Search

Monoclonal gammopathy of renal significance (MGRS) is a pathogenic entity associated with significant morbidity, mainly end stage kidney disease. Proliferative glomerulonephritis with monoclonal immunoglobulin deposition (PGNMID), a type of MGRS, is a specific disease resulting from the deposition of a monoclonal immunoglobulin leading to kidney damage. While PGNMID has been recognized to lead to end-stage kidney disease, until recently there was no evidence to guide treatment. Here, we report a case of a patient with PGNMID who responded well to daratumumab.

Background Acute kidney injury (AKI) is a common complication after cardiac surgery and is associated with worse outcomes. Its management relies on early diagnosis, and therefore, electronic alerts have been used to alert clinicians for development of AKI. Electronic alerts are, however, associated with high rates of alert fatigue. Objectives We designed this study to assess the acceptance of user-centered electronic AKI alert by clinicians. Methods We developed a user-centered electronic AKI alert that alerted clinicians of development of AKI in a persistent yet noninterruptive fashion. As the goal of the alert was to alert toward new or worsening AKI, it disappeared 48 hours after being activated. We assessed the acceptance of the alert using surveys at 6 and 12 months after the alert went live. Results At 6 months after their implementation, 38.9% providers reported that they would not have recognized AKI as early as they did without this alert. This number increased to 66.7% by 12 months of survey. Most providers also shared that they re-dosed or discontinued medications earlier, provided earlier management of volume status, avoided intravenous contrast use, and evaluated patients by using point-of-care ultrasounds more due to the alert. Overall, 83.3% respondents reported satisfaction with the electronic AKI alerts at 6 months and 94.4% at 12 months. Conclusion This study showed high rates of acceptance of a user-centered electronic AKI alert over time by clinicians taking care of patients with AKI.

Background: Medication Regimen Complexity (MRC) refers to the combination of medication classes, dosages, and frequencies. The objective of this study was to examine the relationship between the scores of different MRC tools and the clinical outcomes. Methods: We conducted a retrospective cohort study at Roger William Medical Center, Providence, Rhode Island, which included 317 adult patients admitted to the intensive care unit (ICU) between 1 February 2020 and 30 August 2020. MRC was assessed using the MRC Index (MRCI) and MRC for the Intensive Care Unit (MRC-ICU). A multivariable logistic regression model was used to identify associations among MRC scores, clinical outcomes, and a logistic classifier to predict clinical outcomes. Results: Higher MRC scores were associated with increased mortality, a longer ICU length of stay (LOS), and the need for mechanical ventilation (MV). MRC-ICU scores at 24 h were significantly (p < 0.001) associated with increased ICU mortality, LOS, and MV, with ORs of 1.12 (95% CI: 1.06–1.19), 1.17 (1.1–1.24), and 1.21 (1.14–1.29), respectively. Mortality prediction was similar using both scoring tools (AUC: 0.88 [0.75–0.97] vs. 0.88 [0.76–0.97]. The model with 15 medication classes outperformed others in predicting the ICU LOS and the need for MV with AUCs of 0.82 (0.71–0.93) and 0.87 (0.77–0.96), respectively. Conclusion: Our results demonstrated that both MRC scores were associated with poorer clinical outcomes. The incorporation of MRC scores in real-time therapeutic decision making can aid clinicians to prescribe safer alternatives.

IntroductionMedication Regimen Complexity (MRC) refers to the combination of medication classes, dosages, and frequencies. The relationship between MRC and clinical outcomes in the intensive care unit (ICU) has not been examined. The objective of this study is to examine the association between MRC scoring tools and their utility in predicting clinical outcomes.MethodsWe conducted a retrospective cohort study that includes 322 adult patients admitted and stayed (>24 hours) to the ICU between February 1, 2020, and August 30, 2020 in a community-based, teaching hospital in Rhode Island. Medication complexity was assessed using two MRC scoring tools: MRC Index (MRCI) and the MRC in ICU (MRCICU). We used a multivariable logistic regression model to identify the association between MRC scores and clinical outcomes and to predict the clinical outcomes.RESULTSAmong the 317 patients included in the study (55.2% men with a median age of 62 [IQR: 51-75] years). Higher MRC scores (i.e., > 63 MRCI or > 6 MRCICU) were associated with increased mortality (14% and 15%), longer ICU length of stay (LOS)(30% and 34%), and need for MV (24% and 28%). MRCICU scores at 24 hours were found to be a significant risk factor in all clinical outcomes (ICU mortality, LOS, and MV) with Odds Ratio (ORs) of 1.12 (95% CI: 1.06-1.19), 1.17 (1.1-1.24), and 1.21 (1.14-1.29), respectively. In the prediction models, both MRCI and MRCICU models performed similarly (AUC: 0.88 [0.75-0.97] and 0.88 [0.76-0.97] in predicting mortality. The Medication Model included 15 medication classes outperformed others (AUC: 0.82 [0.71-0.93] in predicting ICU LOS and the MRCICU model outperformed others (AUC: 0.87 [0.77-0.96]) in predicting the need for MV.CONCLUSIONMRC scores are associated with poorer clinical outcomes and improves the prediction of poorer clinical outcomes which will support clinicians to prescribe safer therapies.

We aimed to assess the association between serum potassium and mortality in patients receiving continuous renal replacement therapy (CRRT).We studied 1279 acute kidney injury patients receiving CRRT in a tertiary referral hospital in the United States. We used logistic regression to assess the association of serum potassium before CRRT and mean serum potassium during CRRT with 90-day mortality after CRRT initiation, using serum potassium 4.0-4.4 mmol/L as reference group.Before CRRT, there was a U-shaped association between serum potassium and 90-day mortality. There was a significant increase in mortality when serum potassium before CRRT was ≤3.4 and ≥4.5 mmol/L. During CRRT, progressively increased mortality was noted when mean serum potassium was ≥4.5 mmol/L. The odds ratio of 90-day mortality was significantly higher when mean serum potassium was ≥4.5 mmol/L.Hypokalemia and hyperkalemia before CRRT and hyperkalemia during CRRT predicts 90-day mortality.

BackgroundFluid overload, a critical consequence of acute kidney injury (AKI), is associated with worse outcomes. The optimal fluid removal rate per day during continuous renal replacement therapy (CRRT) is unknown. The purpose of this study is to evaluate the impact of the ultrafiltration rate on mortality in critically ill patients with AKI receiving CRRT.MethodsThis was a retrospective cohort study where we reviewed 1398 patients with AKI who received CRRT between December 2006 and November 2015 at the Mayo Clinic, Rochester, MN, USA. The net ultrafiltration rate (UFNET) was categorized into low- and high-intensity groups (ResultsThe mean ± SD age was 62 ± 15 years, and 827 (59%) were male. There were 696 patients (49.7%) in the low- and 702 (50.2%) in the high-intensity group. Thirty-day mortality was 755 (54%). There were 420 (60%) deaths in the low-, and 335 (48%) in the high-intensity group (P ConclusionsMore intensive fluid removal, UFNET ≥35 mL/kg/day, among AKI patients receiving CRRT is associated with lower mortality. Future prospective studies are required to confirm this finding.

The epidemiology of ANCA-associated vasculitis (AAV) varies by ethnicity and region. Environmental exposure has been implicated in the pathophysiology of MPO-AAV. The aim of this study was to evaluate the epidemiology of AAV and explore a potential relationship with environmental factors in north central West Virginia.This is a retrospective cohort study of 212 patients diagnosed with AAV at West Virginia University and its affiliated hospitals from January 1, 1990 to December 31, 2019. We assessed prevalence of AAV over time according to patient's zip codes and counties. Silica exposure through natural gas extraction was considered as a possible environmental factor.The proportion of patients with MPO-ANCA increased after 2010 (37.5% before 2010 vs 61% after 2010, p = 0.008). At the same time, the prevalence of AAV in Monongalia and surrounding counties has increased significantly after 2010 from 64.8 to 141.9 cases per million (p = 0.001). The increase in prevalence of AAV was primarily due to an increase in MPO-AAV (43 vs 101.7 cases per million before and after 2010, respectively, p = 0.028). During this time, the production of natural gas through fracking increased, rising more than tenfold after 2010 (p-value 0.001). Heat mapping reveals that the increase in cases of AAV occurred in areas of increased fracking activity.There was an increase in the prevalence of patients who were newly diagnosed with AAV over time in north central West Virginia. Further studies are required to ascertain the potential role of environmental exposure in the pathophysiology of AAV.

Background: Serum sodium derangement is common in critically ill patients requiring continuous renal replacement therapy (CRRT). We aimed to assess the association between serum sodium before and during CRRT with mortality. Methods: This is a historical cohort study of 1,520 critically ill patients receiving CRRT from December 2006 through November 2015 in a tertiary hospital in the United States. Using logistic regression analysis, we used serum sodium before CRRT, mean serum sodium, and serum sodium changes during CRRT to predict 90-day mortality after CRRT initiation. Results: Compared with the normal serum sodium levels, the odds ratio (OR) of 90-day mortality in patients with serum sodium before CRRT of 143–147 and ≥148 mmol/L were 1.45 (95% CI 1.03–2.05) and 2.24 (95% CI 1.33–3.87), respectively. There was no significant increase in 90-day mortality in serum sodium of ≤137 mmol/L. During CRRT, the mean serum sodium levels of ≤137 (OR 1.41; 95% CI 1.01–1.98) and ≥143 mmol/L (OR 1.52; 95% CI 1.14–2.03) were associated with higher 90-day mortality. The greater serum sodium changes during CRRT were associated with higher 90-mortality (OR 1.35; 95% CI 1.21–1.51 per 5-mmol/L increase). Conclusion: Before CRRT initiation, hypernatremia and during CRRT, hypo- and hypernatremia were associated with increased mortality.

BACKGROUND: Little is known about the process of deciding to discontinue continuous renal replacement therapy (CRRT) in patients with acute kidney injury (AKI) and the impact of CRRT duration on outcomes. METHODS: We report the clinical parameters of prolonged CRRT exposure and predictors of doubling of serum creatinine or need for dialysis at 90 days after CRRT with propensity score matching, including covariates that were likely to influence patients in the prolonged CRRT group. RESULTS: Among 104 survey responders, most use urine output (87%) to guide CRRT discontinuation, 24% use improvement in clinical or hemodynamic status. In the cohort study, of 854 included patients, 465 participated in the assessment of kidney recovery. Patients with prolonged CRRT had higher SOFA scores (11.9 vs. 11.2) and were more likely to be mechanically ventilated (99% vs. 84%) at CRRT initiation compared to patients without prolonged CRRT, p-value < 0.05. In multivariable logistic regression, daily urine output and cumulative fluid balance leading to CRRT discontinuation or day seven were independently associated with lower [OR 0.87 per 200 ml/day increase] and higher odds [OR 1.03 per 1-L increase] of requiring prolonged CRRT, respectively. After propensity score matching, prolonged exposure to CRRT was independently associated with increased risk of doubling serum creatinine or dialysis at 90 days, OR 3.1 (95% CI 1.23–8.3 p = 0.017). CONCLUSIONS: Resolution of critical illness and signs of kidney recovery are important factors when considering CRRT discontinuation. Prolonged CRRT exposure may be associated with less chance of kidney recovery among survivors.

Declining Helicobacter pylori (H. pylori) eradication rates have prompted a switch in first-line therapy from standard triple (PPI, clarithromycin, and amoxicillin) to bismuth-based quadruple therapy. A caveat of the ACG 2017 H. pylori treatment guidelines was a paucity of recent US eradication data. To determine Rhode Island H. pylori eradication data, in the largest US study from the last two decades. Electronic records were queried for patients with H. pylori infection diagnosed by pathology, urea breath test, or stool antigen from 2015 to 2017. Demographics, diagnostic test, treatment regimen, and test of cure were extracted. Eradication rates were calculated, and treatment regimens were compared. A total of 1710 patients were identified (64% female): 825 (46%) diagnosed by breath test, 755 (42%) by biopsy, and 191 (12%) by stool antigen. Full data were obtained on 1101 patients. Seven regimens were used: quadruple (64%), triple (25%), doxycycline quadruple (5%), and miscellaneous (6%). Quadruple was superior to triple: (85% vs. 75%, P = 0.002), quadruple 14 days versus triple 14 days (87% vs. 79%, P = 0.0052), quadruple 10 days versus triple 10 days (77% vs. 67%, P = 0.33). Increased therapy length improved eradication (quadruple 14 days vs. 10 days, 87% vs. 77%, P = 0.002; triple 14 days versus 10 days 79% vs. 67%, P = 0.13). Finally, substituting doxycycline for tetracycline yielded lower eradication (85% vs. 67%, P = 0.006). Quadruple therapy is superior to triple therapy within the Rhode Island population. Fourteen-day therapy achieves superior eradication compared to 10-day therapy, and doxycycline is inferior to tetracycline for quadruple therapy. Our findings support adherence to ACG and international guidelines advising 14-day quadruple therapy.

The use of chloride-rich crystalloids for resuscitation is associated with acute kidney injury (AKI). We aimed to explore the impact of resuscitation with chloride-rich crystalloids compared to balanced crystalloids on kidney function recovery in patients presenting with sepsis-associated community-acquired AKI (SACA-AKI). This is a single-center, historical cohort study of the adult intensive care unit (ICU) patients who presented to the emergency department (ED) with sepsis-associated community-acquired-AKI at the Mayo Clinic, Rochester, MN, from January 2011 to April 2018. We divided the cohort into two groups based on the primary type of crystalloids they received in the ED and the first 48-h of ICU. The first group received primarily normal saline with

The objective of this study is to evaluate the association between antineutrophil cytoplasmic autoantibody (ANCA) subtype and ANCA titers on clinical outcomes and disease activity among a cohort of patients from Central Appalachia diagnosed with ANCA-associated vasculitis (AAV) over a 3-decade period. This is a retrospective chart review of all patients diagnosed with AAV. ANCA subtypes (myeloperoxidase (MPO) and proteinase 3 (PR3)) and titers at the time of diagnosis and at the time of relapse or last follow-up were evaluated along with patient outcomes. Outcomes of interest included relapse, development of end-stage renal disease (ESRD) and mortality. Sensitivity analysis and multivariable analysis were performed. Of the 202 patients, 111 patients were MPO-ANCA positive and 91 patients were PR3-ANCA positive. Relapse was more frequent among patients with PR3-ANCA compared to MPO-ANCA (35% vs 12%, p

Purpose The mortality of critically ill patients with acute kidney injury (AKI) who require continuous renal replacement therapy (CRRT) remains high. We assessed the incidence and predictors of new-onset atrial fibrillation (NOAF) in this population and its impact on outcomes. Materials and methods This is a retrospective cohort study of adult intensive care units (ICU) patients who had AKI and received CRRT from December 2006 through November 2015 in a tertiary academic medical center. Cox proportional hazard model was used to evaluate the impact of NOAF on overall mortality. Results Out of 1398 screened patients, NOAF occurred in 193 (14%) cases. NOAF occurring on CRRT was independently associated with an increased hazard of death at follow-up (HR: 1.26; 95% CI: 1.03–1.56), compared to the group who did not have NOAF. In the multivariable analysis using time-dependent covariates, higher potassium (HR 1.24, 95%CI: 1.01–1.54) and bicarbonate (HR 0.95, 95%CI: 0.92–0.98) levels were associated with increased and decreased risk of NOAF on CRRT, respectively. Conclusions NOAF in critically ill patients with AKI receiving CRRT is common and carries an unfavorable prognosis. Prospective studies are required to elucidate modifiable risk factors for NOAF occurring on CRRT.

Background Microhematuria is common in immunoglobulin A nephropathy (IgAN). However, current prognostication is based on proteinuria and mesangial hypercellularity, endocapillary hypercellularity, segmental sclerosis, tubulointerstitial fibrosis and crescent (MEST-C) scores. Methods In this retrospective study, we evaluated whether MEST-C score components are associated with the presence of microhematuria at biopsy and whether the degree of microhematuria during follow-up is associated with change in estimated glomerular filtration rate (eGFR), after adjusting for clinical and histological parameters. We identified 125 patients with biopsy-proven IgAN and MEST-C scoring who were not on immunosuppressive therapy at biopsy. Microhematuria was defined as ≥3 red blood cells (RBCs)/high-power field (hpf). Results Of the 125 patients, 97 had microhematuria at baseline and were more likely to have M1, E1 and C ≥ 1 lesions (P Conclusion Degree of microhematuria during follow-up is an independent predictor of eGFR decline after adjusting for clinical and histological parameters. Therefore, monitoring the degree of microhematuria as well as proteinuria is important when evaluating patients with IgAN. Additional studies using improvement in microhematuria as a primary surrogate outcome are needed.

Introduction Hypovitaminosis D affects one-third to two-thirds of children and pregnant women from the Middle East and North Africa (MENA) region. Objective To evaluate in infants, children, adolescents and pregnant women, from the MENA region, the effect of supplementation with different vitamin D doses on the change in 25-hydroxyvitamin D [25(OH)D] level reached, and other skeletal and non-skeletal outcomes. Methods This is a systematic review of randomized controlled trials of vitamin D supplementation conducted in the MENA region. We conducted a comprehensive literature search in 7 databases, without language or time restriction, until November 2016. Two reviewers abstracted data from the included studies, independently and in duplicate. We calculated the mean difference (MD) and 95% CI of 25(OH)D level reached when at least 2 studies were eligible in each comparison (low ( 2000 IU) daily dose of vitamin D, or placebo). We pooled data using RevMan version 5.3. Results We identified a total of 15 eligible trials: one in infants, 4 in children and adolescents and 10 in pregnant women. In children and adolescents, an intermediate vitamin D dose (1901 IU/d), resulted in a mean difference in 25(OH)D level of 13.5 (95% confidence interval (CI) 8.1–18.8) ng/ml, compared to placebo, favoring the intermediate dose ( p In pregnant women, four trials started supplementation at 12–16 weeks of gestation and continued until delivery, and six trials started supplementation at 20–28 weeks' gestation and stopped it at delivery. The MD in 25(OH)D level reached was 8.6 (95% CI 5.3–11.9) ng/ml ( p p p The risk of bias in the included studies, for children, adolescents and pregnant women, ranged from low to high across all doamins. Conclusion In children, adolescents and pregnant women from the MENA, an intermediate vitamin D dose of 1000–2000 IU daily may be necessary to allow for the majority of the population to reach a desirable 25(OH)D level of 20 ng/ml. Further high quality RCTs are required to confirm/refute the beneficial impact of vitamin D supplementation on various clinically important outcomes.

Background: Patients discharged early from the medical intensive care unit (MICU) are at risk of deterioration, MICU readmission, and increased mortality. An earlier discharge to a medical ward is desirable to reduce costs but it may adversely affect outcomes. To address this problem, a new model for the MICU transition of care was implemented at our academic center: The MICU team continued to manage all patients transferred from the MICU to the medical ward for at least 24 hours. Methods: Data were collected for all MICU patients admitted 1 year before and 1 year after the intervention. Hospital length of stay (LOS) after transfer from the MICU, readmission rate, and mortality rate were compared before and after the intervention. A nonparsimonious propensity model based on 30 factors was used to identify matched preintervention and postintervention cohorts. Results: A total of 618 of the 848 patients admitted to the MICU were transferred to medical ward during the year prior to the implementation of the new model, and 600 of the 883 patients were transferred during the following year. Pre- and postintervention cohorts were well matched (n = 483 patients in each group). Poisson regression analysis showed a decrease in the hospital LOS after MICU transfer by 1.17 days ( P < .001) without a significant change in adjusted mortality (lower by 1.9%, P = .181) and MICU readmission rates (lower by 2%, P = .264). Conclusion: A new model for the post-MICU transition of care, with the MICU team continuing to manage all patients transferred to the medical ward for at least 24 hours, significantly decreased duration of hospital stay after MICU transfer without affecting MICU readmission and mortality rate. The implementation of this model may lower medical costs and make transition of care safer without adverse outcomes.

Hypovitaminosis D affects one-third to two-thirds of children and pregnant women from the Middle East and North Africa (MENA) region.To evaluate in infants, children, adolescents and pregnant women, from the MENA region, the effect of supplementation with different vitamin D doses on the change in 25-hydroxyvitamin D [25(OH)D] level reached, and other skeletal and non-skeletal outcomes.This is a systematic review of randomized controlled trials of vitamin D supplementation conducted in the MENA region. We conducted a comprehensive literature search in 7 databases, without language or time restriction, until November 2016. Two reviewers abstracted data from the included studies, independently and in duplicate. We calculated the mean difference (MD) and 95% CI of 25(OH)D level reached when at least 2 studies were eligible in each comparison (low (800IU), intermediate (800-2000IU) or high (2000IU) daily dose of vitamin D, or placebo). We pooled data using RevMan version 5.3.We identified a total of 15 eligible trials: one in infants, 4 in children and adolescents and 10 in pregnant women. In children and adolescents, an intermediate vitamin D dose (1901IU/d), resulted in a mean difference in 25(OH)D level of 13.5 (95% confidence interval (CI) 8.1-18.8) ng/ml, compared to placebo, favoring the intermediate dose (p0.001). The proportion of children and adolescents reaching a 25(OH)D level≥ 20ng/ml was 74% in the intermediate dose group. In pregnant women, four trials started supplementation at 12-16weeks of gestation and continued until delivery, and six trials started supplementation at 20-28weeks' gestation and stopped it at delivery. The MD in 25(OH)D level reached was 8.6 (95% CI 5.3-11.9) ng/ml (p0.001) comparing the high dose (3662IU/d) to the intermediate dose (1836IU/d), and 12.3 (95% CI 6.4-18.2) ng/ml (p0.001), comparing the high dose (3399IU/d) to the low dose (375IU/d). Comparing the intermediate (1832IU/d) to the low dose (301IU/d), the MD in 25(OH)D level achieved was 7.8 (95% CI 4.5-10.8) ng/ml (p0.001). The proportion of pregnant women reaching a 25(OH)D level≥20ng/ml was 80%-90%, 73% and 27%-43% in the high, intermediate, and low dose groups, respectively. The risk of bias in the included studies, for children, adolescents and pregnant women, ranged from low to high across all doamins.In children, adolescents and pregnant women from the MENA, an intermediate vitamin D dose of 1000-2000IU daily may be necessary to allow for the majority of the population to reach a desirable 25(OH)D level of 20ng/ml. Further high quality RCTs are required to confirm/refute the beneficial impact of vitamin D supplementation on various clinically important outcomes.

In the Middle East and North Africa (MENA), a vitamin D dose ≥2000 IU/day may be needed to allow to the majority of the population to reach the target 25-hydroxyvitamin D (25(OH)D) level ≥20 ng/ml. Data in the region on the effect of vitamin D supplementation on various skeletal and extra-skeletal effects are scarce. Hypovitaminosis D is prevalent worldwide, more so in the Middle East and North Africa (MENA). This study aims to determine the effects of vitamin D replacement on the mean difference in 25-hydroxyvitamin D [25(OH)D] level reached and other outcomes, in the MENA. This is a meta-analysis of randomized trials from the MENA, administering vitamin D supplementation for at least 3 months, without language or time restriction. We conducted a comprehensive search in seven databases until July 2015. We abstracted data from published reports, independently and in duplicate. We calculated the mean difference (MD) and 95 % CI of 25(OH)D level reached for eligible comparisons, and pooled data using RevMan version 5.3. We identified 2 studies in elderly and 17 in adults; for the latter, 11 were included in the meta-analysis. Comparing a high vitamin D dose (>2000 IU/day) to placebo (nine studies), the MD in 25(OH)D level achieved was 18.3 (CI 14.1; 22.5) ng/ml; p value

Background Obesity is a public health problem that carries global and substantial social and economic burden. Relative to non-surgical interventions, bariatric surgery has the most substantial and lasting impact on weight loss. However, it leads to a number of nutritional deficiencies requiring long term supplementation. Objectives The aims of this paper are to review 25-hydroxyvitamin D [25(OH)D] status pre and post bariatric surgery, describe the dose response of vitamin D supplementation, and assess the effect of the surgical procedure on 25(OH)D level following supplementation. Methods We searched Medline, PubMed, the Cochrane Library and EMBASE, for relevant observational studies published in English, from 2000 to April 2015. The identified references were reviewed, in duplicate and independently, by two reviewers. Results We identified 51 eligible observational studies assessing 25(OH)D status pre and/or post bariatric surgery. Mean pre-surgery 25(OH)D level was below 30 ng/ml in 29 studies, and 17 of these studies showed mean 25(OH)D levels ≤ 20 ng/ml. Mean 25(OH)D levels remained below 30 ng/ml following bariatric surgery, despite various vitamin D replacement regimens, with only few exceptions. The increase in post-operative 25(OH)D levels tended to parallel increments in vitamin D supplementation dose but varied widely across studies. An increase in 25(OH)D level by 9–13 ng/ml was achieved when vitamin D deficiency was corrected using vitamin D replacement doses of 1100–7100 IU/day, in addition to the usual maintenance equivalent daily dose of 400–2000 IU (total equivalent daily dose 1500–9100 IU). There was no difference in mean 25(OH)D level following supplementation between malabsorptive/combination procedures and restrictive procedures. Conclusion Hypovitaminosisis D persists in obese patients undergoing bariatric surgery, despite various vitamin D supplementation regimens. Further research is needed to determine the optimal vitamin D dose to reach desirable 25(OH)D levels in this population, and to demonstrate whether this dose varies according to the surgical procedure.

Importance It is unclear how medical journals address authors’ financial and non-financial conflict of interest (COI). Objective To assess the policies of clinical journals for disclosure of financial and non-financial COI. Methods Cross sectional study that included both review of public documents as well as a simulation of a manuscript submission for the National Library of Medicine’s “core clinical journals”. The study did not involve human subjects. Investigators who abstracted the data, reviewed “instructions for authors” on the journal website and, in order to reflect the actual implementation of the COI disclosure policy, simulated the submission of a manuscript. Two individuals working in duplicate and independently to abstract information using a standardized data abstraction form, resolved disagreements by discussion or with the help of a third person. Results All but one of 117 core clinical journals had a COI policy. All journals required disclosure of financial COI pertaining to the authors and a minority (35%) asked for financial COI disclosure pertaining to the family members or authors' institution (29%). Over half required the disclosure of at least one form of non-financial COI (57%), out of which only two (3%) specifically referred to intellectual COI. Small minorities of journals (17% and 24% respectively) described a potential impact of disclosed COI and of non-disclosure of COI on the editorial process. Conclusion While financial COI disclosure was well defined by the majority of the journals, many did not have clear policies on disclosure of non-financial COI, disclosure of financial COI of family members and institutions of the authors, and effect of disclosed COI or non-disclosure of COI on editorial policies.

Tunneled pleural catheter (TPC) has been widely used to control malignant pleural effusion (MPE); however, it is still not clear whether it is more effective than chemical pleurodesis. We performed a systematic review with meta-analysis to evaluate success and complication rate of TPC as compared with chemical pleurodesis in the management of MPE. PubMed, EMBASE, Cochrane central register of controlled trials, and MEDLINE were searched for English-language studies of clinical controlled trials comparing TPC with chemical pleurodesis until May 2014. Overall success and complication rate were evaluated. Relative risks (RRs) were estimated using random-effects model, and statistical heterogeneity was assessed using I test. Three trials involving 307 patients with MPE were included. The success rate was comparable between TPC and chemical pleurodesis group when all studies included in the analysis (RR, 0.8; 95% confidence interval, 0.53-1.19; P = 0.27). TPC had slightly higher complication rate but was not statistically significant (RR, 2; 95% confidence interval, 0.91-4.4; P = 0.09). Current evidence suggests that TPC and chemical pleurodesis are both effective treatment for recurrent MPE with similar success and complication rate. Further randomized controlled trials are needed to compare TPC with other therapies in patients with MPE.

Objectives We conducted a systematic survey of the methodological literature to identify recommended approaches for how and what randomised clinical trial (RCT) authors should report on missing participant data and, on the basis of these approaches, to propose guidance for RCT authors. Methods We defined missing participant data (MPD) as missing outcome data for trial participants. We considered both categorical and continuous outcome data. We searched MEDLINE and the Cochrane Methodology Register for articles in which authors proposed approaches to reporting MPD from RCTs. We selected eligible articles independently and in duplicate and extracted data in duplicate. Using an iterative process of discussion and revisions, we used the findings to develop guidance. Results Of 10501 unique citations identified, 13 articles reporting on 10 approaches proved eligible. The identified approaches recommend reporting the following aspects (from most to least frequently recommended): number of participants with MPD (n=10), reasons for MPD (n=7), methods used to handle MPD in the analysis (n=4), flow of participants (n=3), pattern of missingness (eg, whether at random) (n=3), differences in rates of MPD between trial arms (n=2), differences between participants with and without MPD (n=2), results of any sensitivity analyses (n=2), implication of MPD on interpreting the results (n=2) and methods used to prevent missing data (n=1). We propose a guide with nine items related to reporting the number, reasons, patterns, analytical methods and interpretation of MPD. Conclusions Most identified approaches invite trial authors to report the extent of MPD and the underlying reasons. Fewer approaches focus on reporting missingness patterns, methods for handling MPD and implications of MPD on results. Our proposed guidance could help RCT authors to better report, and readers to better identify participants with missing data.

Trabecular bone score (TBS) is a DXA-based tool that assesses bone texture and reflects microarchitecture. It has been shown to independently predict the risk of osteoporotic fracture in the elderly. In this study, we investigated the determinants of TBS in adolescents. TBS is a gray-level textural measurement derived from lumbar spine DXA images. It appears to be an index of bone microarchitecture that provides skeletal information additional to the standard BMD measurement and clinical risk factors. Our objectives were to characterize the relationship between TBS and both age and pubertal stages and identify other predictors in adolescents. We assessed TBS by reanalyzing spine DXA scan images obtained from 170 boys and 168 girls, age range 10–17 years, gathered at study entry and at 1 year, using TBS software. The results are from post hoc analyses obtained using data gathered from a prospective randomized vitamin D trial. Predictors of TBS were assessed using t test or Pearson’s correlation and adjusted using regression analyses, as applicable. The mean age of the study population was 13.2 ± 2.1 years, similar between boys and girls. Age, height, weight, sun exposure, spine BMC and BMD, body BMC and BMD, and lean and fat mass are all significantly correlated with TBS at baseline (r = 0.20–0.75, p

A 48-year-old woman presented with a red, pruritic and painful skin rash on her legs bilaterally after she snorted cocaine. This was associated with fever and cough. Physical examination showed large violaceous plaques and large flaccid bullae, involving bilateral lower extremities. Blood work showed neutropoenia with absolute neutrophil count of 0.64×10(9) cells/L. Antinuclear antibody, perinuclear antineutrophil cytoplasmic antibody and anti-double-stranded DNA were positive. Biopsy showed thrombogenic vasculopathy which is consistent mainly with levamisole ingestion that was reported with levamisole ingestion. The patient was counselled to stop cocaine misuse and treated with skin emollients and antibiotics for the pneumonia that was discovered on the chest X-ray. Skin ulcers improved and she was discharged in stable condition. Ten days after discharge, she was readmitted with new lesions and worsening necrotic ulcers from the old lesions. The patient admitted to snorting cocaine again a few days after being discharged.

A 49-year-old woman with a medical history of hypertension and rheumatoid arthritis presented with severe bilateral hand pain due to arthritis. She was diagnosed with rheumatoid arthritis at the age of 20 years and has been on anti-inflammatory medications and steroids since then. She was treated with methotrexate for a short period of time, but this was stopped due to gastrointestinal intolerance. She has been on prednisone and ibuprofen only for the last 15 years and has been a nursing home resident for the last 5 years due to severe hand deformities and inability to use …