Impact of Uric Acid Levels on Kidney Disease Progression

BACKGROUND

Hyperuricemia is associated with the progression of chronic kidney disease (CKD), but it is not known whether the relationship is causal. We examined the association of hyperuricemia and uric acid lowering therapy (UALT) with progression of CKD in patients with CKD 3 and 4 in the Cleveland Clinic CKD registry.

METHODS

We included 1,676 patients with CKD stages 3 and 4 from Ohio, who had measured their uric acid (UA) levels a year prior to the recording of the second eGFR <60 mL/min/1.73 m2, and follow-up eGFR, between 2005 and 2009. Our primary composite outcome included a 50% drop in eGFR or progression to ESRD. Secondary outcomes included the rate of decline in eGFR, all-cause mortality, progression to ESRD, and a composite measure of progression to ESRD or death. We assessed the association between UA, UALT, and outcomes using Cox models and competing risks regression models.

RESULTS

In multivariable models, higher UA was associated with the composite endpoint, but it reached statistical significance only in the 4th quartile (≥8.9 mg/dL). Receipt of UALT was significantly associated with increased risk of the composite outcome. Neither UA nor UALT (considered a time-dependent covariate) was significantly associated with mortality. The inference was similar for UA as high vs. low, quartiles, or continuous. Similarly, neither high UA nor UALT were significantly associated with ESRD, the composite of ESRD and mortality, or eGFR decline.

CONCLUSIONS

Hyperuricemia is associated with increased risk of progression to ESRD in patients with CKD stages 3 and 4, but UALT does not ameliorate the risk, suggesting that the relationship is not causal.

Impact of Use of Smaller Volume, Smaller Vacuum Blood Collection Tubes on Hemolysis in Emergency Department Blood Samples

OBJECTIVES

Hemolyzed blood samples commonly occur in hospital emergency departments (EDs). Our objective was to determine whether replacing standard large-volume/high-vacuum sample tubes with low-volume/low-vacuum tubes would significantly affect ED hemolysis.

METHODS

This was a prospective intervention of the use of small-volume/vacuum collection tubes. We evaluated all potassium samples in ED patients and associated hemolysis. We used χ2 tests to compare hemolysis incidence prior to and following utilization of small tubes for chemistry collection.

RESULTS

There were 35,481 blood samples collected during the study period. Following implementation of small-volume tubes, overall hemolysis decreased from a baseline of 11.8% to 2.9% (P < .001) with corresponding reductions in hemolysis with comment (8.95% vs 1.99%; P < .001) gross hemolysis (2.84% vs 0.90%; P < .007).

CONCLUSIONS

This work demonstrates that significant improvements in ED hemolysis can be achieved by utilization of small-volume/vacuum sample collection tubes.

Pragmatic Randomized, Controlled Trial of Patient Navigators and Enhanced Personal Health Records in CKD

BACKGROUND AND OBJECTIVES

Patient navigators and enhanced personal health records improve the quality of health care delivered in other disease states. We aimed to develop a navigator program for patients with CKD and an electronic health record-based enhanced personal health record to disseminate CKD stage-specific goals of care and education. We also conducted a pragmatic randomized clinical trial to compare the effect of a navigator program for patients with CKD with enhanced personal health record and compare their combination compared with usual care among patients with CKD stage 3b/4.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Two hundred and nine patients from six outpatient clinics (in both primary care and nephrology settings) were randomized in a 2×2 factorial design into four-study groups: (1) enhanced personal health record only, (2) patient navigator only, (3) both, and (4) usual care (control) group. Primary outcome measure was the change in eGFR over a 2-year follow-up period. Secondary outcome measures included acquisition of appropriate CKD-related laboratory measures, specialty referrals, and hospitalization rates.

RESULTS

Median age of the study population was 68 years old, and 75% were white. At study entry, 54% of patients were followed by nephrologists, and 88% were on renin-angiotensin system blockers. After a 2-year follow-up, rate of decline in eGFR was similar across the four groups (P=0.19). Measurements of CKD-related laboratory parameters were not significantly different among the groups. Furthermore, referral for dialysis education and vascular access placement, emergency room visits, and hospitalization rates were not statistically significant different between the groups.

CONCLUSIONS

We successfully developed a patient navigator program and an enhanced personal health record for the CKD population. However, there were no differences in eGFR decline and other outcomes among the study groups. Larger and long-term studies along with cost-effectiveness analyses are needed to evaluate the role of patient navigators and patient education through an enhanced personal health record in those with CKD.

Sex Differences in Mortality Based on United Network for Organ Sharing Status While Awaiting Heart Transplantation

BACKGROUND

There are sex differences in mortality while awaiting heart transplantation, and the reason remains unclear.

METHODS AND RESULTS

We included all adults in the Scientific Registry of Transplant Recipients placed on the heart transplant active waitlist from 2004 to 2015. The primary end point was all-cause mortality. Multivariable Cox proportional hazards models were performed to evaluate survival by United Network for Organ Sharing (UNOS) status at the time of listing. Random survival forest was used to identify sex interactions for the competing risk of death and transplantation. There were 33 069 patients (25% women) awaiting heart transplantation. This cohort included 7681 UNOS status 1A (26% women), 13 027 UNOS status 1B (25% women), and 12 361 UNOS status 2 (26% women). During a median follow-up of 4.3 months, 1351 women and 4052 men died. After adjusting for >20 risk factors, female sex was associated with a significant risk of death among UNOS status 1A (adjusted hazard ratio, 1.14; 95% confidence interval, 1.01-1.29) and UNOS status 1B (adjusted hazard ratio, 1.17; 95% confidence interval, 1.05-1.30). In contrast, female sex was significantly protective for time to death among UNOS status 2 (adjusted hazard ratio, 0.85; 95% confidence interval, 0.76-0.95). Sex differences in probability of transplantation were present for every UNOS status, and >20 sex interactions were identified for mortality and transplantation.

CONCLUSIONS

When stratified by initial UNOS status, women had a higher mortality than men as UNOS status 1 and a lower mortality as UNOS status 2. With >20 sex interactions for mortality and transplantation, further evaluation is warranted to form a more equitable allocation system.

Diabetes Control and the Risks of ESRD and Mortality in Patients With CKD

BACKGROUND

Diabetes is the leading cause of end-stage renal disease (ESRD) and a significant contributor to mortality in the general population. We examined the associations of hemoglobin A1c (HbA1c) levels with ESRD and death in a population with diabetes and chronic kidney disease (CKD).

STUDY DESIGN

Cohort study.

SETTING & PARTICIPANTS

6,165 patients with diabetes (treated with oral hypoglycemic agents and/or insulin) and CKD stages 1 to 5 at a large health care system.

PREDICTOR

HbA1c level (examined as a categorical and continuous measure).

OUTCOMES

All-cause and cause-specific mortality ascertained from the Ohio Department of Health mortality files and ESRD ascertained from the US Renal Data System.

RESULTS

During a median 2.3 years of follow-up, 957 patients died (887 pre-ESRD deaths) and 205 patients reached ESRD. In a Cox proportional hazards model, after multivariable adjustment including for kidney function, HbA1c level < 6% was associated with higher risk for death when compared with HbA1c levels of 6% to 6.9% (HR, 1.23; 95% CI, 1.01-1.50). Similarly, HbA1c level ≥ 9% was associated with higher risk for all-cause death (HR, 1.34; 95% CI, 1.06-1.69). In competing-risk models, baseline HbA1c level was not associated with ESRD. For cause-specific mortality, diabetes accounted for >12% of deaths overall and >19% of deaths among those with HbA1c levels > 9%.

LIMITATIONS

Small proportion of participants with advanced kidney disease; single-center population.

CONCLUSIONS

In this cohort of patients with CKD with diabetes, HbA1c levels < 6% and ≥9% were associated with higher risk for death. HbA1c levels were not associated with ESRD in this specific CKD population. Diabetes-related deaths increased with higher HbA1c levels.

Blood pressure parameters are associated with all-cause and cause-specific mortality in chronic kidney disease

Previous observational studies reported J or U-shaped associations between blood pressure parameters and mortality in patients with chronic kidney disease (CKD). Here we examined the associations of different blood pressure levels with various causes of death in a CKD population that included patients with eGFR 15-59 ml/min/1.73 m² with underlying hypertension receiving at least one antihypertensive agent. We obtained data on date and cause of death from State Department of Health mortality files and classified deaths into three categories: cardiovascular, malignancy-related, and non-cardiovascular/non-malignancy related. Cox models were fitted for overall mortality, and separate competing risk regression models for each major cause of death category, to evaluate their associations with various systolic and diastolic blood pressures. During a median follow-up of 3.9 years, 13,332 of 45,412 patients died. Systolic blood pressures under 100, 100-109, 110-119, and over 150 (vs. 130-139 mm Hg) were associated with higher all-cause and cardiovascular mortality. Systolic blood pressures under 100 mm Hg and 100-109 were associated with higher non-cardiovascular/non-malignancy related mortality. Diastolic blood pressures under 50 and 50-59 (vs. 70-79 mm Hg) were associated with higher all-cause and non-cardiovascular/non-malignancy-related mortality while diastolic blood pressures over 90 mm Hg was associated with higher cardiovascular but lower non-cardiovascular/non-malignancy related mortality. Thus, in a non-dialysis dependent CKD population, systolic blood pressures under 110 and over 150 mm Hg were associated with cardiovascular and non-cardiovascular/non-malignancy related deaths. However, diastolic blood pressure under 60 mm Hg was associated in contrast with all-cause mortality and non-cardiovascular/non-malignancy-related deaths.

Integrating APOL1 Gene Variants Into Renal Transplantation: Considerations Arising From the American Society of Transplantation Expert Conference

Thirteen percent of individuals of African ancestry express two variant copies of the gene encoding apolipoprotein 1 (APOL1) that has been associated with an increased risk of end-stage renal disease (ESRD) in the general population. Limited studies suggest that the survival of transplanted kidneys from donors expressing two APOL1 risk alleles is inferior to that of kidneys from donors with zero or one risk allele. In living kidney donation, two case reports describe donors expressing two APOL1 risk alleles who developed ESRD. Given the potential impact of APOL1 variants on the utility and safety of kidney transplantation and living kidney donation, the American Society of Transplantation convened a meeting with the goals of summarizing the current state of knowledge with respect to transplantation and APOL1, identifying knowledge gaps and studies to address these gaps, and considering approaches to integrating APOL1 into clinical practice. The authors recognize that current data are not sufficient to support traditional evidence-based guidelines but also recognize that it may require several years to generate the necessary data. Thus, approaches as to how APOL1 might currently be integrated into the clinical decision-making process were considered. This report summarizes the group's deliberations.

Comparing Outcomes between Antibody Induction Therapies in Kidney Transplantation

Kidney transplant recipients often receive antibody induction. Previous studies of induction therapy were often limited by short follow-up and/or absence of information about complications. After linking Organ Procurement and Transplantation Network data with Medicare claims, we compared outcomes between three induction therapies for kidney recipients. Using novel matching techniques developed on the basis of 15 clinical and demographic characteristics, we generated 1:1 pairs of alemtuzumab-rabbit antithymocyte globulin (rATG) (5330 pairs) and basiliximab-rATG (9378 pairs) recipients. We used paired Cox regression to analyze the primary outcomes of death and death or allograft failure. Secondary outcomes included death or sepsis, death or lymphoma, death or melanoma, and healthcare resource utilization within 1 year. Compared with rATG recipients, alemtuzumab recipients had higher risk of death (hazard ratio [HR], 1.14; 95% confidence interval [95% CI], 1.03 to 1.26; P<0.01) and death or allograft failure (HR, 1.18; 95% CI, 1.09 to 1.28; P<0.001). Results for death as well as death or allograft failure were generally consistent among elderly and nonelderly subgroups and among pairs receiving oral prednisone. Compared with rATG recipients, basiliximab recipients had higher risk of death (HR, 1.08; 95% CI, 1.01 to 1.16; P=0.03) and death or lymphoma (HR, 1.12; 95% CI, 1.01 to 1.23; P=0.03), although these differences were not confirmed in subgroup analyses. One-year resource utilization was slightly lower among alemtuzumab recipients than among rATG recipients, but did not differ between basiliximab and rATG recipients. This observational evidence indicates that, compared with alemtuzumab and basiliximab, rATG associates with lower risk of adverse outcomes, including mortality.

Predonation Prescription Opioid Use: A Novel Risk Factor for Readmission After Living Kidney Donation

Implications of opioid use in living kidney donors for key outcomes, including readmission rates after nephrectomy, are unknown. We integrated Scientific Registry of Transplant Recipients data with records from a nationwide pharmacy claims warehouse and administrative records from an academic hospital consortium to quantify predonation prescription opioid use and postdonation readmission events. Associations of predonation opioid use (adjusted odds ratio [aOR]) in the year before donation and other baseline clinical, procedural, and center factors with readmission within 90 days postdonation were examined by using multivariate logistic regression. Among 14 959 living donors, 11.3% filled one or more opioid prescriptions in the year before donation. Donors with the highest level of predonation opioid use (>305 mg/year) were more than twice as likely as nonusers to be readmitted (6.8% vs. 2.6%; aOR 2.49, 95% confidence interval 1.74-3.58). Adjusted readmission risk was also significantly (p < 0.05) higher for women (aOR = 1.25), African Americans (aOR = 1.45), spouses (aOR = 1.42), exchange participants (aOR = 1.46), uninsured donors (aOR = 1.40), donors with predonation estimated glomerular filtration rate <60 mL/min/1.73 m² (aOR = 2.68), donors with predonation pulmonary conditions (aOR = 1.54), and after robotic nephrectomy (aOR = 1.68). Predonation opioid use is independently associated with readmission after donor nephrectomy. Future research should examine underlying mechanisms and approaches to reducing risks of postdonation complications.

Abstract 054: Mortality Decline After Ischemic Stroke-the Medicare Cohort From 2009 to 2013

Objectives: After a declined in mortality by 25.4% from 1996 to 2005, stroke became the fifth leading cause of death in men and the second leading cause of death in women. Stroke mortality decline in the past was mainly attributed to the improvement of stroke prevention. Stroke system of care has gone through evolutional changes in the past decade in both acute stroke treatment, preventing complications, identifying stroke etiology and stroke prevention. This study is to examine whether there was greater decline of mortality after ischemic stroke hospitalization from 2009 and 2013.

Methods: We examined the one-year mortality in Medicare beneficiaries aged ≥65 years who were hospitalized between January 1, 2009 and December 31, 2013 with a primary discharge diagnosis of ischemic stroke. The data of the patient information were obtained from the Medicare Provider Analysis and Review (MEDPAR) file. The list and characteristics of hospitals were obtained from the American Hospital Association Annual Survey Database. All statistical analyses were performed using SAS Version 9.4 software.

Results: A total of 1165,960 Medicare Beneficiaries was hospitalized for ischemic stroke between 2009 and 2013. The one-year mortality showed a steady declined by 17.6 % over the five years period. The one-year mortality declined by 17.4% in female, 17.8% in male, 17.0% in black,17.6 % in white, 22.6% in Hispanic, and 20.3% in Asian. Among the ten-year age group, people aged 65 to 74 years had the greatest decline in mortality, 22.5%, followed by 19.2% decline in the group 75 to 84 years, and 14.7% in the group 85 years and over.

Conclusion: The one-year mortality among Medicare beneficiaries after ischemic stroke hospitalization showed a dramatic decline from 2009 to 2013. Further study is needed to determine whether this is attributable to the change of stroke system of care in the past decade.

Utility of Ecological Risk Factors for Evaluation of Transplant Center Performance

There is substantial evidence across different healthcare contexts that social determinants of health are strongly associated with morbidity and mortality in the United States. These factors, including socioeconomic status, behavior and environmental risks, education, social support, healthy food, and access to healthcare also vary widely by region and individual communities. One of the implications of heterogeneity in these risks is the potential impact on measured quality of healthcare providers. In particular, there is concern that providers treating disproportionally vulnerable communities may be disadvantaged by lack of risk adjustment for these factors that affect health but not indicators of quality of care. Recently, the National Quality Forum has endorsed risk adjustment for sociodemographic characteristics based on these concerns. These issues are salient to transplant programs since social determinants of health impact transplant patient outcomes and vary by region. In this viewpoint, we argue that integration of ecological (area-level) factors in risk adjustment models used to assess transplant center quality should be strongly considered. We believe this reform could be accomplished rapidly, would attenuate disparities in access to care by reducing disincentives to treat patients from vulnerable communities, and improve risk adjustment and calibration of models used for center evaluations.

Measuring transplant center performance: The goals are not controversial but the methods and consequences can be

PURPOSE OF REVIEW

Risks of regulatory scrutiny has generated widespread concern about increasingly risk averse transplant center behaviors regarding both donor and candidate acceptance patterns. To address potential unintended consequences threatening access to care, we discuss recent changes in regulatory metrics and potential improvements in quality oversight of transplant centers.

RECENT FINDINGS

Despite many recent changes to one-year patient and graft survival regulatory criteria, the capacity to accurately identify true underperforming centers and avoiding false positive flagging remains an area of great concern. Numerous studies have demonstrated restrictions in transplant volume and access following transplant center flagging.

SUMMARY

Current regulatory criteria are limited in their capacity to accurately identify poorly performing centers and potentially encourage risk-averse behavior by transplant centers. Efforts to address these concerns should focus on (1) improving risk-adjustment models with better data which captures the acuity of candidate and donor risk, (2) reconsidering primary outcomes measured to assess comprehensive transplant center performance, (3) improving education to address rational or perceived disincentives, and (4) using data more effectively to share best practices.

Abstract WP318: Mortality Among Newly Certified Stroke Centers and Other Hospitals in the U.S

Introduction: Primary Stroke Center (PSC) certification was established to improve stroke care. The numbers of PSCs have significantly increased in the past decade. However, it remains unclear whether PSC certification has any impact on stroke mortality. We examined the short term mortality of hospitals that received initial PSC certification between 2009 and 2013 (new PSCs), compared to those received PSC certification before 2009 (existing PSCs) and those never received PSC certification (NSCs).

Method: The inclusion criteria was Medicare beneficiaries aged ≥65 years who were hospitalized between January 1, 2009 to December 31, 2013 with a primary discharge diagnosis of ischemic stroke. The patient information were obtained from the Medicare Provider Analysis and Review (MEDPAR) file. The list and characteristics of hospitals were obtained from the American Hospital Association Annual Survey Database. This study included only those general hospitals with emergency departments. All statistical analyses were performed using SAS Version 9.4 software.

Results: Among 1165,960 Medicare beneficiaries included in this study, 28.9% were treated at 2640 NSCs, 24.6% were treated at 634 new PSCs, and 46.6% were treated at 785 existing PSCs. Higher percentages of patients at new and existing PSCs had complicated hypertension, myocardial infarction, congestive heart failure, atrial fibrillation, prior history of cerebrovascular disease, any malignancy, metastatic cancer, peripheral artery disease and smoking (p<0.0001). New PSCs had the lowest unadjusted in-hospital all-cause mortality, followed by NSCs and existing PSCs (4.2%, 4.6% and 5% respectively). Both New and existing PSC groups had lower unadjusted 30 day compared to NSCs (12.5%, 13.2% and 13.7%). New PSCs had lower unadjusted and adjusted 30 day mortality than existing PSCs (Hazard Ratio 0.981, 95% Confidence Interval (0.968, 0.993)).

Conclusion: The PSCs that were newly certified between 2009 and 2013 had lower unadjusted in-hospital and 30 day mortality after stroke than existing PSCs and NSCs. It is important to further understand whether this difference results from change in patient population or quality of care.

National Impact of Maintenance Dialysis or Renal Transplantation on Outcomes Following ST Elevation Myocardial Infarction

BACKGROUND

Though cardiovascular disease is an important cause of mortality in patients with end-stage renal disease, epidemiology of ST-elevation myocardial infarction (STEMI) is less well described in this population.

METHODS

This study included STEMI hospitalizations in patients aged ≥20 using Nationwide Inpatient Sample Database from 2006 to 2010. Primary outcomes were incidence and trends of STEMI hospitalizations based on renal function status. We also looked at utilization of revascularization procedures, all-cause-hospital mortality and predictors of mortality.

RESULTS

Of the estimated 882,447 STEMI hospitalizations, 11,383 were on maintenance dialysis and 1,076 had renal transplants. The incidence of STEMI was over 7 times in patients on maintenance dialysis and 1.73 times in renal transplant recipients compared to the general population. This incidence has however declined in those on maintenance dialysis (p for trend <0.001) to a greater extent than the general population and patients with renal transplant. Utilization of revascularization procedures was lowest in patients on maintenance dialysis (51.6 vs. 73.3% in renal transplant recipients and 77.0% in general population; p < 0.001) and mortality was highest (21.6 vs. 10.9 vs. 6.8%; p < 0.001). Being on maintenance dialysis or having a renal transplant were both independent predictors of mortality in patients hospitalized with STEMI. There was a differential effect of cardiac catheterization on odds of mortality with lesser impact in patients on maintenance dialysis.

CONCLUSIONS

STEMI hospitalizations are more common in patients on maintenance dialysis and with renal transplants. The utilization of revascularizations procedures remains low and mortality high in these patients.

Preanalytic process linked to spuriously elevated HIV viral loads: improvement on an FDA-approved process

The processing of specimens often occurs in a central processing area within laboratories. We demonstrated that plasma centrifuged in the central laboratory but allowed to remain within the primary tube following centrifugation was associated with spuriously elevated HIV viral loads compared with recentrifugation of the plasma just prior to testing.

Predictors and Moderators of Educational Interventions to Increase the Likelihood of Potential Living Donors for Black Patients Awaiting Kidney Transplantation

Our aim was to identify predictors and moderators of the effects of a house calls (HC) educational intervention, relative to a group-based (GB) intervention and to individual counseling (IC), in a randomized controlled trial to increase the likelihood of having living donor (LD) evaluations initiated and live donor kidney transplantation (LDKT). Black adults wait listed for kidney transplantation (N = 152) were randomized into one of the three educational conditions. We examined demographic, clinical, psychosocial, and socio-contextual baseline characteristics as predictors and moderators of having a potential LD initiate evaluation. HC assignment (OR = 2.024.7311.05, P = 0.001), younger age (OR = 0.910.940.98, P = 0.001), more willingness to discuss donation with others (OR = 1.081.371.75, P = 0.01), and larger social network (OR = 1.011.091.18, P = 0.04) were significant multivariable predictors of having ≥1 LD initiate evaluation. Age (P = 0.03) and social network size (P = 0.02) moderated the effect of HC relative to IC and GB, but not GB relative to IC, on LD evaluation initiation. Our findings suggest that HC is most effective for patients <60 years old and those with average or large social network size.

Effects of High-Risk Kidneys on Scientific Registry of Transplant Recipients Program Quality Reports

There is a perception that transplanting high-risk kidneys causes programs to be identified as underperforming, thereby increasing the frequency of discards and diminishing access to transplant. Thus, the Organ Procurement and Transplantation Network (OPTN) has considered excluding transplants using kidneys from donors with high Kidney Donor Profile Index (KDPI) scores (≥0.85) when assessing program performance. We examined whether accepting high-risk kidneys (KDPI ≥0.85) for transplant yields worse outcome evaluations. Despite a clear relationship between KDPI and graft failure and mortality, there was no relationship between a program's use of high-KDPI kidneys and poor performance evaluations after risk adjustment. Excluding high-KDPI donor transplants from the June 2015 evaluations did not alter the programs identified as underperforming, because in every case underperforming programs also had worse-than-expected outcomes among lower-risk donor transplants. Finally, we found that hypothetically accepting and transplanting additional kidneys with KDPI similar to that of kidneys currently discarded would not adversely affect program evaluations. Based on the study findings, there is no evidence that programs that accept higher-KDPI kidneys are at greater risk for low performance evaluations, and risk aversion may limit access to transplant for candidates while providing no measurable benefit to program evaluations.

Concern for Lost Income Following Donation Deters Some Patients From Talking to Potential Living Donors

CONTEXT

Some living kidney donors report lost income during recovery from surgery. Little is known about whether concern for living donor's lost income affects the decision to undergo donation evaluation and the willingness of transplant candidates to discuss living kidney donation (LKD) with others.

OBJECTIVE

To examine whether transplant patients were told by potential donors about lost income concerns and whether patients chose not to discuss LKD with others due to lost income concerns.

DESIGN, SETTING, AND PATIENTS

Kidney transplant patients (185 wait-listed candidates, 171 deceased donor recipients, and 100 live donor recipients) at 2 centers completed a questionnaire to assess whether concern about donor's lost income was a consideration in discussion about LKD with others.

RESULTS

One-third (32%) were told by a family member/friend that they were willing to donate but were concerned about potential lost income. The majority of those who expressed financial concern (64%) did not initiate donation evaluation. Many patients (42%) chose not to discuss living donation with a family member/friend due to concern about the impact of lost income on the donor. In the multivariable model, lower annual household income was the only statistically significant predictor of both having a potential donor expressing lost income concern and choosing not to talk to someone because of lost income concern.

CONCLUSION

Findings from the current study underscore how concern about income loss for living donors may affect decision-making by both transplant candidates and potential donors.

Determinants of breastfeeding initiation and cessation among employed mothers: a prospective cohort study

Background

The U.S. continues to have one of the lowest breastfeeding rates in the industrialized world. Studies have shown that full-time employment and early return to work decreased breastfeeding duration, but little is known about the relationship between leave policies and breastfeeding initiation and cessation. This study aimed to identify workplace-related barriers and facilitators associated with breastfeeding initiation and cessation in the first 6 months postpartum.

Methods

A prospective cohort study design was utilized to recruit 817 Minnesota women aged 18 and older while hospitalized for childbirth. Selection criteria included English-speaking, employed mothers with a healthy, singleton birth. These women were followed up using telephone interviews at 6 weeks, 12 weeks, and 6 months after childbirth. The main study outcomes were breastfeeding initiation, measured during hospital enrollment, and breastfeeding cessation by 6 months postpartum.

Results

Women were 30 years old; 86 % were White, and 73 % were married. Breastfeeding rates were 81 % at childbirth, 67 % at 6 weeks, 49 % at 12 weeks, and 33 % at 6 months postpartum. Logistic regression revealed the odds of breastfeeding initiation were higher for women who: held professional jobs, were primiparae, had graduate degree, did not smoke prenatally, had no breastfeeding problems, and had family or friends who breastfeed. Survival analyses showed the hazard for breastfeeding cessation by 6 months was: higher for women who returned to work at any time during the 6 months postpartum versus those who did not return, lower for professional workers, higher among single than married women, higher for every educational category compared to graduate school, and higher for those with no family or friends who breastfeed.

Conclusions

While employer paid leave policy did not affect breastfeeding initiation or cessation, women who took shorter leaves were more likely to stop breastfeeding in the first 6 months postpartum. Future research should examine women’s awareness of employer policies regarding paid and unpaid leave.

Secondary syphilis in HIV positive individuals: correlation with histopathologic findings, CD4 counts, and quantity of treponemes in microscopic sections

BACKGROUND

Although syphilis is uncommon, infection rates are much higher in HIV-infected individuals than the general population. A proposed explanation is impaired cellular immunity with HIV infection.

METHODS

A search of one institution yielded 10 patients with a diagnosis of secondary syphilis on skin biopsy, positive syphilis serology and available CD4 counts. We evaluated 11 biopsies from the 10 patients. We correlated the patients' CD4 counts with the histologic findings and with the number of treponemes on skin biopsies, highlighted by immunohistochemistry (IHC). We also compared the detection of spirochetes in silver stained sections (e.g. Warthin-Starry) with T. pallidum IHC. All biopsies were assessed for various histologic features.

RESULTS

The sensitivity of IHC to detect treponemes was 64% and of silver stain was 9% (p-value 0.04). The number of treponemes on the biopsies was determined by IHC. High numbers of spirochetes (i.e. >100 per 10 hpf) were only seen in patients with CD4 counts less than 250 cells/ml.

CONCLUSION

The most consistent histologic finding was a moderate to severe lymphoplasmacytic infiltrate. Although the study is small, it appears that a higher number of spirochetes is associated with CD4 counts less than 250 cell/ml. The T. pallidum IHC stain was vastly superior to the Warthin-Starry stain.

Does Pneumatic Tube System Transport Contribute to Hemolysis in ED Blood Samples?

INTRODUCTION

Our goal was to determine if the hemolysis among blood samples obtained in an emergency department and then sent to the laboratory in a pneumatic tube system was different from those in samples that were hand-carried.

METHODS

The hemolysis index is measured on all samples submitted for potassium analysis. We queried our hospital laboratory database system (SunQuest(®)) for potassium results for specimens obtained between January 2014 and July 2014. From facility maintenance records, we identified periods of system downtime, during which specimens were hand-carried to the laboratory.

RESULTS

During the study period, 15,851 blood specimens were transported via our pneumatic tube system and 92 samples were hand delivered. The proportions of hemolyzed specimens in the two groups were not significantly different (13.6% vs. 13.1% [p=0.90]). Results were consistent when the criterion was limited to gross (3.3% vs 3.3% [p=0.99]) or mild (10.3% vs 9.8% [p=0.88]) hemolysis. The hemolysis rate showed minimal variation during the study period (12.6%-14.6%).

CONCLUSION

We found no statistical difference in the percentages of hemolyzed specimens transported by a pneumatic tube system or hand delivered to the laboratory. Certain features of pneumatic tube systems might contribute to hemolysis (e.g., speed, distance, packing material). Since each system is unique in design, we encourage medical facilities to consider whether their method of transport might contribute to hemolysis in samples obtained in the emergency department.