassionate presence to clinical care; (c) understand the role of spirituality in professional life; (d) identify ethical issues in inter-professional spiritual care. Clinicians need to address patients’ spiritual needs.

A Consensus Definition of Supratotal Resection for Anatomically Distinct Primary Glioblastoma: An AANS/CNS Section on Tumors Survey of Neurosurgical Oncologists

Introduction: Supratotal resection (SpTR) of glioblastoma may be associated with improved survival, but published results have varied in part from lack of consensus on the definition and appropriate use of SpTR. A previous small survey of neurosurgical oncologists with expertise performing SpTR found resection 1-2 cm beyond contrast enhancement was an acceptable definition and glioblastoma involving the right frontal and bilateral anterior temporal lobes were considered most amenable to SpTR. The general neurosurgical oncology community has not yet confirmed the practicality of this definition. Methods Seventy-six general neurosurgical oncology members of the AANS/CNS Tumor Section were surveyed using a crowdsourcing approach. Participants were presented with 11 definitions of SpTR and rated each definition’s appropriateness. Participants additionally reviewed magnetic resonance imaging for 10 anatomically distinct glioblastomas and assessed the tumor location's eloquence, perceived equipoise of enrolling patients in a randomized trial comparing gross total to SpTR, and their personal treatment plans. Results Fifty-two neurosurgeons (73.2%) agreed that resection 1-2 cm beyond contrast enhancement was an acceptable definition for SpTR. Cases were divided into three anatomically distinct groups by perceived equipoise between gross total and SpTR. The best clinical trial candidates were right anterior temporal (n=58, 76.3%) and right frontal (n=55, 73.3%) glioblastomas. Conclusion Support exists within the neurosurgical oncology community to adopt the proposed consensus definition of SpTR of glioblastoma and to treat right anterior temporal and right frontal glioblastomas using SpTR. A smaller proportion of general neurosurgical oncologists than SpTR experts consider SpTR feasible in the left anterior temporal lobe.

The association between vitamin D levels and metabolic syndrome components among metropolitan adolescent population

Objectives Vitamin D promotes both lipolysis and lipogenesis, and some pediatric studies showed inconsistent associations between vitamin D and metabolic syndrome (MetS). This cross-sectional study aimed to examine the association between vitamin D levels and MetS components among metropolitan adolescents. Methods A total of 4,149 adolescents aged 10–18 years were recruited from 23 metropolises in China. The MetS conditions were assessed according to the International Diabetes Federation consensus definition, and the serum 25-hydroxy vitamin D (25(OH)D) concentrations were analyzed. The association between MetS components and serum 25(OH)D levels was analyzed by the logistic regression model. Restricted cubic spline was applied to the model nonlinear association. Results Prevalence of vitamin D deficiency was 74.9%, and 41.2% of study participants had at least one MetS component. After adjustment, the significant trend for a lower waist-to-height ratio was not observed in study participants with higher serum 25(OH)D quartile (p=0.57), but a significant nonlinear association between abdominal obesity and serum 25(OH)D levels was found (p=0.04): the highest risk of abdominal obesity occurred at 14.1 ng/mL of serum 25(OH)D. The association of serum 25(OH)D was significantly inverse with MetS (OR: 0.95; 95% CI: 0.92–0.98), but not with raised triglycerides (OR: 0.99; 95% CI: 0.96–1.01), raised blood pressure (OR: 0.99; 95% CI: 0.97–1.01) and impaired fasting glycemia (OR: 1.03; 95% CI: 1.01–1.04). Conclusions The net effect of vitamin D on lipid metabolism may be concentration-dependent, and the actual effect of vitamin D on MetS process may be complex among metropolitan adolescents, though serum 25(OH)D is inversely associated with MetS.

Use of environmental scans in health services delivery research: a scoping review

ObjectiveTo examine the extent and nature of evidence on the use of the environmental scan (ES) in the health services delivery literature.DesignScoping review.MethodsThis scoping review followed the five-stage scoping review methodology outlined by Khalil et al. A Peer Review of Electronic Search Strategies was completed. Seven electronic databases and the grey literature were searched. Pairs of researchers independently performed two levels of screening and data extraction. Data were analysed using qualitative content and thematic analysis.ResultsNinety-six studies were included in the scoping review. Researchers conducted ESs for many purposes, the most common being to examine the current state of programmes, services or policies. Recommendations were informed by ESs in 20% of studies. Most common data collection methods were literature review (71%), key informant or semistructured interviews (46%) and surveys (35%). Over half (53%) of the studies used a combination of passive (looking at information eg, literature, policies, guidelines) and active (looking for information eg, surveys, interviews) approaches to data collection. Person sources of data (eg, healthcare stakeholders, community representatives) and non-person sources of data (eg, documents, electronic databases, the web) were drawn on to a similar extent. The thematic analysis of the definitions/descriptions yielded several themes including instrument of discovery, knowledge synthesis, forward-looking and decision making. Research gaps identified included absence of a standard definition, inconsistencies in terminology and lack of guiding frameworks in the health services delivery context.ConclusionESs were conducted to gather evidence and to help inform decision making on a range of policy and health services delivery issues across the continuum of care. Consistency in terminology, a consensus definition and more guidance on ES design may help provide structure for researchers and other stakeholders, and ultimately advance ES as a methodological approach. A working definition of ES in a health services delivery context is presented.