Balboa Nephrology Medical Group

OPTIMIZE was a randomized, open-label study evaluating different tenapanor initiation methods. OPTIMIZE evaluated tenapanor alone and in combination with phosphate binders (PBs) to achieve target serum phosphate (P) ≤5.5 mg/dL. Patients with inadequately controlled P receiving maintenance dialysis from 42 US locations who were taking PBs with baseline P >5.5 mg/dL and ≤10.0 mg/dL, or were PB-naive with baseline P >4.5 mg/dL and ≤10.0 mg/dL, were included in OPTIMIZE. Participants taking PBs at baseline were randomized to switch from PBs to tenapanor (Straight Switch; n = 151) or reduce PB dosage by ≥50% and add tenapanor (Binder Reduction; n = 152); PB-naive patients started tenapanor alone (Binder-Naive; n = 30). Participants received tenapanor 30 mg twice a day for 10 weeks (part A), followed by an elective, 16-week open-label extension (part B). Outcomes included changes from baseline in P, intact fibroblast growth factor 23 (iFGF23), parathyroid hormone (PTH), serum calcium, and medication burden; patient-reported outcomes; and safety. By part A endpoint, 34.4% (Straight Switch), 38.2% (Binder Reduction), and 63.3% (Binder-Naive) of patients achieved P ≤5.5 mg/dL. Mean P reduction and median pill burden reduction from baseline to part A endpoint were 0.91± 1.7 mg/dL and 4 pills/day for the Straight Switch and 0.99± 1.8 mg/dL and 1 pill/day for the Binder Reduction group. The mean P reduction for Binder-Naive patients was 0.87± 1.5 mg/dL. Among Straight Switch and Binder Reduction patients who completed patient experience questionnaires, 205 of 243 (84.4%) reported an improved phosphate-management routine. Diarrhea was the most common adverse event (133 of 333 [39.9%]). Tenapanor as monotherapy or in combination with PBs effectively lowered P toward the target range in patients who were PB naïve or who were not at goal despite PB use. Ardelyx, Inc. NCT04549597.

Scholars have highlighted the importance of preventing hospital admissions and readmissions for individuals with costly chronic conditions. Providing effective care management strategies can help reduce inpatient admissions, thereby reducing rising health care costs. However, implementing effective care management strategies may be more difficult for independent physician associations (IPAs) that contract with multiple organizations that have competing interests and agendas. This study aims to identify and investigate strategies that facilitate the implementation of evidence-based best practices among IPAs. The research synthesized peer-reviewed literature to identify best practices in chronic disease management for Medicare beneficiaries. Subsequently, 20key informant interviews were conducted to explore barriers and facilitators in adapting these best practices in IPA settings. Informant interviews were conducted with 3 key groups: executives, medical directors, and care managers. Key informant interviews were conducted to explore barriers and facilitators in implementing best care management practices. Key informants provided unique insights regarding the challenges of implementing best care management practices among IPAs. These challenges included implementing and sustaining the operations of evidence-based care management programs while maintaining contractual obligations to health plans, engaging physicians in large and diverse networks, and building high-touch programs in large geographic areas using risk-stratifying algorithms. IPA managed care organizations require unique considerations in regard to selected strategies used to manage chronic disease in Medicare populations. These considerations are critical for optimal management of the population, particularly in a risk-based or pay-for-performance environment.

Cardiovascular disease is a leading cause of morbidity and mortality and is becoming more prevalent as the population ages and risk factors increase. This is most apparent in the end-stage renal disease (ESRD) patient population. In part, this is due to cofactors such as diabetes and hypertension commonly predisposing to progressive renal disease, as well as being a direct consequence of having renal failure. Of all major organ failures, kidney failure is the most likely to be managed chronically using renal replacement therapy and, ultimately, transplant. However, lack of transplant organs and a large renal failure cohort means waiting lists are often quite long and may extend to 5–10 years. Due to the cardiac risk factors inherent in patients awaiting transplant, many succumb to cardiac issues while waiting and present an increased per-procedural cardiac risk that extends into the post-transplant period. We aim to review the epidemiology of coronary artery disease in this population and the etiology as it relates to ESRD and its associated co-factors. We also will review the current approaches, recommendations and evidence for management of these patients as it relates to transplant waiting lists before and after the surgery. Recommendations on how to best manage patients in this cohort revolve around the available evidence and are best customized to the institution and the structure of the program. It is not clear whether the revascularization of patients without symptoms and with a good functional status yields any improvement in outcomes. Therefore, each individual case should be considered based on the risk factors, symptoms and functional status, and approached as part of a multi-disciplinary assessment program.

<p>La figura del monstruo puede servir para formar una metáfora sobre la configuración de algunas ciudades<br />contemporáneas y de cómo nos van construyendo. El texto propone reconsiderar la ciudad de<br />Tokio como un paradigma de diversos miedos y monstruosidades urbanas en diferentes momentos<br />de su historia. Primero se reconoce una monstruosidad cosmogónica y mitológica, la cual fue, posteriormente,<br />corporeizada en diversos desastres que cambiarían radicalmente la morfología de la urbe.<br />Con una ciudad casi devastada en su totalidad durante la segunda Guerra Mundial, una nueva monstruosidad<br />simulada aparecería, más como ficción, de la mano de los avances tecnológicos y mediáticos,<br />donde el monstruo pasa de ser una figura consumidora a una consumible. Una última monstruosidad<br />urbana se reconoce en la arquitectura más contemporánea, con bases en la arquitectura del grupo<br />de los metabolistas en los años sesenta, la cual durante la postmodernidad devendría en la colección<br />disímbola y mutante de sus partes. El texto busca explicar esta monstruosidad más reciente mediante<br />una analogía con el cuerpo extendido a través de la prótesis y de la posibilidad de mutación continua<br />que le confiere. Al final, se encuentra en la metáfora del monstruo una figura dinámica, capaz de regenerar<br />las diferentes fuerzas que van formando y deformando nuestras ciudades.</p>

Melanoma will often metastasize diffusely, and involvement of every organ has been reported. The nature of these metastases is unusual and permits radiographic identification when mucosal surfaces are implicated. The gallbladder is said to be involved in 15 per cent of the fatal cases of malignant melanoma (1). It is somewhat surprising, therefore, that in only one case so reported was the tumor demonstrated (but not recognized) on oral cholecystography (2). This is probably because these tumors do not tend to obstruct the biliary or cystic ducts and so do not cause specific symptoms which would lead to such an examination. This report is concerned with a case of malignant melanoma metastatic to the gallbladder, which was visualized (but not recognized) on oral cholecystography. Because the findings were specific enough to permit the recognition of similar lesions in the future, the case is presented as the first of its kind in the radiological literature. Case Report A 47-year-old white male was admitted with a three-week history of progessive right upper quadrant discomfort, fullness, and tenderness associated with nausea and four episodes of emesis. There was no history of jaundice, hematemesis, melena, or other gastrointestinal symptoms. The past history included excision of three benign skin moles, one from the sole of the foot, approximately five or six years previously. Physical examination did not disclose any significant abnormalities. The chest films demonstrated multiple bilateral pulmonary metastases with left mediastinal adenopathy. Oral cholecystography showed an opacified gallbladder containing two radiolucent defects of an unusual nature. One might represent a gallstone, but the other was fixed in the neck of the gallbladder and did not change position (Figs. 1 and 2). A liver scan demonstrated patchy infiltration consistent with cirrhosis or metastatic malignant tumor. The left hepatic lobe was not seen. Findings on brain scanning were within normal limits. Cholecystectomy and laparotomy were performed. Pathological examination of the gallbladder revealed multiple polypoid masses varying from 2 to 25 mm in diameter, some with black pigmentation. The final diagnosis was melanocarcinoma (Fig. 3). The postoperative course was characterized by deterioration, progression of neurologic symptoms, and coma leading to death in one week. Autopsy confirmed the presence of metastases to the brain, dura, liver, mesentery, adrenals, lymph nodes, and lungs. As an incidental finding, the left lobe of the liver was replaced by a benign hemangioma. On a review of the slides of the skin moles excised in the past, it was thought that melanocarcinoma was demonstrated in one of the lesions. Discussion The detailed pathological description of the gallbladder which Rosenthal (3) interpreted as primary melanoma of the organ would probably be currently classified as metastatic.

A review of related research from epidemiological surveys and other sources on multiple disabilities, specifically the mentally retarded-visually impaired diad, reveals the following: 1) Lack of a theoretical concept concerning the syndromes of multiple disabilities. 2) Confusion and lack of agreement on definitions, classifications, and terminology. 3) Inadequacy of a rationale by investigators in assigning priority to a disability. 4) Conflicting viewpoints concerning which facilities are most appropriate and the extent and availability of such facilities. 5) Inconsistencies in reported incidence and prevalence rates. 6) Lack of a precise methodology for teaching children with multiple disabilities. The educational problem presented by children who have multiple disabilities is as old as man's attempt to provide services to exceptional children. For far too many years special educators have been dealing with handicapped children in a unitary fashion. Special classes have been organized, classified, and categorized according to a primary schema of disabilities which has little meaning for educational planning and remediation. There is urgent need for additional research in all aspects of multiple disabilities. The results of this research will have immediate and serious implications for organizing instruction and teacher training in the rapidly growing field of special education.