Dialysis-Requiring Acute Kidney Injury in Denmark 2000-2012: Time Trends of Incidence and Prevalence of Risk Factors—A Nationwide Study

Introduction

Dialysis-requiring acute kidney injury is a severe illness associated with poor prognosis. However, information pertaining to incidence rates and prevalence of risk factors remains limited in spite of increasing focus. We evaluate time trends of incidence rates and changing patterns in prevalence of comorbidities, concurrent medication, and other risk factors in nationwide retrospective cohort study.

Materials and Methods

All patients with dialysis-requiring acute kidney injury were identified between January 1^st 2000 and December 31^st 2012. By cross-referencing data from national administrative registries, the association of changing patterns in dialysis treatment, comorbidity, concurrent medication and demographics with incidence of dialysis-requiring acute kidney injury was evaluated.

Results

A total of 18,561 adult patients with dialysis-requiring AKI were identified between 2000 and 2012. Crude incidence rate of dialysis-requiring AKI increased from 143 per million (95% confidence interval, 137–144) in 2000 to 366 per million (357–375) in 2006, and remained stable hereafter. Notably, incidence of continuous veno-venous hemodialysis (CRRT) and use of acute renal replacement therapy in elderly >75 years increased substantially from 23 per million (20–26) and 328 per million (300–355) in 2000, to 213 per million (206–220) and 1124 per million (1076–1172) in 2012, respectively. Simultaneously, patient characteristics and demographics shifted towards increased age and comorbidity.

Conclusions

Although growth in crude incidence rate of dialysis-requiring AKI stabilized in 2006, continuous growth in use of CRRT, and acute renal replacement therapy of elderly patients >75 years, was observed. Our results indicate an underlying shift in clinical paradigm, as opposed to unadulterated growth in incidence of dialysis-requiring AKI.     

Does Celiac Disease Influence Survival in Sepsis? A Nationwide Longitudinal Study

BackgroundIndividuals with celiac disease (CD) are at increased risk of sepsis. The aim of this study was to examine whether CD influences survival in sepsis of bacterial origin.MethodsNationwide longitudinal registry-based study. Through data on small intestinal biopsies from Sweden’s 28 pathology departments, we identified 29,096 individuals with CD (villous atrophy, Marsh stage III). Each individual with CD was matched with five population-based controls. Among these, 5,470 had a record of sepsis according to the Swedish Patient Register (1,432 celiac individuals and 4,038 controls). Finally we retrieved data on mortality in sepsis patients through the Swedish Cause of Death Registry.ResultsCD was associated with a 19% increase in overall mortality after sepsis (95% confidence interval (CI) = 1.09–1.29), with the highest relative risk occurring in children (adjusted hazard ratio (aHR) = 1.62; 95%CI = 0.67–3.91). However, aHR for death from sepsis was lower (aHR = 1.10) and failed to reach statistical significance (95%CI = 0.72–1.69). CD did not influence survival within 28 days after sepsis (aHR = 0.98; 95%CI = 0.80–1.19).ConclusionsAlthough individuals with CD seem to be at an increased risk of overall death after sepsis, that excess risk does not differ from the general excess mortality previously seen in celiac patients in Sweden. CD as such does not seem to influence short-term or sepsis-specific survival in individuals with sepsis and therefore is not an independent risk factor for poor prognosis in sepsis.     

A Corpus Investigation of Syntactic Embedding in Pirah?

The Pirahã language has been at the center of recent debates in linguistics, in large part because it is claimed not to exhibit recursion, a purported universal of human language. Here, we present an analysis of a novel corpus of natural Pirahã speech that was originally collected by Dan Everett and Steve Sheldon. We make the corpus freely available for further research. In the corpus, Pirahã sentences have been shallowly parsed and given morpheme-aligned English translations. We use the corpus to investigate the formal complexity of Pirahã syntax by searching for evidence of syntactic embedding. In particular, we search for sentences which could be analyzed as containing center-embedding, sentential complements, adverbials, complementizers, embedded possessors, conjunction or disjunction. We do not find unambiguous evidence for recursive embedding of sentences or noun phrases in the corpus. We find that the corpus is plausibly consistent with an analysis of Pirahã as a regular language, although this is not the only plausible analysis.     

Ethnic Variations in Severe Maternal Morbidity in the UK– A Case Control Study

Background

Previous studies showed a higher risk of maternal morbidity amongst black and other minority ethnic (BME) groups, but were unable to investigate whether this excess risk was concentrated within specific BME groups in the UK. Our aim was to analyse the specific risks and to investigate reasons for any disparity.

Methods

Unmatched case-control analysis using data from the United Kingdom Obstetric Surveillance System (UKOSS), February 2005-January 2013. Cases were 1,753 women who experienced severe morbidity during the peripartum period. Controls were 3,310 women who delivered immediately before the cases in the same hospital. Multivariable logistic regression modelling was used to adjust for known confounders and to understand their effects.

Results

Compared with white European women, the odds of severe maternal morbidity were 83% higher among black African women (adjusted odds ratio (aOR) = 1.83; 95% Confidence Interval (CI) = 1.39–2.40), 80% higher among black Caribbean (aOR = 1.80; 95% CI = 1.14–2.82), 74% higher in Bangladeshi (aOR = 1.74; 95% CI = 1.05–2.88), 56% higher in other non-whites (non-Asian) (aOR = 1.56; 95% CI = 1.05–2.33) and 43% higher among Pakistani women (aOR = 1.43; 95% CI = 1.07–1.92). There was no evidence of substantial confounding. Anaemia in current pregnancy, previous pregnancy problems, inadequate utilisation of antenatal care, pre-existing medical conditions, parity>3, and being younger and older were independent risk factors but, the odds of severe maternal morbidity did not differ by socioeconomic status, between smokers and non-smokers or by BMI.

Discussion

This national study demonstrates an increased risk of severe maternal morbidity among women of ethnic minority backgrounds which could not be explained by known risk factors for severe maternal morbidity.     

How Cheap Is Soaring Flight in Raptors? A Preliminary Investigation in Freely-Flying Vultures

Measuring the costs of soaring, gliding and flapping flight in raptors is challenging, but essential for understanding their ecology. Among raptors, vultures are scavengers that have evolved highly efficient soaring-gliding flight techniques to minimize energy costs to find unpredictable food resources. Using electrocardiogram, GPS and accelerometer bio-loggers, we report the heart rate (HR) of captive griffon vultures (Gyps fulvus and G. himalayensis) trained for freely-flying. HR increased three-fold at take-off (characterized by prolonged flapping flight) and landing (>300 beats-per-minute, (bpm)) compared to baseline levels (80–100 bpm). However, within 10 minutes after the initial flapping phase, HR in soaring/gliding flight dropped to values similar to baseline levels, i.e. slightly lower than theoretically expected. However, the extremely rapid decrease in HR was unexpected, when compared with other marine gliders, such as albatrosses. Weather conditions influenced flight performance and HR was noticeably higher during cloudy compared to sunny conditions when prolonged soaring flight is made easier by thermal ascending air currents. Soaring as a cheap locomotory mode is a crucial adaptation for vultures who spend so long on the wing for wide-ranging movements to find food.     

Infective Endocarditis in the U.S., 1998–2009: A Nationwide Study

Background

Previous studies based on local case series estimated the annual incidence of endocarditis in the U.S. at about 4 per 100,000 population. Small-scale studies elsewhere have reported similar incidence rates. However, no nationally-representative population-based studies have verified these estimates.

Methods and Findings

Using the 1998–2009 Nationwide Inpatient Sample, which provides diagnoses from about 8 million U.S. hospitalizations annually, we examined endocarditis hospitalizations, bacteriology, co-morbidities, outcomes and costs. Hospital admissions for endocarditis rose from 25,511 in 1998 to 38, 976 in 2009 (12.7 per 100,000 population in 2009). The age-adjusted endocarditis admission rate increased 2.4% annually. The proportion of patients with intra-cardiac devices rose from 13.3% to 18.9%, while the share with drug use and/or HIV fell. Mortality remained stable at about 14.5%, as did cardiac valve replacement (9.6%). Other serious complications increased; 13.3% of patients in 2009 suffered a stroke or CNS infection, and 5.5% suffered myocardial infarction. Amongst cases with identified pathogens, Staphylococcus aureus was the most common, increasing from 37.6% in 1998 to 49.3% in 2009, 53.3% of which were MRSA. Streptococci were mentioned in 24.7% of cases, gram-negatives in 5.6% and Candida species in 1.0%. We detected no inflection in hospitalization rates after changes in prophylaxis recommendations in 2007. Mean age rose from 58.6 to 60.8 years; elderly patients suffered higher rates of myocardial infarction and death, but slightly lower rates of Staphylococcus aureus infections and neurologic complications. Our study relied on clinically diagnosed cases of endocarditis that may not meet strict criteria. Moreover, since some patients are discharged and readmitted during a single episode of endocarditis, our hospitalization figures probably slightly overstate the true incidence of this illness.

Conclusions

Endocarditis is more common in the U.S. than previously believed, and is steadily increasing. Preventive efforts should focus on device-associated and health-care-associated infections.     

Weekly Pattern of Stroke Onset in an Asian Country: A Nationwide Population‐Based Study

This study used a nationwide population‐based dataset to explore the variation among the days of week of stroke onset within population subgroups defined by age, sex, and stroke type. We used ambulatory care data from the 2002 Taiwan National Health Insurance Research Database, focusing on 42,779 emergency room (ER) visits for stroke that year. All analyses were stratified by sex, age (<60 and ≥60 yrs), and type of stroke. Auto‐Regressive Integrated Moving Average (ARIMA) was performed to investigate the relationship between daily number of stroke events and holidays and days of the week after adjusting for the effects of seasonality and trends. One‐way ANOVA revealed significant differences in stroke ER admissions according to day of week according to age <60 (p<0.01), age ≥60 (p<0.001), male (p<0.001), female (p<0.001), ischemic stroke (IS) (p<0.001), and unspecified stroke (UNSP) (p<0.001). However, the analysis by type—subarachnoid hemorrhage and intracerebral hemorrhage—did not show significant relationships between daily emergency room stroke admissions, holidays, or day of the week. The ARIMA regression analyses also showed that Mondays had the highest rate of emergency room admissions for stroke regardless of sex, age, or IS and UNSP types of stroke, after adjusting for seasonality and trends. We conclude that stroke occurs more frequently on Mondays than on the other days of the week, which might be associated with short‐term changes in lifestyle or due to the sudden return of stress on the first working day of the week, and on holidays.     

A fish oil-rich diet reduces vascular oxidative stress in apoE–/– mice

Abstract

Oxidative stress contributes to lipid peroxidation and decreases nitric oxide (NO) bioavailability in atherosclerosis. While long-chain (n-3) polyunsaturated fatty acids (PUFA) are easily oxidized in vitro, they improve endothelial function. Hence, this study postulates that long-chain (n-3) PUFA decrease atherogenic oxidative stress in vivo. To test this, apoE^–/– mice were fed a corn oil- or a fish oil (FO)-rich diet for 8, 14 or 20 weeks and parameters related to NO and superoxide (O₂^.–) plus markers of lipid peroxidation and protein oxidative damage in the aortic root were evaluated. The FO-rich diet increased NO production and endothelial NO synthase (NOS) expression and lowered inducible NOS, p22^phox expression and O₂^.–production after 14 and 20 weeks of diet. Protein lipoxidative damage (including 4-hydroxynonenal) was decreased after a long-term FO-diet. This supports the hypothesis that a FO-rich diet could counteract atherogenic oxidative stress, showing beneficial effects of long-chain (n-3) PUFA.     

Fragmentation of Care Threatens Patient Safety in Peripheral Vascular Catheter Management in Acute Care– A Qualitative Study

Background

The use of peripheral vascular catheters (PVCs) is an extremely common and necessary clinical intervention, but inappropriate PVC care poses a major patient safety risk in terms of infection. Quality improvement initiatives have been proposed to reduce the likelihood of adverse events, but a lack of understanding about factors that influence behaviours of healthcare professionals limits the efficacy of such interventions. We undertook qualitative interviews with clinical staff from a large group of hospitals in order to understand influences on PVC care behaviors and subsequent patient safety.

Methods

Ten doctors, ten clinical pharmacists, 18 nurses and one midwife at a National Health Service hospital group in London (United Kingdom) were interviewed between December 2010 and July 2011 using qualitative methods. Responses were analysed using a thematic framework.

Results

Four key themes emerged: 1) Fragmentation of management and care, demonstrated with a lack of general overview and insufficient knowledge about expected standards of care or responsibility of different professionals; 2) feelings of resentment and frustration as a result of tensions in the workplace, due to the ambiguity about professional responsibilities; 3) disregard for existing hospital policy due to perceptions of flaws in the evidence used to support it; and 4) low-risk perception for the impact of PVC use on patient safety.

Conclusion

Fragmentation of practice resulted in ill-defined responsibilities and interdisciplinary resentment, which coupled with a generally low perception of risk of catheter use, appeared to result in lack of maintaining policy PVC standards which could reduced patient safety. Resolution of these issues through clearly defining handover practice, teaching interdisciplinary duties and increasing awareness of PVC risks could result in preventing thousands of BSIs and other PVC-related infections annually.     

The Secular Trends in the Incidence Rate and Outcomes of Out-of-Hospital Cardiac Arrest in Taiwan—A Nationwide Population-Based Study

Objective

This study investigated the trends in incidence and mortality of out-of-hospital cardiac arrest (OHCA), as well as factors associated with OHCA outcomes in Taiwan.

Methods

Our study included OHCA patients requiring cardiopulmonary resuscitation (CPR) upon arrival at the hospital. We used national time-series data on annual OHCA incidence rates and mortality rates from 2000 to 2012, and individual demographic and clinical data for all OHCA patients requiring mechanical ventilation (MV) care from March of 2010 to September of 2011. Analytic techniques included the time-series regression and the logistic regression.

Results

There were 117,787 OHCAs in total. The overall incidence rate during the 13 years was 51.1 per 100,000 persons, and the secular trend indicates a sharp increase in the early 2000s and a decrease afterwards. The trend in mortality was also curvilinear, revealing a substantial increase in the early 2000s, a subsequent steep decline and finally a modest increase. Both the 30-day and 180-day mortality rates had a long-term decreasing trend over the period (p<0.01). For both incidence and mortality rates, a significant second-order autoregressive effect emerged. Among OHCA patients with MV, 1-day, 30-day and 180-day mortality rates were 31.3%, 75.8%, and 86.0%, respectively. In this cohort, older age, the female gender, and a Charlson comorbidity index score ≥ 2 were associated with higher 180-day mortality; patients delivered to regional hospitals and those residing in non-metropolitan areas had higher death risk.

Conclusions

Overall, both the 30-day and the 180-day mortality rates after OHCA had a long-term decreasing trend, while the 1-day mortality had no long-term decline. Among OHCA patients requiring MV, those delivered to regional hospitals and those residing in non-metropolitan areas tended to have higher mortality, suggesting a need for effort to further standardize and improve in-hospital care across hospitals and to advance pre-hospital care in non-metropolitan areas.     

Reactivation of Snail Genes in Renal Fibrosis and Carcinomas: A Process of Reversed Embryogenesis?

While the activity of Snail genes is required during embryonic development for the formation of different tissues and organs, they must be repressed in the adult in order to maintain epithelial integrity and homeostasis. Indeed, pathological activation of Snail in epithelial tumors induces malignancy and the recurrence of tumors. Here we show that in dedifferentiated areas of human renal carcinomas, Snail undergoes a process of reactivation. In addition to tumor progression, renal fibrosis is also linked to the activity of Snail genes and indeed, reactivation of Snail in the adult kidney is sufficient to induce fibrosis. Thus, Snail genes illustrate a paradigm whereby reactivation of crucial embryonic genes in adult tissues provokes the onset of devastating diseases.     

A Western-Fed Diet Increases Plasma HDL and LDL-Cholesterol Levels in ApoD–/– Mice

Objective

Plasma apolipoprotein (apo)D, a ubiquitously expressed protein that binds small hydrophobic ligands, is found mainly on HDL particles. According to studies of human genetics and lipid disorders, plasma apoD levels positively correlate with HDL-cholesterol and apoAI levels. Thus, we tested the hypothesis that apoD was a regulator of HDL metabolism.

Methods & Results

We compared the plasma lipid and lipoprotein profiles of wild-type (WT) C57BL/6 mice with apoD−/− mice on a C57BL/6 background after receiving a high fat-high cholesterol diet for 12 weeks. ApoD−/− mice had higher HDL-cholesterol levels (61±13-apoD−/− vs. 52±10-WT-males; 37±11-apoD−/− vs. 22±2 WT-female) than WT mice with sex-specific changes in total plasma levels of cholesterol and other lipids. Compared to WT, the HDL of apoD−/− mice showed an increase in large, lipid-rich HDL particles and according to size various quantities and sizes of LDL particles. Plasma levels of lecithin:cholesterol acyltransferase in the control and apoD−/− mice were not different, however, plasma phospholipid transfer protein activity was modestly elevated (+10%) only in male apoD−/− mice. An in vivo HDL metabolism experiment with isolated Western-fed apoD−/− HDL particles showed that female apoD−/− mice had a 36% decrease in the fractional catabolic rate of HDL cholesteryl ester. Hepatic SR-BI and LDLR protein levels were significantly decreased; accordingly, LDL-cholesterol and apoB levels were increased in female mice.

Conclusion

In the context of a high fat-high cholesterol diet, apoD deficiency in female mice is associated with increases in both plasma HDL and LDL-cholesterol levels, reflecting changes in expression of SR-BI and LDL receptors, which may impact diet-induced atherosclerosis.