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Jung J, Waller JL, Tran S, Baer SL, Kheda M, Mohammed A, Padala S, Young L, Siddiqui B, Bollag WB. Cutaneous squamous cell carcinoma and mortality in end-stage renal disease. Am J Med Sci 2023; 365:249-257. [PMID: 36403674 DOI: 10.1016/j.amjms.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 09/08/2022] [Accepted: 10/12/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND In the general population, cutaneous squamous cell carcinoma (cSCC) is associated with increased all-cause mortality. Transplant patients have been shown to have an increased risk of developing cSCC, and their cSCC is associated with an increased risk for mortality. In end-stage renal disease (ESRD) patients, there is extensive mortality and immune dysfunction. Because of this immune system dysfunction, we examined whether cSCC is associated with increased risk of all-cause mortality among ESRD patients, as well as the risk factors for cSCC. METHODS We analyzed ESRD patients in the United States Renal Data System from 2004-2014, excluding organ transplant recipients. We assessed mortality using a Cox Proportional Hazards (CPH) model to control for various demographic and clinical parameters, identified using international classification of diseases (ICD)-9 codes. RESULTS Of the 1,035,193 patients included, 624 (0.1%) were diagnosed with cSCC. The median survival time for those with cSCC was 3.91 years [95% confidence interval (CI) = 3.67-4.15], versus 2.92 years [95%CI = 2.92-2.93] for patients without cSCC. ESRD patients with cSCC were at lower risk of death [adjusted hazard ratio = 0.75; 95%CI = 0.69-0.82] compared to those without. Decreased risk of death was also associated with parameters such as black race, Hispanic ethnicity, tobacco dependence and actinic keratosis. Increased mortality risk was associated with increasing age, male sex, hemodialysis (versus peritoneal dialysis) and alcohol dependence. CONCLUSIONS Contrary to expectations, ESRD patients with a cSCC diagnosis showed reduced all-cause mortality risk relative to those without. The reason for this discrepancy remains unclear, suggesting the need for further study.
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Affiliation(s)
- Joo Jung
- Medical College of Georgia at Augusta University, Augusta, GA, United States
| | - Jennifer L Waller
- Medical College of Georgia at Augusta University, Augusta, GA, United States
| | - Sarah Tran
- Medical College of Georgia at Augusta University, Augusta, GA, United States
| | - Stephanie L Baer
- Medical College of Georgia at Augusta University, Augusta, GA, United States; Charlie Norwood VA Medical Center, Augusta, GA, United States
| | - Mufaddal Kheda
- Medical College of Georgia at Augusta University, Augusta, GA, United States
| | - Azeem Mohammed
- Medical College of Georgia at Augusta University, Augusta, GA, United States
| | - Sandeep Padala
- Medical College of Georgia at Augusta University, Augusta, GA, United States
| | - Lufei Young
- College of Nursing at Augusta University, Augusta, GA, United States
| | - Budder Siddiqui
- Medical College of Georgia at Augusta University, Augusta, GA, United States
| | - Wendy B Bollag
- Medical College of Georgia at Augusta University, Augusta, GA, United States; Charlie Norwood VA Medical Center, Augusta, GA, United States.
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Khaltourina D, Matveyev Y, Alekseev A, Cortese F, Ioviţă A. Aging Fits the Disease Criteria of the International Classification of Diseases. Mech Ageing Dev 2020; 189:111230. [PMID: 32251691 DOI: 10.1016/j.mad.2020.111230] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 03/04/2020] [Accepted: 03/09/2020] [Indexed: 12/24/2022]
Abstract
The disease criteria used by the World Health Organization (WHO) were applied to human biological aging in order to assess whether aging can be classified as a disease. These criteria were developed for the 11th revision of the International Classification of Diseases (ICD) and included disease diagnostics, mechanisms, course and outcomes, known interventions, and linkage to genetic and environmental factors. RESULTS: Biological aging can be diagnosed with frailty indices, functional, blood-based biomarkers. A number of major causal mechanisms of human aging involved in various organs have been described, such as inflammation, replicative cellular senescence, immune senescence, proteostasis failures, mitochondrial dysfunctions, fibrotic propensity, hormonal aging, body composition changes, etc. We identified a number of clinically proven interventions, as well as genetic and environmental factors of aging. Therefore, aging fits the ICD-11 criteria and can be considered a disease. Our proposal was submitted to the ICD-11 Joint Task force, and this led to the inclusion of the extension code for "Ageing-related" (XT9T) into the "Causality" section of the ICD-11. This might lead to greater focus on biological aging in global health policy and might provide for more opportunities for the new therapy developers.
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Affiliation(s)
- Daria Khaltourina
- Department of Risk Factor Prevention, Federal Research Institute for Health Organization and Informatics of Ministry of Health of the Russian Federation, Dobrolyubova St. 11, Moscow, 127254, Russia; International Longevity Alliance, 19 avenue Jean Jaurès, Sceaux, 92330, France.
| | - Yuri Matveyev
- Research Lab, Moscow Regional Research and Clinical Institute, Schepkina St. 61/2 k.1, Moscow, 129110, Russia
| | - Aleksey Alekseev
- Faculty of Physics, Lomonosov Moscow State University, Leninskie Gory, GSP-1, Moscow, 119991, Russia
| | - Franco Cortese
- Biogerontology Research Foundation, Apt 2354 Chynoweth House, Trevissome Park, Truro, London, TR4 8UN, UK
| | - Anca Ioviţă
- International Longevity Alliance, 19 avenue Jean Jaurès, Sceaux, 92330, France
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Kleine CE, Obi Y, Streja E, Hsiung JT, Park C, Holick MF, Kalantar-Zadeh K. Seasonal variation of serum 25-hydroxyvitamin D and parameters of bone and mineral disorder in dialysis patients. Bone 2019; 124:158-165. [PMID: 30858148 DOI: 10.1016/j.bone.2019.03.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 02/20/2019] [Accepted: 03/04/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Vitamin D deficiency is common among dialysis patients and may impact blood concentrations of calcium, phosphorus, intact parathyroid hormone (iPTH), and alkaline phosphatase (ALP). Seasonal variation of serum 25-hydroxyvitamin D [25(OH)D] concentrations has been well established for the general population; however, less is known about circannual variation in 25(OH)D as well as other parameters of mineral and bone disorder among dialysis patients. METHOD Based on 57,500 serum 25(OH)D measurements collected over two years from January 2009 to December 2010 among 25,025 dialysis patients, we evaluated the circannual variations in serum concentrations of 25(OH)D, calcium, phosphorus, iPTH, and ALP by a linear regression model with a cosinor function for the time period (month). We adjusted for potential confounders including case-mix variables, and ultraviolet index. RESULTS Serum 25(OH)D concentrations showed significant circannual variation and mean serum 25(OH)D was 3.2 ng/mL higher in summer than in winter. Furthermore, 25(OH)D concentration increased steadily by 1.3 ng/mL per year. While serum calcium concentrations showed statistically significant but clinically negligible seasonal variation (0.02 mg/dL in peak-trough difference), serum phosphorus did not follow such a pattern. Serum iPTH concentrations also showed a modest seasonal variation with 9% higher values in winter than in summer. Concordantly, ALP concentrations in the winter were 2% higher than in the summer time. Seasonal variation of 25(OH)D was greater in male (vs. female), African-American (vs. non-African-American), and younger (vs. older) dialysis patients. CONCLUSION Serum 25(OH)D and iPTH concentrations show seasonal variation among dialysis patients while the variation in other parameters of mineral and bone disorder was clinically irrelevant, if any. Serum 25(OH)D also showed a gradual increase over time. Clinicians and researchers should be aware of these changes when interpreting laboratory results in dialysis patients.
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Affiliation(s)
- Carola-Ellen Kleine
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, CA, USA; Long Beach Veterans Affairs Healthcare System, Long Beach, CA, USA
| | - Yoshitsugu Obi
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, CA, USA; Long Beach Veterans Affairs Healthcare System, Long Beach, CA, USA
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, CA, USA; Long Beach Veterans Affairs Healthcare System, Long Beach, CA, USA
| | - Jui-Ting Hsiung
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, CA, USA; Long Beach Veterans Affairs Healthcare System, Long Beach, CA, USA
| | - Christina Park
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, CA, USA; Long Beach Veterans Affairs Healthcare System, Long Beach, CA, USA
| | - Michael F Holick
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, CA, USA; Long Beach Veterans Affairs Healthcare System, Long Beach, CA, USA.
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Yoon UA, Kim YC, Lee H, Kwon S, An JN, Kim DK, Kim YS, Lim CS, Lee JP, Kim H. The impact of sunlight exposure on mortality of patients with end stage renal disease. Sci Rep 2019; 9:2230. [PMID: 30778098 PMCID: PMC6379426 DOI: 10.1038/s41598-019-38522-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 12/31/2018] [Indexed: 02/06/2023] Open
Abstract
Recent data suggest that reduced sunlight exposure is associated with increased mortality in the general population. To date, the association between sunlight exposure and mortality in dialysis patients has not been examined. Among 134,478 dialysis patients in the Korean end-stage renal disease (ESRD) cohort from 2001 to 2014, 31,291 patients were enrolled from seven metropolitan cities, and data were analyzed using bi-directional case-crossover design. We examined the association between short-term sunlight exposure and mortality in ESRD patients. We adjusted for temperature, humidity, and daily concentrations of nitrogen dioxide (NO2), sulfur dioxide (SO2), ozone (O3), carbon monoxide (CO), and particle matter (PM10) as confounders. The characteristics of the study population included age (65.6 ± 12.26 (mean ± standard deviation [SD]) years), sex (male, 59.96%; female, 41.04%), comorbidity (diabetes, 53.58%; hypertension, 40.5%), and kidney dialysis type (hemodialysis, 73.02%; peritoneal dialysis, 26.98%). The mean ± SD follow-up time was 4.68 ± 4.37 years. The daily sunlight exposure was significantly decreased in the case group compared with the control group (P = 0.004). Sunlight exposure was associated with all-cause death overall (ORs [95% CI]: 0.99 [0.98-0.99], P = 0.042) in a fully adjusted model. Patients with diabetes (ORs [95% CI]: 0.98 [0.97-0.99], P = 0.016) or aged higher than 75 years (ORs [95% CI]; 0.97 [0.96-0.99], P = 0.020) had higher risks of mortality than patients without diabetes or aged below 75 years, respectively. These findings suggest that sunlight exposure is inversely correlated with all-cause mortality in dialysis patients.
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Affiliation(s)
- Una Amelia Yoon
- Department of Biostatistics and Epidemiology, School of Public Health, Seoul National University, Seoul, Korea
| | - Yong Chul Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Hyewon Lee
- Department of Neuropsychiatry, Seoul National University Bundang Hospital, Seongnam, Korea.,Institute of Health and Environment, Seoul National University, Seoul, Korea
| | - Soie Kwon
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Jung Nam An
- Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, Korea
| | - Dong Ki Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Yon Su Kim
- Kidney Research Institute, Seoul National University Hospital, Seoul, Korea.,Department of Medical Science, Seoul National University College of Medicine, Seoul, Korea
| | - Chun Soo Lim
- Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Jung Pyo Lee
- Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, Korea. .,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.
| | - Ho Kim
- Department of Biostatistics and Epidemiology, School of Public Health, Seoul National University, Seoul, Korea. .,Institute of Health and Environment, Seoul National University, Seoul, Korea.
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Rhee CM, Ravel VA, Streja E, Mehrotra R, Kim S, Wang J, Nguyen DV, Kovesdy CP, Brent GA, Kalantar-Zadeh K. Thyroid Functional Disease and Mortality in a National Peritoneal Dialysis Cohort. J Clin Endocrinol Metab 2016; 101:4054-4061. [PMID: 27525529 PMCID: PMC5095247 DOI: 10.1210/jc.2016-1691] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
CONTEXT AND OBJECTIVE End-stage renal disease patients have a higher risk of thyroid disease compared with those without kidney disease. Although thyroid dysfunction is associated with higher death risk in the general population and those undergoing hemodialysis, little is known about the effect of thyroid disease upon mortality in patients treated with peritoneal dialysis (PD). DESIGN, SETTING, PARTICIPANTS, AND MAIN OUTCOME We examined the association of thyroid status, assessed by serum TSH, with all-cause mortality among PD patients from a large national dialysis organization who underwent one or more TSH measurements over 5 years (January 2007 to December 2011). Thyroid status was categorized as overt-hyperthyroid, subclinical-hyperthyroid, low-normal, high-normal, subclinical-hypothyroid, and overt-hypothyroid range (TSH < 0.1, 0.1–<0.5, 0.5–<3.0, 3.0–<5.0, 5.0–<10.0, and ≥10.0 mIU/L, respectively). We examined the association between TSH and mortality using case mix–adjusted time-dependent Cox models to assess short-term thyroid function–mortality associations and to account for changes in thyroid function over time. RESULTS Among 1484 patients, 7 and 18% had hyperthyroidism and hypothyroidism, respectively, at baseline. We found that both lower and higher time-dependent TSH levels were associated with higher mortality (reference: TSH, 0.5-<3.0 mIU/L): adjusted hazard ratios (95% confidence intervals) 2.09 (1.08-4.06), 1.53 (0.87-2.70), 1.05 (0.75-1.46), 1.63 (1.11-2.40), and 3.11 (2.08-4.63) for TSH levels, <0.1, 0.1-<0.5, 0.5-<3.0, 3.0-<5.0, 5.0-<10.0, and ≥10.0 mIU/L, respectively. CONCLUSION Time-dependent TSH levels < 0.1 mIU/L and ≥ 5.0 mIU/L were associated with higher mortality, suggesting hyper- and hypothyroidism carry short-term risk in PD patients. Additional studies are needed to determine mechanisms underlying the thyroid dysfunction-mortality association, and whether normalization of TSH with treatment ameliorates mortality in this population.
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Affiliation(s)
- Connie M Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension (C.M.R., V.A.R., E.S., J.W., K.K.-Z.), University of California-Irvine, Orange, California 92868; Kidney Research Institute and Harborview Medical Center, Division of Nephrology (R.M.), University of Washington, Seattle, Washington 98195; Department of Mathematics and Statistics (S.K.), California State University-Monterey Bay, Seaside, California 93955; Department of Medicine (D.V.N.), University of California-Irvine, Orange, California 92868; University of Tennessee Health Science Center (C.P.K.), Memphis, Tennessee 38163; Memphis Veterans Affairs Medical Center (C.P.K.), Memphis, Tennessee 38104; and Department of Medicine (G.A.B.), David Geffen School of Medicine at UCLA, Los Angeles, California 90095
| | - Vanessa A Ravel
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension (C.M.R., V.A.R., E.S., J.W., K.K.-Z.), University of California-Irvine, Orange, California 92868; Kidney Research Institute and Harborview Medical Center, Division of Nephrology (R.M.), University of Washington, Seattle, Washington 98195; Department of Mathematics and Statistics (S.K.), California State University-Monterey Bay, Seaside, California 93955; Department of Medicine (D.V.N.), University of California-Irvine, Orange, California 92868; University of Tennessee Health Science Center (C.P.K.), Memphis, Tennessee 38163; Memphis Veterans Affairs Medical Center (C.P.K.), Memphis, Tennessee 38104; and Department of Medicine (G.A.B.), David Geffen School of Medicine at UCLA, Los Angeles, California 90095
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension (C.M.R., V.A.R., E.S., J.W., K.K.-Z.), University of California-Irvine, Orange, California 92868; Kidney Research Institute and Harborview Medical Center, Division of Nephrology (R.M.), University of Washington, Seattle, Washington 98195; Department of Mathematics and Statistics (S.K.), California State University-Monterey Bay, Seaside, California 93955; Department of Medicine (D.V.N.), University of California-Irvine, Orange, California 92868; University of Tennessee Health Science Center (C.P.K.), Memphis, Tennessee 38163; Memphis Veterans Affairs Medical Center (C.P.K.), Memphis, Tennessee 38104; and Department of Medicine (G.A.B.), David Geffen School of Medicine at UCLA, Los Angeles, California 90095
| | - Rajnish Mehrotra
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension (C.M.R., V.A.R., E.S., J.W., K.K.-Z.), University of California-Irvine, Orange, California 92868; Kidney Research Institute and Harborview Medical Center, Division of Nephrology (R.M.), University of Washington, Seattle, Washington 98195; Department of Mathematics and Statistics (S.K.), California State University-Monterey Bay, Seaside, California 93955; Department of Medicine (D.V.N.), University of California-Irvine, Orange, California 92868; University of Tennessee Health Science Center (C.P.K.), Memphis, Tennessee 38163; Memphis Veterans Affairs Medical Center (C.P.K.), Memphis, Tennessee 38104; and Department of Medicine (G.A.B.), David Geffen School of Medicine at UCLA, Los Angeles, California 90095
| | - Steven Kim
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension (C.M.R., V.A.R., E.S., J.W., K.K.-Z.), University of California-Irvine, Orange, California 92868; Kidney Research Institute and Harborview Medical Center, Division of Nephrology (R.M.), University of Washington, Seattle, Washington 98195; Department of Mathematics and Statistics (S.K.), California State University-Monterey Bay, Seaside, California 93955; Department of Medicine (D.V.N.), University of California-Irvine, Orange, California 92868; University of Tennessee Health Science Center (C.P.K.), Memphis, Tennessee 38163; Memphis Veterans Affairs Medical Center (C.P.K.), Memphis, Tennessee 38104; and Department of Medicine (G.A.B.), David Geffen School of Medicine at UCLA, Los Angeles, California 90095
| | - Jiaxi Wang
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension (C.M.R., V.A.R., E.S., J.W., K.K.-Z.), University of California-Irvine, Orange, California 92868; Kidney Research Institute and Harborview Medical Center, Division of Nephrology (R.M.), University of Washington, Seattle, Washington 98195; Department of Mathematics and Statistics (S.K.), California State University-Monterey Bay, Seaside, California 93955; Department of Medicine (D.V.N.), University of California-Irvine, Orange, California 92868; University of Tennessee Health Science Center (C.P.K.), Memphis, Tennessee 38163; Memphis Veterans Affairs Medical Center (C.P.K.), Memphis, Tennessee 38104; and Department of Medicine (G.A.B.), David Geffen School of Medicine at UCLA, Los Angeles, California 90095
| | - Danh V Nguyen
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension (C.M.R., V.A.R., E.S., J.W., K.K.-Z.), University of California-Irvine, Orange, California 92868; Kidney Research Institute and Harborview Medical Center, Division of Nephrology (R.M.), University of Washington, Seattle, Washington 98195; Department of Mathematics and Statistics (S.K.), California State University-Monterey Bay, Seaside, California 93955; Department of Medicine (D.V.N.), University of California-Irvine, Orange, California 92868; University of Tennessee Health Science Center (C.P.K.), Memphis, Tennessee 38163; Memphis Veterans Affairs Medical Center (C.P.K.), Memphis, Tennessee 38104; and Department of Medicine (G.A.B.), David Geffen School of Medicine at UCLA, Los Angeles, California 90095
| | - Csaba P Kovesdy
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension (C.M.R., V.A.R., E.S., J.W., K.K.-Z.), University of California-Irvine, Orange, California 92868; Kidney Research Institute and Harborview Medical Center, Division of Nephrology (R.M.), University of Washington, Seattle, Washington 98195; Department of Mathematics and Statistics (S.K.), California State University-Monterey Bay, Seaside, California 93955; Department of Medicine (D.V.N.), University of California-Irvine, Orange, California 92868; University of Tennessee Health Science Center (C.P.K.), Memphis, Tennessee 38163; Memphis Veterans Affairs Medical Center (C.P.K.), Memphis, Tennessee 38104; and Department of Medicine (G.A.B.), David Geffen School of Medicine at UCLA, Los Angeles, California 90095
| | - Gregory A Brent
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension (C.M.R., V.A.R., E.S., J.W., K.K.-Z.), University of California-Irvine, Orange, California 92868; Kidney Research Institute and Harborview Medical Center, Division of Nephrology (R.M.), University of Washington, Seattle, Washington 98195; Department of Mathematics and Statistics (S.K.), California State University-Monterey Bay, Seaside, California 93955; Department of Medicine (D.V.N.), University of California-Irvine, Orange, California 92868; University of Tennessee Health Science Center (C.P.K.), Memphis, Tennessee 38163; Memphis Veterans Affairs Medical Center (C.P.K.), Memphis, Tennessee 38104; and Department of Medicine (G.A.B.), David Geffen School of Medicine at UCLA, Los Angeles, California 90095
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension (C.M.R., V.A.R., E.S., J.W., K.K.-Z.), University of California-Irvine, Orange, California 92868; Kidney Research Institute and Harborview Medical Center, Division of Nephrology (R.M.), University of Washington, Seattle, Washington 98195; Department of Mathematics and Statistics (S.K.), California State University-Monterey Bay, Seaside, California 93955; Department of Medicine (D.V.N.), University of California-Irvine, Orange, California 92868; University of Tennessee Health Science Center (C.P.K.), Memphis, Tennessee 38163; Memphis Veterans Affairs Medical Center (C.P.K.), Memphis, Tennessee 38104; and Department of Medicine (G.A.B.), David Geffen School of Medicine at UCLA, Los Angeles, California 90095
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