Recognition and management of community-acquired acute kidney injury in low-resource settings in the ISN 0by25 trial: A multi-country feasibility study

BackgroundAcute kidney injury (AKI) is increasingly encountered in community settings and contributes to morbidity, mortality, and increased resource utilization worldwide. In low-resource settings, lack of awareness of and limited access to diagnostic and therapeutic interventions likely influence patient management. We evaluated the feasibility of the use of point-of-care (POC) serum creatinine and urine dipstick testing with an education and training program to optimize the identification and management of AKI in the community in 3 low-resource countries.Methods and findingsPatients presenting to healthcare centers (HCCs) from 1 October 2016 to 29 September 2017 in the cities Cochabamba, Bolivia; Dharan, Nepal; and Blantyre, Malawi, were assessed utilizing a symptom-based risk score to identify patients at moderate to high AKI risk. POC testing for serum creatinine and urine dipstick at enrollment were utilized to classify these patients as having chronic kidney disease (CKD), acute kidney disease (AKD), or no kidney disease (NKD). Patients were followed for a maximum of 6 months with repeat POC testing. AKI development was assessed at 7 days, kidney recovery at 1 month, and progression to CKD and mortality at 3 and 6 months. Following an observation phase to establish baseline data, care providers and physicians in the HCCs were trained with a standardized protocol utilizing POC tests to evaluate and manage patients, guided by physicians in referral hospitals connected via mobile digital technology. We evaluated 3,577 patients, and 2,101 were enrolled: 978 in the observation phase and 1,123 in the intervention phase. Due to the high number of patients attending the centers daily, it was not feasible to screen all patients to assess the actual incidence of AKI. Of enrolled patients, 1,825/2,101 (87%) were adults, 1,117/2,101 (53%) were females, 399/2,101 (19%) were from Bolivia, 813/2,101 (39%) were from Malawi, and 889/2,101 (42%) were from Nepal. The age of enrolled patients ranged from 1 month to 96 years, with a mean of 43 years (SD 21) and a median of 43 years (IQR 27–62). Hypertension was the most common comorbidity (418/2,101; 20%). At enrollment, 197/2,101 (9.4%) had CKD, and 1,199/2,101 (57%) had AKD. AKI developed in 30% within 7 days. By 1 month, 268/978 (27%) patients in the observation phase and 203/1,123 (18%) in the intervention phase were lost to follow-up. In the intervention phase, more patients received fluids (observation 714/978 [73%] versus intervention 874/1,123 [78%]; 95% CI 0.63, 0.94; p = 0.012), hospitalization was reduced (observation 578/978 [59%] versus intervention 548/1,123 [49%]; 95% CI 0.55, 0.79; p < 0.001), and admitted patients with severe AKI did not show a significantly lower mortality during follow-up (observation 27/135 [20%] versus intervention 21/178 [11.8%]; 95% CI 0.98, 3.52; p = 0.057). Of 504 patients with kidney function assessed during the 6-month follow-up, de novo CKD arose in 79/484 (16.3%), with no difference between the observation and intervention phase (95% CI 0.91, 2.47; p = 0.101). Overall mortality was 273/2,101 (13%) and was highest in those who had CKD (24/106; 23%), followed by those with AKD (128/760; 17%), AKI (85/628; 14%), and NKD (36/607; 6%). The main limitation of our study was the inability to determine the actual incidence of kidney dysfunction in the health centers as it was not feasible to screen all the patients due to the high numbers seen daily.ConclusionsThis multicenter, non-randomized feasibility study in low-resource settings demonstrates that it is feasible to implement a comprehensive program utilizing POC testing and protocol-based management to improve the recognition and management of AKI and AKD in high-risk patients in primary care.

Etienne Macedo and colleagues report on a point-of-care testing program for acute kidney injury and disease in high-risk primary care patients.     

AN ASSESSMENT OF VARIABILITY IN THEROPOD DINOSAUR REMAINS FROM THE BATHONIAN (MIDDLE JURASSIC) OF STONESFIELD AND NEW PARK QUARRY, UK AND TAXONOMIC IMPLICATIONS FOR MEGALOSAURUS BUCKLANDII AND ILIOSUCHUS INCOGNITUS

Abstract:  The assemblage of large-bodied theropod remains from the Taynton Limestone Formation (middle Bathonian) of Stonesfield, Oxfordshire and the Chipping Norton Limestone Formation (lowest Bathonian) of New Park Quarry, Gloucestershire, UK is interpreted as monospecific. An assessment of morphological variation in theropod fossils from these localities reveals no taxonomically-significant variation among remains representing large-bodied individuals. Previous observations of anatomical variation among femora, ilia and scapulocoracoids are attributed to postmortem damage and deformation. Referral of all such material to the first named dinosaur taxon, Megalosaurus bucklandii Mantell, is therefore justified. ' Iliosuchus incognitus ' lacks autapomorphies and is a nomen dubium . However, other remains of small-bodied theropods from Stonesfield indicate a minimum of two small-bodied taxa that are distinct from M. bucklandii.     

Proceedings of the 11th Oamaru Penguin Symposium 2018

This paper records the abstracts of the presentations given at the 11th Oamaru Penguin Symposium, held at the Opera House, Oamaru, New Zealand, 3 and 4 May, 2018.     

The late Oligocene molluscan fauna from Otranto (Apulia, Southern Italy): an example of alternating freshwater, lagoonal and emerged environments

Abstract:  Eighteen gastropod and five bivalve species are taxonomically described from an Upper Oligocene succession cropping out near Otranto (southern Salento, Apulia, Italy). Among these, Tectarius ( Echininus ) japigiae , Hydrobia dubuissoni hydruntina , Pseudamnicola messapica , Pseudamnicola palmariggii and Stenothyrella salentina are new taxa. Nonmarine and lagoonal environments characterize almost the whole succession, as testified by species-poor assemblages rich in specimens of freshwater and oligo- to mesohaline prosobranchs, such as Neritinidae, Hydrobiidae, Stenothyridae, Thiaridae, Potamididae, Batillariidae, pulmonates, including Planorbidae and bivalves comprising Dreissenidae and Cyrenidae. The genera Theodoxus , Hydrobia , Melanoides , Potamides , Terebralia , Batillaria , Granulolabium , Mytilopsis and Polymesoda alternately dominate. Littoral marine elements, such as Tectarius , Turritella , Barbatia , Anadara and Chama , are scattered present in the succession, but some prevail towards the top. The fauna is palaeobiogeographically significant having strong affinities with those of the Oligo–Miocene basins of Aquitaine, Mainz, Bavaria, North Alpine Foreland, Vienna, Greece and Turkey. The analysed Otranto succession is assigned to the Chattian Galatone Formation of southernmost Apulia (Salento) based on lithological evidence and supported by the palaeontological data.