Chronic Kidney Disease of Unknown Cause in Agricultural Communities | NEJM

Chronic Kidney Disease of Unknown Cause in Agricultural Communities | NEJM

In recent years, numerous cases of chronic kidney disease have emerged among agricultural workers, as well as among others performing manual labor, in various regions of the world. The disease does not appear to be due to the classic causes of kidney disease (e.g., diabetes, hypertension, and glomerular disease). In this review, we describe the clinical presentation and epidemiology of chronic kidney disease that is endemic in this workforce in these areas, as well as possible causes. The disease is strongly associated with working and living in a hot environment, but whether the cause is a toxin, an infectious agent, a heat-associated injury, or a combination of factors is not yet known. We also discuss some of the assumptions and limitations in our understanding of chronic kidney disease in agricultural communities.

Imaging the left atrial appendage using TTE

Squeezing more out of imaging

The standard views that are recommended in the guidelines are an important part of learning and standardizing echocardiography. But sometimes I wonder who came up with exactly these views? While I agree that the standard views were well chosen I am convinced that it will always be necessary to use atypical views that focus on the pathology or the structure you want to study.

Mitral Regurgitation in Heart Failure

The following are key points to remember from this review on mitral regurgitation (MR) in heart failure (HF) and its treatment:

1. Secondary or functional MR is commonly seen in HF with reduced ejection fraction (HFrEF) patients and is a poor prognostic marker. Available therapies that improve outcomes in this population include cardiac resynchronization therapy (CRT), left ventricular (LV) assist devices, and cardiac transplantation. In contrast, surgery for secondary MR is not supported by existing evidence and is being supplanted by transcatheter treatments after the recent MITRA-FR and COAPT trials.
2. The MITRA-FR trial, based out of France, randomized 307 patients with HFrEF and severe functional MR to optimal medical therapy versus optimal therapy and MitraClip. Reduction of MR to grade 2+ at discharge was achieved in 92% of patients, but had no impact on all-cause mortality or HF rehospitalization at 1 year.
3. The COAPT trial was based out of the United States and randomized 614 patients with symptomatic HFrEF and moderate-severe MR to MitraClip and optimal medical therapy versus optimal medical therapy only. Patients with Stage D HF or severe LV dilatation >7 cm were excluded. Implementation of optimal therapy including CRT was supervised by the core committee.
4. In COAPT, 98% of patients achieved a successful reduction in MR, and MitraClip in combination with medical therapy demonstrated a statistically significant reduction in HF hospitalization (number needed to treat of 3.1) and a reduction in 2-year all-cause mortality.
5. Differences between the results of these two trials can be explained by differences in patient characteristics, trial design, and duration of follow-up. The COAPT trial excluded patients with Stage D HF and severe LV dilatation (>7 cm), enrolled patients with more severe MR, mandated a run-in period on maximal medical therapy with demonstration of persistent symptoms, and had a longer follow-up period of 2 years. Rates of procedural complications in COAPT were lower.
6. Appropriate patient selection is an important factor to take into consideration when evaluating patients for transcatheter mitral therapies. Patients with extreme LV dilatation and less severe secondary MR are unlikely to benefit from this therapy.
7. Other key takeaway points from these trials include poor prognosis in patients with secondary MR and HFrEF despite optimal medical therapy: two-thirds of the control group had an HF hospitalization and 50% of patients died within 2 years.
8. The COAPT trial also highlights the importance of a team-based approach in management of this patient population with a close synergy between HF specialists and interventional cardiologists. Apart from appropriate patient selection, this trial highlights early MitraClip referral for those with persistent symptoms on optimal medical therapy to reduce mortality and HF rehospitalizations.

Tiến trình hình thành ung thư ở người khỏe mạnh

Trong quá trình phân chia tế bào sẽ có những tế bào bị lỗi ADN, chúng tiếp tục phân chia và phát triển thành khối u.

How to Spot and Deal With Attention Deficit Trait

Although ADD and ADHD have become more commonplace to identify and treat, an attention deficient trait (ADT) is one that may present like ADD or ADHD but is not genetically inherited and is typically produced from an overabundance of noise and distractions in the modern workplace. According to psychiatrist Dr. Edward Hallowell the condition may have a negative impact on your overall productivity because your brain is overwhelmed with chatter. “It's sort of like the normal version of attention deficit disorder,” he explains. “But it's a condition induced by modern life, in which you've become so busy attending to so many inputs and outputs that you become increasingly distracted, irritable, impulsive, restless and, over the long term, underachieving. In other words, it costs you efficiency because you're doing so much or trying to do so much, it's as if you're juggling one more ball than you possibly can.” What can you do to spot the signs of ADT and how can you reduce its effects?

ACC/AHA vs. ESC/ESH on Hypertension Guidelines

The following are key points to remember from this comparison of the blood pressure guidelines from the American College of Cardiology/American Heart Association (ACC/AHA) and the European Society of Cardiology/European Society of Hypertension (ESC/ESH):

1. The authors compared the recommendations of the most recent ACC/AHA and ESC/ESH blood pressure guidelines, each of which represented updates and reinforced concepts of prevention regarding elevated blood pressure (BP).
2. Both guidelines provide general recommendations of a low-sodium diet (<2300 mg of sodium), exercise, body weight reduction, low to moderate alcohol intake, and adequate potassium intake.
3. The guidelines agree on the importance of proper methods of BP measurement, the use of home BP monitoring and ambulatory monitoring, focusing on detecting and improving adherence, and both support the use of BP telemonitoring and digital health solutions for follow-up.
4. Both recommend use of absolute cardiovascular (CV) risk estimates computed with risk calculators and that a >10% 10-year risk of atherosclerotic CV disease should be treated more aggressively. And both provide a concise definition of organ damage assessment. The ACC/AHA guideline details guidance for ethnic/racial groups. ESC/ESH emphasizes the importance of environmental and altitude effects on BP.
5. There are major disagreements with the level of BP defining hypertension, the specific BP targets for treatment, and the use of initial combination therapy. ACC/AHA does not address isolated systolic hypertension, which is detailed in the ESC/ESH guideline, with target systolic BP to <140 mm Hg. ESC/ESH limits BP reduction to no lower than 120/70 mm Hg regardless of baseline, age, and target organ damage.
6. The initial single-pill combination is strongly recommended in both guidelines with angiotensin-converting enzyme inhibitor or angiotensin-receptor blocker + thiazide or calcium channel blocker. However, ESC/ESH recommends it as initial therapy in patients at ≥140/90 mm Hg and the ACC/AHA recommends a single-pill combination in patients with >20/10 mm Hg above BP goal.
7. The most important distinction is that ACC/AHA maintains that all people with a BP >130/80 mm Hg have hypertension and BP should be targeted to <130/80 mm Hg. While this implies increased cost, the ACC/AHA guideline stresses lifestyle change for BP for the first 6 months except for those at high risk or with target organ damage.
8. The ESC/ESH guideline defines hypertension as >140/90 mm Hg with the goal being 130 to <140/70-79 mm Hg for all but targeting to <130/70-79 mm Hg or lower only in those at high cardiovascular risk defined as diabetes, post-stroke, and coronary artery disease.
9. The authors suggest that a more evidence-based statement for the guideline would be to set the lower BP target for treatment at >15% 10-year CV risk, because all trials had cohorts with >15% CV risk.

Medmastery’s chest x-ray algorithm

Medmastery’s chest x-ray algorithm—a systematic approach for evaluating any chest x-ray

So you're looking at a patient's chest x-ray and you've identified an abnormality–great! But how do you make sure you're not missing something else? In this video, from our Chest X-ray Essentials course, you'll master a powerful step-by-step algorithm that'll make sure you never miss a significant problem again.

This video was taken from our Chest X-ray Essentials course. If you want to watch all the teaching videos that lead up to the algorithm, then take the course and register for the Medmastery membership.