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Miller-Patterson C, Hsu JY, Barrett MJ, Cloud LJ, Berman BD, Chelimsky TC. Supine hypertension is longitudinally associated with verbal memory decline in Parkinson disease. Clin Auton Res 2024:10.1007/s10286-024-01026-3. [PMID: 38554233 DOI: 10.1007/s10286-024-01026-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Accepted: 02/29/2024] [Indexed: 04/01/2024]
Affiliation(s)
- Cameron Miller-Patterson
- Department of Neurology, Virginia Commonwealth University School of Medicine, 1101 E Marshall St, Richmond, VA, 23298, USA.
| | - Jesse Y Hsu
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, 423 Guardian Dr, Philadelphia, PA, 19104, USA
| | - Matthew J Barrett
- Department of Neurology, Virginia Commonwealth University School of Medicine, 1101 E Marshall St, Richmond, VA, 23298, USA
| | - Leslie J Cloud
- Department of Neurology, Virginia Commonwealth University School of Medicine, 1101 E Marshall St, Richmond, VA, 23298, USA
| | - Brian D Berman
- Department of Neurology, Virginia Commonwealth University School of Medicine, 1101 E Marshall St, Richmond, VA, 23298, USA
| | - Thomas C Chelimsky
- Department of Neurology, Virginia Commonwealth University School of Medicine, 1101 E Marshall St, Richmond, VA, 23298, USA
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Talwar AA, Desai AA, McAuliffe PB, Broach RB, Hsu JY, Liu T, Udupa JK, Tong Y, Torigian DA, Fischer JP. Optimal computed tomography-based biomarkers for prediction of incisional hernia formation. Hernia 2024; 28:17-24. [PMID: 37676569 DOI: 10.1007/s10029-023-02835-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 07/04/2023] [Indexed: 09/08/2023]
Abstract
PURPOSE Unstructured data are an untapped source for surgical prediction. Modern image analysis and machine learning (ML) can harness unstructured data in medical imaging. Incisional hernia (IH) is a pervasive surgical disease, well-suited for prediction using image analysis. Our objective was to identify optimal biomarkers (OBMs) from preoperative abdominopelvic computed tomography (CT) imaging which are most predictive of IH development. METHODS Two hundred and twelve rigorously matched colorectal surgery patients at our institution were included. Preoperative abdominopelvic CT scans were segmented to derive linear, volumetric, intensity-based, and textural features. These features were analyzed to find a small subset of OBMs, which are maximally predictive of IH. Three ML classifiers (Ensemble Boosting, Random Forest, SVM) trained on these OBMs were used for prediction of IH. RESULTS Altogether, 279 features were extracted from each CT scan. The most predictive OBMs found were: (1) abdominopelvic visceral adipose tissue (VAT) volume, normalized for height; (2) abdominopelvic skeletal muscle tissue volume, normalized for height; and (3) pelvic VAT volume to pelvic outer aspect of body wall skeletal musculature (OAM) volume ratio. Among ML prediction models, Ensemble Boosting produced the best performance with an AUC of 0.85, accuracy of 0.83, sensitivity of 0.86, and specificity of 0.81. CONCLUSION These OBMs suggest increased intra-abdominopelvic volume/pressure as the salient pathophysiologic driver and likely mechanism for IH formation. ML models using these OBMs are highly predictive for IH development. The next generation of surgical prediction will maximize the utility of unstructured data using advanced image analysis and ML.
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Affiliation(s)
- A A Talwar
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, 3400 Civic Center Boulevard, 14th floor South Tower, Philadelphia, PA, 19104, USA
| | - A A Desai
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, 3400 Civic Center Boulevard, 14th floor South Tower, Philadelphia, PA, 19104, USA
| | - P B McAuliffe
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, 3400 Civic Center Boulevard, 14th floor South Tower, Philadelphia, PA, 19104, USA
| | - R B Broach
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, 3400 Civic Center Boulevard, 14th floor South Tower, Philadelphia, PA, 19104, USA
| | - J Y Hsu
- Division of Biostatistics, Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA, USA
| | - T Liu
- School of Information Science and Engineering, Yanshan University, Qinhuangdao, China
| | - J K Udupa
- Medical Image Processing Group, Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Y Tong
- Medical Image Processing Group, Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - D A Torigian
- Medical Image Processing Group, Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - J P Fischer
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, 3400 Civic Center Boulevard, 14th floor South Tower, Philadelphia, PA, 19104, USA.
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Dember LM, Hsu JY, Bernardo L, Cavanaugh KL, Charytan DM, Crowley ST, Cukor D, Doorenbos AZ, Edwards DA, Esserman D, Fischer MJ, Jhamb M, Joffe S, Johansen KL, Kalim S, Keefe FJ, Kimmel PL, Krebs EE, Kuzla N, Mehrotra R, Mishra P, Pellegrino B, Steel JL, Unruh ML, White DM, Yabes JG, Becker WC. The design and baseline characteristics for the HOPE Consortium Trial to reduce pain and opioid use in hemodialysis. Contemp Clin Trials 2024; 136:107409. [PMID: 38086444 PMCID: PMC10922728 DOI: 10.1016/j.cct.2023.107409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 11/07/2023] [Accepted: 12/06/2023] [Indexed: 01/07/2024]
Abstract
The HOPE Consortium Trial to Reduce Pain and Opioid Use in Hemodialysis (HOPE Trial) is a multicenter randomized trial addressing chronic pain among patients receiving maintenance hemodialysis for end-stage kidney disease. The trial uses a sequential, multiple assignment design with a randomized component for all participants (Phase 1) and a non-randomized component for a subset of participants (Phase 2). During Phase 1, participants are randomized to Pain Coping Skills Training (PCST), an intervention designed to increase self-efficacy for managing pain, or Usual Care. PCST consists of weekly, live, coach-led cognitive behavioral therapy sessions delivered by video- or tele-conferencing for 12 weeks followed by daily interactive voice response sessions delivered by telephone for an additional 12 weeks. At 24 weeks (Phase 2), participants in both the PCST and Usual Care groups taking prescription opioid medications at an average dose of ≥20 morphine milligram equivalents per day are offered buprenorphine, a partial opioid agonist with a more favorable safety profile than full-agonist opioids. All participants are followed for 36 weeks. The primary outcome is pain interference ascertained, for the primary analysis, at 12 weeks. Secondary outcomes include additional patient-reported measures and clinical outcomes including falls, hospitalizations, and death. Exploratory outcomes include acceptability, tolerability, and efficacy of buprenorphine. The enrollment target of 640 participants was met 27 months after trial initiation. The findings of the trial will inform the management of chronic pain, a common and challenging issue for patients treated with maintenance hemodialysis. NCT04571619.
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Affiliation(s)
- Laura M Dember
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America; Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America.
| | - Jesse Y Hsu
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Leah Bernardo
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Kerri L Cavanaugh
- Division of Nephrology & Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - David M Charytan
- Nephrology Division, Department of Medicine, New York University Grossman School of Medicine, and NYU Langone Health, New York, NY, United States of America
| | - Susan T Crowley
- Section of Nephrology, Department of Medicine, Yale School of Medicine, New Haven, CT, United States of America; Kidney Medicine Program, Medical Services, VA Connecticut Healthcare System, West Haven, CT, United States of America
| | - Daniel Cukor
- Behavioral Health, The Rogosin Institute, New York, NY, United States of America
| | - Ardith Z Doorenbos
- College of Nursing, University of Illinois Chicago, Chicago, IL, United States of America
| | - David A Edwards
- Division of Pain Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Denise Esserman
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, United States of America
| | - Michael J Fischer
- Department of Medicine, University of Illinois Chicago, Chicago, IL, United States of America; Medical Service, Jesse Brown VA Medical Center, Chicago, IL, United States of America; Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr. VA Hospital, Hines, IL, United States of America
| | - Manisha Jhamb
- Renal and Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America
| | - Steven Joffe
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Kirsten L Johansen
- Nephrology Division, Hennepin Healthcare, Department of Medicine, University of Minnesota, Minneapolis, MN, United States of America
| | - Sahir Kalim
- Department of Medicine, Division of Nephrology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States of America
| | - Francis J Keefe
- Pain Prevention and Treatment Research Program, Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, United States of America
| | - Paul L Kimmel
- Division of Kidney, Urologic, and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, United States of America
| | - Erin E Krebs
- General Internal Medicine, Minneapolis VA Health Care System, University of Minnesota Medical School, Minneapolis, MN, United States of America
| | - Natalie Kuzla
- Clinical Research Computing Unit, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Rajnish Mehrotra
- Kidney Research Institute, Division of Nephrology, Department of Medicine, University of Washington School of Medicine, Seattle, WA, United States of America
| | - Puneet Mishra
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Bethany Pellegrino
- Division of Nephrology, Department of Medicine, West Virginia University School of Medicine, Morgantown, WV, United States of America
| | - Jennifer L Steel
- Division of Hepatobiliary Surgery, Department of Surgery, Psychiatry, and Psychology, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America
| | - Mark L Unruh
- Division of Nephrology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM, United States of America; Research Service, Department of Medicine, Raymond G. Murphy Veterans Affairs Medical Center and University of New Mexico School of Medicine, Albuquerque, NM, United States of America
| | - David M White
- American Association of Kidney Patients, Tampa, FL, United States of America
| | - Jonathan G Yabes
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America
| | - William C Becker
- Section of General Internal Medicine, Department of Medicine, Yale School of Medicine, New Haven, CT, United States of America; Pain Research, Informatics, Multi-morbidities & Education Center of Innovation, VA Connecticut Healthcare System, West Haven, CT, United States of America
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Jimenez JV, Ackrivo J, Hsu JY, Wilson MW, Labaki WW, Hansen-Flaschen J, Hyzy RC, Choi PJ. Lowering P CO2 With Noninvasive Ventilation Is Associated With Improved Survival in Chronic Hypercapnic Respiratory Failure. Respir Care 2023; 68:1613-1622. [PMID: 37137711 PMCID: PMC10676248 DOI: 10.4187/respcare.10813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 05/01/2023] [Indexed: 05/05/2023]
Abstract
BACKGROUND Chronic hypercapnic respiratory failure is associated with high mortality. Although previous work has demonstrated a mortality improvement with high-intensity noninvasive ventilation in COPD, it is unclear whether a PCO2 reduction strategy is associated with improved outcomes in other populations of chronic hypercapnia. METHODS The objective of this study was to investigate the association between PCO2 reduction (by using transcutaneous PCO2 as an estimate for PaCO2 and survival in a broad population of individuals treated with noninvasive ventilation for chronic hypercapnia. We hypothesized that reductions in PCO2 would be associated with improved survival. Therefore, we performed a cohort study of all the subjects evaluated from February 2012 to January 2021 for noninvasive ventilation initiation and/or optimization due to chronic hypercapnia at a home ventilation clinic in an academic center. We used multivariable Cox proportional hazard models with time-varying coefficients and PCO2 as a time-varying covariate to test the association between PCO2 and all-cause mortality and when adjusting for known cofounders. RESULTS The mean ± SD age of 337 subjects was 57 ± 16 years, 37% women, and 85% white. In a univariate analysis, survival probability increased with reductions in PCO2 to < 50 mm Hg after 90 d, and these remained significant after adjusting for age, sex, race, body mass index, diagnosis, Charlson comorbidity index, and baseline PCO2 . In the multivariable analysis, the subjects who had a PaCO2 < 50 mm Hg had a reduced mortality risk of 94% between 90 and 179 d (hazard ratio [HR] 0.06, 95% CI 0.01-0.50), 69% between 180 and 364 d (HR 0.31, 95% CI 0.12-0.79), and 73% for 365-730 d (HR 0.27, 95% CI 0.13-0.56). CONCLUSIONS Reduction in PCO2 from baseline for subjects with chronic hypercapnia treated with noninvasive ventilation was associated with improved survival. Management strategies should target the greatest attainable reductions in PCO2 .
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Affiliation(s)
- Jose Victor Jimenez
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, Michigan. Dr Jimenez is affiliated with the Department of Internal Medicine, Yale New Haven Hospital, New Haven, Connecticut
| | - Jason Ackrivo
- Pulmonary, Allergy, and Critical Care Division, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jesse Y Hsu
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mathew W Wilson
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, Michigan. Dr Jimenez is affiliated with the Department of Internal Medicine, Yale New Haven Hospital, New Haven, Connecticut
| | - Wassim W Labaki
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, Michigan. Dr Jimenez is affiliated with the Department of Internal Medicine, Yale New Haven Hospital, New Haven, Connecticut
| | - John Hansen-Flaschen
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, Michigan. Dr Jimenez is affiliated with the Department of Internal Medicine, Yale New Haven Hospital, New Haven, Connecticut
| | - Robert C Hyzy
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, Michigan. Dr Jimenez is affiliated with the Department of Internal Medicine, Yale New Haven Hospital, New Haven, Connecticut
| | - Philip J Choi
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, Michigan. Dr Jimenez is affiliated with the Department of Internal Medicine, Yale New Haven Hospital, New Haven, Connecticut.
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Keim G, Percy AG, Himebauch AS, Hsu JY, Christie JD, Yehya N. Acute respiratory failure-related excess mortality in pediatric sepsis. Thorax 2023; 78:1135-1137. [PMID: 37225415 PMCID: PMC10953703 DOI: 10.1136/thorax-2022-219961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Excess mortality risk imparted by acute respiratory failure in children is unknown. We determined excess mortality risk associated with mechanically ventilated acute respiratory failure in pediatric sepsis. Novel ICD10-based algorithms were derived and validated to identify a surrogate for acute respiratory distress syndrome to calculate excess mortality risk. Algorithm-identified ARDS was identified with specificity of 96.7% (CI 93.0 - 98.9) and sensitivity of 70.5% (CI 44.0 - 89.7). Excess risk of mortality for ARDS was 24.4% (CI 22.9 - 26.2). Development of ARDS requiring mechanical ventilation imparts modest excess risk of mortality in septic children.
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Affiliation(s)
- Garrett Keim
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania, USA
| | - Andrew G Percy
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Adam S Himebauch
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Jesse Y Hsu
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Jason D Christie
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Nadir Yehya
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania, USA
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Abbott EE, Buckler DG, Hsu JY, Abella BS, Richardson LD, Carr BG, Zebrowski AM. Association of Racial Residential Segregation With Long-Term Outcomes and Readmissions After Out-of-Hospital Cardiac Arrest Among Medicare Beneficiaries. J Am Heart Assoc 2023; 12:e030138. [PMID: 37750559 PMCID: PMC10727234 DOI: 10.1161/jaha.123.030138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 08/10/2023] [Indexed: 09/27/2023]
Abstract
Background The national impact of racial residential segregation on out-of-hospital cardiac arrest outcomes after initial resuscitation remains poorly understood. We sought to characterize the association between measures of racial and economic residential segregation at the ZIP code level and long-term survival and readmissions after out-of-hospital cardiac arrest among Medicare beneficiaries. Methods and Results In this retrospective cohort study, using Medicare claims data, our primary predictor was the index of concentration at the extremes, a measure of racial and economic segregation. The primary outcomes were death up to 3 years and readmissions. We estimated hazard ratios (HRs) across all 3 types of index of concentration at the extremes measures for each outcome while adjusting for beneficiary demographics, treating hospital characteristics, and index hospital procedures. In fully adjusted models for long-term survival, we found a decreased hazard of death and risk of readmission for beneficiaries residing in the more segregated White communities and higher-income ZIP codes compared with the more segregated Black communities and lower-income ZIP codes across all 3 indices of concentration at the extremes measures (race: HR, 0.87 [95% CI, 0.81-0.93]; income: HR, 0.75 [95% CI, 0.69-0.78]; and race+income: HR, 0.77 [95% CI, 0.72-0.82]). Conclusions We found a decreased hazard of death and risk for readmission for those residing in the more segregated White communities and higher-income ZIP codes compared with the more segregated Black communities and lower-income ZIP codes when using validated measures of racial and economic segregation. Although causal pathways and mechanisms remain unclear, disparities in outcomes after out-of-hospital cardiac arrest are associated with the structural components of race and wealth and persist up to 3 years after discharge.
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Affiliation(s)
- Ethan E. Abbott
- Department of Emergency Medicine, Icahn School of Medicine at Mount SinaiNew YorkNY
- Department of Population Health Science and PolicyIcahn School of Medicine at Mount SinaiNew YorkNY
- Institute for Health Equity Research, Icahn School of Medicine at Mount SinaiNew YorkNY
| | - David G. Buckler
- Department of Emergency Medicine, Icahn School of Medicine at Mount SinaiNew YorkNY
| | - Jesse Y. Hsu
- Department of Biostatistics, Epidemiology, and InformaticsUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPA
| | - Benjamin S. Abella
- Center for Resuscitation Science and Department of Emergency Medicine, University of PennsylvaniaPhiladelphiaPA
| | - Lynne D. Richardson
- Department of Emergency Medicine, Icahn School of Medicine at Mount SinaiNew YorkNY
- Department of Population Health Science and PolicyIcahn School of Medicine at Mount SinaiNew YorkNY
- Institute for Health Equity Research, Icahn School of Medicine at Mount SinaiNew YorkNY
| | - Brendan G. Carr
- Department of Emergency Medicine, Icahn School of Medicine at Mount SinaiNew YorkNY
- Department of Population Health Science and PolicyIcahn School of Medicine at Mount SinaiNew YorkNY
| | - Alexis M. Zebrowski
- Department of Emergency Medicine, Icahn School of Medicine at Mount SinaiNew YorkNY
- Department of Population Health Science and PolicyIcahn School of Medicine at Mount SinaiNew YorkNY
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Keim G, Hsu JY, Pinto NP, McSherry ML, Gula AL, Christie JD, Yehya N. Readmission Rates After Acute Respiratory Distress Syndrome in Children. JAMA Netw Open 2023; 6:e2330774. [PMID: 37682574 PMCID: PMC10492185 DOI: 10.1001/jamanetworkopen.2023.30774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 07/19/2023] [Indexed: 09/09/2023] Open
Abstract
Importance An increasing number of children survive after acute respiratory distress syndrome (ARDS). The long-term morbidity affecting these survivors, including the burden of hospital readmission and key factors associated with readmission, is unknown. Objective To determine 1-year readmission rates among survivors of pediatric ARDS and to investigate the associations of 3 key index hospitalization factors (presence or development of a complex chronic condition, receipt of a tracheostomy, and hospital length of stay [LOS]) with readmission. Design, Setting, and Participants This retrospective cohort study used data from the commercial or Medicaid IBM MarketScan databases between 2013 and 2017, with follow-up data through 2018. Participants included hospitalized children (aged ≥28 days to <18 years) who received mechanical ventilation and had algorithm-identified ARDS. Data analysis was completed from March 2022 to March 2023. Exposures Complex chronic conditions (none, nonrespiratory, and respiratory), receipt of tracheostomy, and index hospital LOS. Main Outcomes and Measures The primary outcome was 1-year, all-cause hospital readmission. Univariable and multivariable Cox proportional hazard models were created to test the association of key hospitalization factors with readmission. Results One-year readmission occurred in 3748 of 13 505 children (median [IQR] age, 4 [0-14] years; 7869 boys [58.3%]) with mechanically ventilated ARDS who survived to hospital discharge. In survival analysis, the probability of 1-year readmission was 30.0% (95% CI, 29.0%-30.8%). One-half of readmissions occurred within 61 days of discharge (95% CI, 56-67 days). Both respiratory (adjusted hazard ratio [aHR], 2.69; 95% CI, 2.42-2.98) and nonrespiratory (aHR, 1.86; 95% CI, 1.71-2.03) complex chronic conditions were associated with 1-year readmission. Placement of a new tracheostomy (aHR, 1.98; 95% CI, 1.69-2.33) and LOS 14 days or longer (aHR, 1.87; 95% CI, 1.62-2.16) were associated with readmission. After exclusion of children with chronic conditions, LOS 14 days or longer continued to be associated with readmission (aHR, 1.92; 95% CI, 1.49-2.47). Conclusions and Relevance In this retrospective cohort study of children with ARDS who survived to discharge, important factors associated with readmission included the presence or development of chronic medical conditions during the index admission, tracheostomy placement during index admission, and index hospitalization of 14 days or longer. Future studies should evaluate whether postdischarge interventions (eg, telephonic contact, follow-up clinics, and home health care) may help reduce the readmission burden.
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Affiliation(s)
- Garrett Keim
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Jesse Y. Hsu
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Neethi P. Pinto
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Megan L. McSherry
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Annie Laurie Gula
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jason D. Christie
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Division of Pulmonary, Allergy and Critical Care Medicine, Hospital of the University of Pennsylvania, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Nadir Yehya
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
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Han M, Moon S, Lee S, Kim K, An WJ, Ryu H, Kang E, Ahn JH, Sung HY, Park YS, Lee SE, Lee SH, Jeong KH, Ahn C, Kelly TN, Hsu JY, Feldman HI, Park SK, Oh KH. Novel Genetic Variants Associated with Chronic Kidney Disease Progression. J Am Soc Nephrol 2023; 34:857-875. [PMID: 36720675 PMCID: PMC10125649 DOI: 10.1681/asn.0000000000000066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 12/11/2022] [Indexed: 02/02/2023] Open
Abstract
SIGNIFICANCE STATEMENT eGFR slope has been used as a surrogate outcome for progression of CKD. However, genetic markers associated with eGFR slope among patients with CKD were unknown. We aimed to identify genetic susceptibility loci associated with eGFR slope. A two-phase genome-wide association study identified single nucleotide polymorphisms (SNPs) in TPPP and FAT1-LINC02374 , and 22 of them were used to derive polygenic risk scores that mark the decline of eGFR by disrupting binding of nearby transcription factors. This work is the first to identify the impact of TPPP and FAT1-LINC02374 on CKD progression, providing predictive markers for the decline of eGFR in patients with CKD. BACKGROUND The incidence of CKD is associated with genetic factors. However, genetic markers associated with the progression of CKD have not been fully elucidated. METHODS We conducted a genome-wide association study among 1738 patients with CKD, mainly from the KoreaN cohort study for Outcomes in patients With CKD. The outcome was eGFR slope. We performed a replication study for discovered single nucleotide polymorphisms (SNPs) with P <10 -6 in 2498 patients with CKD from the Chronic Renal Insufficiency Cohort study. Several expression quantitative trait loci (eQTL) studies, pathway enrichment analyses, exploration of epigenetic architecture, and predicting disruption of transcription factor (TF) binding sites explored potential biological implications of the loci. We developed and evaluated the effect of polygenic risk scores (PRS) on incident CKD outcomes. RESULTS SNPs in two novel loci, TPPP and FAT1-LINC02374 , were replicated (rs59402340 in TPPP , Pdiscovery =7.11×10 -7 , PCRIC =8.13×10 -4 , Pmeta =7.23×10 -8 ; rs28629773 in FAT1-LINC02374 , Pdiscovery =6.08×10 -7 , PCRIC =4.33×10 -2 , Pmeta =1.87×10 -7 ). The eQTL studies revealed that the replicated SNPs regulated the expression level of nearby genes associated with kidney function. Furthermore, these SNPs were near gene enhancer regions and predicted to disrupt the binding of TFs. PRS based on the independently significant top 22 SNPs were significantly associated with CKD outcomes. CONCLUSIONS This study demonstrates that SNP markers in the TPPP and FAT1-LINC02374 loci could be predictive markers for the decline of eGFR in patients with CKD.
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Affiliation(s)
- Miyeun Han
- Department of Internal Medicine, National Medical Center, Seoul, Korea
| | - Sungji Moon
- Department of Preventive Medicine, Seoul National University College of Medicine, Seoul, Korea
- Cancer Research Institute, Seoul National University, Seoul, Korea
- Interdisciplinary Program in Cancer Biology, Seoul National University College of Medicine, Seoul, Korea
- Genomic Medicine Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Sangjun Lee
- Department of Preventive Medicine, Seoul National University College of Medicine, Seoul, Korea
- Cancer Research Institute, Seoul National University, Seoul, Korea
- Department of Biomedical Science, Seoul National University Graduate School, Seoul, Korea
| | - Kyungsik Kim
- Department of Preventive Medicine, Seoul National University College of Medicine, Seoul, Korea
- Cancer Research Institute, Seoul National University, Seoul, Korea
- Department of Biomedical Science, Seoul National University Graduate School, Seoul, Korea
| | - Woo Ju An
- Department of Preventive Medicine, Seoul National University College of Medicine, Seoul, Korea
- Cancer Research Institute, Seoul National University, Seoul, Korea
- Integrated Major in Innovative Medical Science, Seoul National University College of Medicine, Seoul, Korea
| | - Hyunjin Ryu
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Eunjeong Kang
- Department of Internal Medicine, Ewha Womans University Seoul Hospital, Ewha Womans University College of Medicine, Seoul, Korea
| | - Jung-Hyuck Ahn
- Department of Biochemistry, Ewha Womans University College of Medicine, Seoul, Korea
| | - Hye Youn Sung
- Department of Biochemistry, Ewha Womans University College of Medicine, Seoul, Korea
| | - Yong Seek Park
- Department of Microbiology, School of Medicine, Kyung Hee University, Seoul, Korea
| | - Seung Eun Lee
- Department of Microbiology, School of Medicine, Kyung Hee University, Seoul, Korea
| | - Sang-Ho Lee
- Department of Internal Medicine, Kyung Hee University School of Medicine, Seoul, Korea
| | - Kyung Hwan Jeong
- Department of Internal Medicine, Kyung Hee University School of Medicine, Seoul, Korea
| | - Curie Ahn
- Department of Internal Medicine, National Medical Center, Seoul, Korea
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Tanika N. Kelly
- Department of Epidemiology, Tulane University, New Orleans, Louisiana
| | - Jesse Y. Hsu
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Harold I. Feldman
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Sue K. Park
- Department of Preventive Medicine, Seoul National University College of Medicine, Seoul, Korea
- Cancer Research Institute, Seoul National University, Seoul, Korea
- Integrated Major in Innovative Medical Science, Seoul National University College of Medicine, Seoul, Korea
| | - Kook-Hwan Oh
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
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9
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Kellier DJ, de Prado BM, Haagen D, Grabner P, Raj N, Lechtenberg L, Velasquez G, Hsu JY, Farrar JT, Hershey AD, Szperka CL. Validity of self-reported migraine in adolescents and children. Headache 2023; 63:634-641. [PMID: 37140013 PMCID: PMC10478717 DOI: 10.1111/head.14498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 02/19/2023] [Accepted: 02/24/2023] [Indexed: 05/05/2023]
Abstract
OBJECTIVE To assess agreement for migraine day between self-report and diagnostic guidelines for children and adolescents using a headache diary. BACKGROUND Trial guidelines recommend prospective collection of headache features and adoption of migraine day as an outcome measure, but there is no clear consensus on the definition of migraine day. METHODS This is a secondary analysis of data from two projects-a prospective cohort study validating a pediatric scale of treatment expectancy and a clinical trial of occipital nerve blocks to treat status migrainosus. Participants completed a text message-based diary for 4 or 12 weeks (depending on treatment), and a detailed headache assessment on a random 20% of headache days. Using this assessment, we determined whether a headache day qualified for migraine or probable migraine, based on the International Classification of Headache Disorders, 3rd edition (ICHD-3). RESULTS Of 122 enrolled children and adolescents, 106 (86.9%) completed ≥1 detailed headache assessment (438 entries). We found moderate agreement between self-reported and ICHD-derived migraine day, with a Cohen's Kappa of 0.50 (positive predictive value [PPV]: 0.66; negative predictive value [NPV]: 0.85; correlation: 0.51). Allowing for ICHD-derived probable migraine significantly increased PPV (0.66 vs. 0.94; 95% CI: 0.57-0.74 vs. 0.90-0.97), but decreased NPV (0.85 vs. 0.293; CI: 0.77-0.90 vs. 0.199-0.40), Cohen's Kappa (0.50 vs. 0.237; CI: 0. 389-0.60 vs. 0.139-0.352), and correlation (r = 0.51 vs. 0.302; CI: 0.41-0.61 vs. 0.192-0.41). Pain severity (OR: 5.7; CI: 2.39-13.8), photophobia (OR: 4.1; CI: 1.02-16.6), and phonophobia (OR: 7.5; CI: 1.95-29.3) were significantly associated with participants' perception of migraine. CONCLUSION We found only moderate agreement between self-reported and ICHD-derived migraine day, suggesting both measures are not equal but may represent overlapping aspects of migraine as a disease. This highlights the difficulty of applying ICHD criteria to individual attacks. We recommend greater methodological transparency in future research to avoid readers conflating both measures.
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Affiliation(s)
- Danielle J. Kellier
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Children’s Hospital of Philadelphia, Philadelphia, USA
| | | | - Dana Haagen
- Children’s Hospital of Philadelphia, Philadelphia, USA
| | | | - Nichelle Raj
- Children’s Hospital of Philadelphia, Philadelphia, USA
| | | | | | - Jesse Y. Hsu
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - John T. Farrar
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Andrew D. Hershey
- Cincinnati Children’s Hospital, Cincinnati, USA
- University of Cincinnati College of Medicine, Cincinnati, USA
| | - Christina L. Szperka
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Children’s Hospital of Philadelphia, Philadelphia, USA
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10
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McCoy IE, Hsu JY, Zhang X, Diamantidis CJ, Taliercio J, Go AS, Liu KD, Drawz P, Srivastava A, Horwitz EJ, He J, Chen J, Lash JP, Weir MR, Hsu CY. Probing the Association between Acute Kidney Injury and Cardiovascular Outcomes. Clin J Am Soc Nephrol 2023; 18:01277230-990000000-00137. [PMID: 37116457 PMCID: PMC10356151 DOI: 10.2215/cjn.0000000000000163] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 04/17/2023] [Indexed: 04/30/2023]
Abstract
BACKGROUND Patients hospitalized with AKI have higher subsequent risks of heart failure, atherosclerotic cardiovascular events, and mortality than their counterparts without AKI, but these higher risks may be due to differences in prehospitalization patient characteristics, including the baseline level of estimated glomerular filtration rate (eGFR), the rate of prior eGFR decline, and the proteinuria level, rather than AKI itself. METHODS Among 2177 adult participants in the Chronic Renal Insufficiency Cohort study who were hospitalized in 2013-2019, we compared subsequent risks of heart failure, atherosclerotic cardiovascular events, and mortality between those with serum creatinine-based AKI (495 patients) and those without AKI (1682 patients). We report both crude associations and associations sequentially adjusted for prehospitalization characteristics including eGFR, eGFR slope, and urine protein-creatinine ratio (UPCR). RESULTS Compared with patients hospitalized without AKI, those with hospitalized AKI had lower eGFR prehospitalization (42 versus 49 ml/min per 1.73 m 2 ), faster chronic loss of eGFR prehospitalization (-0.84 versus -0.51 ml/min per 1.73 m 2 per year), and more proteinuria prehospitalization (UPCR 0.28 versus 0.16 g/g); they also had higher prehospitalization systolic BP (130 versus 127 mm Hg; P < 0.01 for all comparisons). Adjustment for prehospitalization patient characteristics attenuated associations between AKI and all three outcomes, but AKI remained an independent risk factor. Attenuation of risk was similar after adjustment for absolute eGFR, eGFR slope, or proteinuria, individually or in combination. CONCLUSIONS Prehospitalization variables including eGFR, eGFR slope, and proteinuria confounded associations between AKI and adverse cardiovascular outcomes, but these associations remained significant after adjusting for prehospitalization variables.
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Affiliation(s)
- Ian E. McCoy
- Division of Nephrology, University of California San Francisco, San Francisco, California
| | - Jesse Y. Hsu
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Xiaoming Zhang
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Jonathan Taliercio
- Department of Kidney Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Alan S. Go
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Kathleen D. Liu
- Division of Nephrology, University of California San Francisco, San Francisco, California
| | - Paul Drawz
- Division of Nephrology and Hypertension, University of Minnesota, Minneapolis, Minnesota
| | - Anand Srivastava
- Division of Nephrology, Department of Medicine, University of Illinois Chicago, Chicago, Illinois
| | - Edward J. Horwitz
- Division of Nephrology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Jiang He
- Department of Epidemiology, Tulane University, New Orleans, Louisiana
| | - Jing Chen
- Department of Epidemiology, Tulane University, New Orleans, Louisiana
- Division of Nephrology, Tulane University, New Orleans, Louisiana
| | - James P. Lash
- Department of Medicine, University of Illinois College of Medicine at Chicago, Chicago, Illinois
| | - Matthew R. Weir
- Division of Nephrology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Chi-yuan Hsu
- Division of Nephrology, University of California San Francisco, San Francisco, California
- Division of Research, Kaiser Permanente Northern California, Oakland, California
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11
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Mc Causland FR, Hsu JY, Himmelfarb J, Ikizler TA, Raj DS, Mehrotra R, Waikar SS, Kimmel PL, Kliger AS, Dember LM, Charytan DM. Effects of Spironolactone on Arrhythmias in Hemodialysis Patients: Secondary Results of the SPin-D Randomized Controlled Trial. Kidney360 2023; 4:e486-e495. [PMID: 36763641 PMCID: PMC10278797 DOI: 10.34067/kid.0000000000000067] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 12/21/2022] [Indexed: 02/12/2023]
Abstract
Key Points The effects of spironolactone on arrhythmia in patients receiving maintenance hemodialysis are unclear. In these post hoc analyses, spironolactone resulted in a higher frequency of bradycardia and conduction blocks, compared with placebo. Close monitoring may be warranted for patients on maintenance hemodialysis receiving MRAs, while definitive trial results are awaited. Background Patients receiving maintenance hemodialysis (HD) have a high incidence of cardiovascular events, including arrhythmia and sudden death. Spironolactone reduces the risk of cardiovascular events and sudden death in patients with heart failure, but the effects of spironolactone on arrhythmic events in patients treated with maintenance HD are unclear. Methods The Safety and Cardiovascular Efficacy of Spironolactone in Dialysis-Dependent ESRD (SPin-D) trial was a 36-week randomized, placebo-controlled, double-blind trial comparing three different doses of spironolactone with placebo in maintenance HD patients. We performed a post hoc analysis in a subset (n =57) who underwent extended electrocardiographic monitoring using a wearable device at baseline and follow-up. Generalized estimating equations models were fit to determine the associations of spironolactone (individual doses and combined) versus placebo on the incidence rate of predefined categories of arrhythmic events. Results The average age of participants was 55±12 years, 61% were male, and 77% were Black. The overall proportion of patients with at least one arrhythmia event was 43% (15/35) at baseline and 81% (43/53) at the end of follow-up. At the end of follow-up, the rate of bradycardic events or conduction blocks was higher in the combined spironolactone group, compared with placebo (82.4 versus 38.7 events/100 patient-days; P <0.001). Similar findings were noted in adjusted models, but did not meet statistical significance (adjusted rate ratio of 2.04; 95% confidence interval 0.83–5.05). Conclusions In a 36-week trial of patients receiving maintenance HD, a higher frequency of bradycardia and conduction blocks was observed among those treated with spironolactone treatment compared with placebo. Larger studies are required to investigate the longer-term effects of spironolactone on cardiac conduction in patients receiving HD.
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Affiliation(s)
- Finnian R Mc Causland
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Jesse Y Hsu
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jonathan Himmelfarb
- Kidney Research Institute, Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington
| | - Talat Alp Ikizler
- Division of Nephrology and Hypertension, Department of Medicine, and Vanderbilt Center for Kidney Disease, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Dominic S Raj
- Division of Renal Diseases and Hypertension, George Washington University School of Medicine, Washington, DC
| | - Rajnish Mehrotra
- Kidney Research Institute, Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington
| | - Sushrut S Waikar
- Section of Nephrology, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Paul L Kimmel
- National Institute of Diabetes Digestive and Kidney Diseases, Bethesda, Maryland
| | - Alan S Kliger
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Laura M Dember
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Renal, Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - David M Charytan
- Nephrology Division, Department of Medicine, New York University Grossman School of Medicine, New York, New York
- NYU Langone Health, New York, New York
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12
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Wang CH, Negoianu D, Zhang H, Casper S, Hsu JY, Kotanko P, Raimann J, Dember LM. Dynamics of Plasma Refill Rate and Intradialytic Hypotension During Hemodialysis: Retrospective Cohort Study With Causal Methodology. Kidney360 2023; 4:e505-e514. [PMID: 36790867 PMCID: PMC10278774 DOI: 10.34067/kid.0000000000000082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 01/18/2023] [Indexed: 02/16/2023]
Abstract
Key Points Directly studying plasma refill rate (PRR) during hemodialysis (HD) can offer insight into physiologic mechanisms that change throughout HD. PRR at the start and during HD is associated with intradialytic hypotension, independent of ultrafiltration rate. A rising PRR during HD may be an early indicator of compensatory mechanisms for impending circulatory instability. Background Attaining the optimal balance between achieving adequate volume removal while preserving organ perfusion is a challenge for patients receiving maintenance hemodialysis (HD). Current strategies to guide ultrafiltration are inadequate. Methods We developed an approach to calculate the plasma refill rate (PRR) throughout HD using hematocrit and ultrafiltration data in a retrospective cohort of patients receiving maintenance HD at 17 dialysis units from January 2017 to October 2019. We studied whether (1 ) PRR is associated with traditional risk factors for hemodynamic instability using logistic regression, (2 ) low starting PRR is associated with intradialytic hypotension (IDH) using Cox proportional hazard regression, and (3 ) time-varying PRR throughout HD is associated with hypotension using marginal structural modeling. Results During 180,319 HD sessions among 2554 patients, PRR had high within-patient and between-patient variability. Female sex and hypoalbuminemia were associated with low PRR at multiple time points during the first hour of HD. Low starting PRR has a higher hazard of IDH, whereas high starting PRR was protective (hazard ratio [HR], 1.26, 95% confidence interval [CI], 1.18 to 1.35 versus HR, 0.79, 95% CI, 0.73 to 0.85, respectively). However, when accounting for time-varying PRR and time-varying confounders, compared with a moderate PRR, while a consistently low PRR was associated with increased risk of hypotension (odds ratio [OR], 1.09, 95% CI, 1.02 to 1.16), a consistently high PRR had a stronger association with hypotension within the next 15 minutes (OR, 1.38, 95% CI, 1.30 to 1.45). Conclusions We present a straightforward technique to quantify plasma refill that could easily integrate with devices that monitor hematocrit during HD. Our study highlights how examining patterns of plasma refill may enhance our understanding of circulatory changes during HD, an important step to understand how current technology might be used to improve hemodynamic instability.
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Affiliation(s)
- Christina H. Wang
- Renal, Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Dan Negoianu
- Renal, Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Sabrina Casper
- Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
| | - Jesse Y. Hsu
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Peter Kotanko
- Renal Research Institute, New York, New York
- Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Laura M. Dember
- Renal, Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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13
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Estrella ML, Allen-Meares P, Ricardo AC, Fischer MJ, Gordon EJ, Carmona-Powell E, Sondheimer J, Chen J, Horwitz E, Wang X, Hsu JY, Lash JP, Lora C. Prospective associations of health literacy with clinical outcomes in adults with CKD: findings from the CRIC study. Nephrol Dial Transplant 2023; 38:904-912. [PMID: 35746879 PMCID: PMC10064835 DOI: 10.1093/ndt/gfac201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Limited health literacy is associated with significant morbidity and mortality in the general population but the relation of health literacy with long-term clinical outcomes among adults with chronic kidney disease (CKD) is less clear. METHODS Prospective data from the Chronic Renal Insufficiency Cohort (CRIC) Study (n = 3715) were used. Health literacy was assessed with the Short Test of Functional Health Literacy in Adults (dichotomized as limited/adequate). Cox proportional hazards models were used to separately examine the relations of health literacy with CKD progression, cardiovascular event (any of the following: myocardial infarction, congestive heart failure, stroke or peripheral artery disease), and all-cause, cardiovascular and non-cardiovascular mortality. Poisson regression was used to assess the health literacy-hospitalization association. Models were sequentially adjusted: Model 1 adjusted for potential confounders (sociodemographic factors), while Model 2 additionally adjusted for potential mediators (clinical and lifestyle factors) of the associations of interest. RESULTS In confounder-adjusted models, participants with limited (vs adequate) health literacy [555 (15%)] had an increased risk of CKD progression [hazard ratio (HR) 1.34; 95% confidence interval (CI) 1.06-1.71], cardiovascular event (HR 1.67; 95% CI 1.39-2.00), hospitalization (rate ratio 1.33; 95% CI 1.26-1.40), and all-cause (HR 1.54; 95% CI 1.27-1.86), cardiovascular (HR 2.39; 95% CI 1.69-3.38) and non-cardiovascular (HR 1.27; 95% CI 1.01-1.60) mortality. Additional adjustments for potential mediators (Model 2) showed similar results except that the relations of health literacy with CKD progression and non-cardiovascular mortality were no longer statistically significant. CONCLUSIONS In the CRIC Study, adults with limited (vs adequate) health literacy had a higher risk for CKD progression, cardiovascular event, hospitalization and mortality-regardless of adjustment for potential confounders.
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Affiliation(s)
- Mayra L Estrella
- Department of Epidemiology, Human Genetics and Environmental Sciences, The University of Texas Health Science Center at Houston (UTHealth) School of Public Health, Brownsville, TX, USA
- Institute for Minority Health Research, University of Illinois at Chicago, Chicago, IL, USA
| | - Paula Allen-Meares
- Institute for Minority Health Research, University of Illinois at Chicago, Chicago, IL, USA
- Office of Health Literacy, University of Illinois at Chicago, Chicago, IL, USA
| | - Ana C Ricardo
- Division of Nephrology, Department of Medicine, University of Illinois at Chicago, Chicago, IL, USA
| | - Michael J Fischer
- Division of Nephrology, Department of Medicine, University of Illinois at Chicago, Chicago, IL, USA
- Medicine/Nephrology, Jesse Brown VA Medical Center, Chicago, IL, USA
- Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr VA Hospital, Hines, IL, USA
| | - Elisa J Gordon
- Division of Transplantation, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Eunice Carmona-Powell
- Division of Nephrology, Department of Medicine, University of Illinois at Chicago, Chicago, IL, USA
| | - James Sondheimer
- Department of Medicine, Wayne State University, Detroit, MI, USA
| | - Jing Chen
- Department of Medicine, Tulane University, New Orleans, LA, USA
| | - Edward Horwitz
- Case Western Reserve University, School of Medicine, MetroHealth Medical Center, Cleveland, OH, USA
| | - Xue Wang
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Jesse Y Hsu
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - James P Lash
- Division of Nephrology, Department of Medicine, University of Illinois at Chicago, Chicago, IL, USA
| | - Claudia Lora
- Department of Epidemiology, Human Genetics and Environmental Sciences, The University of Texas Health Science Center at Houston (UTHealth) School of Public Health, Brownsville, TX, USA
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14
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Miller-Patterson C, Hsu JY, Willis AW, Hamedani AG. Functional Impairment in Individuals With Prodromal or Unrecognized Parkinson Disease. JAMA Neurol 2023; 80:200-204. [PMID: 36534377 PMCID: PMC9856705 DOI: 10.1001/jamaneurol.2022.4621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 09/02/2022] [Indexed: 12/23/2022]
Abstract
Importance Daily functioning in individuals with prodromal Parkinson disease requires more detailed description. Objective To evaluate whether functional limitations exist in individuals with Parkinson disease prior to diagnosis compared with the general population. Design, Setting, and Participants This case-control study used Medicare-linked data from the National Health and Aging Trends Study (NHATS), a longitudinal survey in the US, for a random subsample of Medicare beneficiaries aged 65 years or older, with Black and older individuals oversampled by design. Patients with incident Parkinson disease were defined as having 2 or more Medicare diagnoses from January 2011 to December 2017, with Medicare eligibility 2 or more consecutive years prior to the first diagnosis. Controls were defined as individuals with Medicare eligibility at a baseline year and 2 or more years prior, with no Parkinson disease diagnosis. Analyses were conducted from November 2021 to June 2022. Exposures Responses to survey questions addressing dexterity, eating, mobility, mood, pain, sleep, speech, strength, and vision. Main Outcome and Measures Associations between survey responses and Parkinson disease diagnosis in the first year of diagnosis (baseline) and up to 3 years prior to diagnosis (ie, during the prodromal phase) were examined using logistic regression. Results A total of 6674 participants were included. The participant numbers and case prevalence each year varied from 3492 to 5049 and from 700 to 1180 per 100 000 population, respectively. The median age groups were 75 to 79 years and 80 to 84 years, and the percentage of females varied from 48.21% (27 of 56 cases) to 59.98% (2079 of 3466 controls) across all years, with similar proportions among cases and controls. Individuals with prodromal Parkinson disease were less likely to report being able to walk 6 blocks (odds ratio [OR], 0.34; 95% CI, 0.15-0.82), stand independently from a kneeling position (OR, 0.30; 95% CI, 0.11-0.85), or lift a heavy object above one's head (OR, 0.36; 95% CI, 0.15-0.87) and were more likely to report imbalance (OR, 2.77; 95% CI, 1.24-6.20) 3 years prior to diagnosis. Conclusions and Relevance The findings suggest that individuals with prodromal or unrecognized Parkinson disease may have greater impairment in activities involving mobility and strength up to 3 years prior to diagnosis compared with the general population. Identification of prodromal disease may facilitate earlier intervention to improve function.
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Affiliation(s)
- Cameron Miller-Patterson
- Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Jesse Y. Hsu
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia
| | - Allison W. Willis
- Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia
| | - Ali G. Hamedani
- Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia
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Abbott EE, Buckler DG, Hsu JY, Jacoby SF, Abella BS, Richardson LD, Carr BG, Zebrowski AM. Survival After Out-of-Hospital Cardiac Arrest: The Role of Racial Residential Segregation. J Urban Health 2022; 99:998-1011. [PMID: 36216971 PMCID: PMC9727016 DOI: 10.1007/s11524-022-00691-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/15/2022] [Indexed: 12/31/2022]
Abstract
Racial and racialized economic residential segregation has been empirically associated with outcomes across multiple health conditions but not yet explored in relation to out-of-hospital cardiac arrest (OHCA). We sought to examine if measures of racial and economic residential segregation are associated with differences in survival to discharge after OHCA for Black and White Medicare beneficiaries. Utilizing age-eligible Medicare fee-for-service claims data from 2013 to 2015, we identified OHCA claims and determined survival to discharge. The primary predictor, residential segregation, was calculated using the index of concentration at the extremes (ICE) for the beneficiary residential ZIP code. Multilevel modified Poisson regression models were used to determine the association of OHCA outcomes and ZIP code level ICE measures. In total, 194,263 OHCA cases were identified among beneficiaries residing in 75% of US ZIP codes. Black beneficiaries exhibited 12.1% survival to discharge, compared with 12.5% of White beneficiaries. In fully adjusted models of the three ICE measures accounting for differences in treating hospital characteristics, there was as high as a 28% (RR 1.28, CI 1.23-1.26) higher relative likelihood of survival to discharge in the most segregated White ZIP codes (Q5) as compared to the most segregated Black ZIP codes (Q1). Racial residential segregation is independently associated with disparities in OHCA outcomes; among Medicare beneficiaries who generated a claim after suffering an OHCA, ICE measures of racial segregation are associated with a lower likelihood of survival to discharge for those living in the most segregated Black and lower income quintiles compared to higher quintiles.
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Affiliation(s)
- Ethan E Abbott
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - David G Buckler
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jesse Y Hsu
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Sara F Jacoby
- School of Nursing, University of Pennsylvania, University of Pennsylvania, Philadelphia, PA, USA
| | - Benjamin S Abella
- Center for Resuscitation Science and Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Lynne D Richardson
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Icahn School of Medicine at Mount Sinai, Institute for Health Equity Research, New York, NY, USA
| | - Brendan G Carr
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Alexis M Zebrowski
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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16
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Miller-Patterson C, Hsu JY, Chahine LM, Morley JF, Willis AW. Selected autonomic signs and symptoms as risk markers for phenoconversion and functional dependence in prodromal Parkinson's disease. Clin Auton Res 2022; 32:463-476. [PMID: 36057046 PMCID: PMC10979289 DOI: 10.1007/s10286-022-00889-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Accepted: 08/22/2022] [Indexed: 01/31/2023]
Abstract
PURPOSE To determine whether dysautonomia can stratify individuals with other prodromal markers of Parkinson's disease (PD) for risk of phenoconversion and functional decline, which may help identify subpopulations appropriate for experimental studies. METHODS Data were obtained from Parkinson's Progression Markers Initiative. Cohorts without PD but with at-risk features were included (hyposmia and/or rapid-eye-movement-sleep behavior disorder, LRRK2 gene mutation, GBA gene mutation). Dysautonomia measures included Scales-for-Outcomes-in-Parkinson's-Disease Autonomic (SCOPA-AUT), seven SCOPA-AUT subscales, and cardiovascular dysfunction (supine hypertension, low pulse pressure, neurogenic orthostatic hypotension). Outcome measures were phenoconversion and Schwab-and-England Activities-of-Daily-Living (SE-ADL) ≤ 70, which indicates functional dependence. Cox proportional-hazards regression was used to evaluate survival to phenoconversion/SE-ADL ≤ 70 for each dysautonomia measure. If a significant association was identified, a likelihood-ratio test was employed to evaluate whether a significant interaction existed between the measure and cohort. If so, regression analysis was repeated stratified by cohort. RESULTS Median follow-up was 30 months. On multivariable analysis, gastrointestinal and female sexual dysfunction subscales were associated with increased risk of phenoconversion, while the cardiovascular subscale and neurogenic orthostatic hypotension were associated with increased risk of SE-ADL ≤ 70; respective hazard ratios (95% confidence intervals) were 1.13 (1.01-1.27), 3.26 (1.39-7.61), 1.87 (1.16-2.99), 5.45 (1.40-21.25). Only the association between the cardiovascular subscale and SE-ADL ≤ 70 was modified by cohort. CONCLUSIONS Symptoms of gastrointestinal and female sexual dysfunction predict phenoconversion in individuals with other risk markers for PD, while signs and symptoms of cardiovascular dysfunction may be associated with functional decline.
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Affiliation(s)
- Cameron Miller-Patterson
- Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, 3900 Woodland Ave., Philadelphia, PA, 19104, USA.
| | - Jesse Y Hsu
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Lana M Chahine
- Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - James F Morley
- Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Allison W Willis
- Department of Epidemiology and Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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17
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Dember LM, Hung A, Mehrotra R, Hsu JY, Raj DS, Charytan DM, Mc Causland FR, Regunathan-Shenk R, Landis JR, Kimmel PL, Kliger AS, Himmelfarb J, Ikizler TA. A randomized controlled pilot trial of anakinra for hemodialysis inflammation. Kidney Int 2022; 102:1178-1187. [PMID: 35863559 PMCID: PMC9588554 DOI: 10.1016/j.kint.2022.06.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 06/02/2022] [Accepted: 06/10/2022] [Indexed: 12/14/2022]
Abstract
Chronic inflammation is highly prevalent among patients receiving maintenance hemodialysis and is associated with morbidity and mortality. Inhibiting inflammation with anti-cytokine therapy has been proposed but not well studied in this population. Therefore, we conducted the ACTION trial, a pilot, multicenter, randomized, placebo-controlled trial of an IL-1 receptor antagonist, anakinra, to evaluate safety, tolerability, and feasibility, and explore efficacy. Eighty hemodialysis patients with plasma concentrations of high sensitivity C-reactive protein (hsCRP) 2 mg/L and above were randomized 1:1 to placebo or anakinra 100 mg, three times per week via the hemodialysis circuit for 24 weeks, with an additional 24 weeks of post-treatment safety monitoring. Efficacy outcomes included changes in hsCRP (primary), cytokines, and patient-reported outcomes. Rates of serious adverse events and deaths were similar with anakinra and placebo (serious adverse events: 2.71 vs 2.74 events/patient-year; deaths: 0.12 vs 0.22 events/patient-year). The rate of adverse events of interest (including infections and cytopenias) was significantly lower with anakinra than placebo (0.48 vs 1.40 events/patient-year). Feasibility was demonstrated by attaining the enrollment target, a retention rate of 80%, and administration of 72% of doses. The median decrease in hsCRP from baseline to Week 24 was 41% in the anakinra group and 6% in the placebo group, a between-group difference that was not statistically significant. For IL-6, the median decreases were significant: 25% and 0% in the anakinra and placebo groups, respectively. An effect of anakinra on patient-reported outcomes was not evident. Thus, anakinra was well tolerated and did not increase infections or cytopenias. The promising safety data and potential efficacy on CRP and IL-6 provide support for conducting definitive trials of IL-1 inhibition to improve outcomes in hemodialysis patients.
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Affiliation(s)
- Laura M Dember
- Renal, Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Adriana Hung
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Vanderbilt O'Brien Kidney Center, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Veterans Affairs, Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - Rajnish Mehrotra
- Kidney Research Institute, Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington, USA; Division of Nephrology, Department of Medicine, Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | - Jesse Y Hsu
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Dominic S Raj
- Division of Renal Diseases and Hypertension, George Washington University School of Medicine, Washington, DC, USA
| | - David M Charytan
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Finnian R Mc Causland
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA
| | - Renu Regunathan-Shenk
- Division of Renal Diseases and Hypertension, George Washington University School of Medicine, Washington, DC, USA
| | - J Richard Landis
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Paul L Kimmel
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Alan S Kliger
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA; Yale New Haven Health System, New Haven, Connecticut, USA
| | - Jonathan Himmelfarb
- Kidney Research Institute, Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington, USA.
| | - T Alp Ikizler
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Vanderbilt O'Brien Kidney Center, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Veterans Affairs, Tennessee Valley Healthcare System, Nashville, Tennessee, USA.
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18
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McAuliffe PB, Desai AA, Talwar AA, Broach RB, Hsu JY, Serletti JM, Liu T, Tong Y, Udupa JK, Torigian DA, Fischer JP. Preoperative Computed Tomography Morphological Features Indicative of Incisional Hernia Formation After Abdominal Surgery. Ann Surg 2022; 276:616-625. [PMID: 35837959 PMCID: PMC9484790 DOI: 10.1097/sla.0000000000005583] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To investigate key morphometric features identifiable on routine preoperative computed tomography (CT) imaging indicative of incisional hernia (IH) formation following abdominal surgery. BACKGROUND IH is a pervasive surgical disease that impacts all surgical disciplines operating in the abdominopelvic region and affecting 13% of patients undergoing abdominal surgery. Despite the significant costs and disability associated with IH, there is an incomplete understanding of the pathophysiology of hernia. METHODS A cohort of patients (n=21,501) that underwent colorectal surgery was identified, and clinical data and demographics were extracted, with a primary outcome of IH. Two datasets of case-control matched pairs were created for feature measurement, classification, and testing. Morphometric linear and volumetric measurements were extracted as features from anonymized preoperative abdominopelvic CT scans. Multivariate Pearson testing was performed to assess correlations among features. Each feature's ability to discriminate between classes was evaluated using 2-sided paired t testing. A support vector machine was implemented to determine the predictive accuracy of the features individually and in combination. RESULTS Two hundred and twelve patients were analyzed (106 matched pairs). Of 117 features measured, 21 features were capable of discriminating between IH and non-IH patients. These features are categorized into three key pathophysiologic domains: 1) structural widening of the rectus complex, 2) increased visceral volume, 3) atrophy of abdominopelvic skeletal muscle. Individual prediction accuracy ranged from 0.69 to 0.78 for the top 3 features among 117. CONCLUSIONS Three morphometric domains identifiable on routine preoperative CT imaging were associated with hernia: widening of the rectus complex, increased visceral volume, and body wall skeletal muscle atrophy. This work highlights an innovative pathophysiologic mechanism for IH formation hallmarked by increased intra-abdominal pressure and compromise of the rectus complex and abdominopelvic skeletal musculature.
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Affiliation(s)
- Phoebe B McAuliffe
- Division of Plastic Surgery, University of Pennsylvania, Philadelphia, PA
| | - Abhishek A Desai
- Division of Plastic Surgery, University of Pennsylvania, Philadelphia, PA
| | - Ankoor A Talwar
- Division of Plastic Surgery, University of Pennsylvania, Philadelphia, PA
| | - Robyn B Broach
- Division of Plastic Surgery, University of Pennsylvania, Philadelphia, PA
| | - Jesse Y Hsu
- Division of Biostatistics, Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA
| | - Joseph M Serletti
- Division of Plastic Surgery, University of Pennsylvania, Philadelphia, PA
| | - Tiange Liu
- School of Information Science and Engineering, Yanshan University, Qinhuangdao, China
| | - Yubing Tong
- Medical Image Processing Group, Department of Radiology, University of Pennsylvania, Philadelphia, PA
| | - Jayaram K Udupa
- Medical Image Processing Group, Department of Radiology, University of Pennsylvania, Philadelphia, PA
| | - Drew A Torigian
- Medical Image Processing Group, Department of Radiology, University of Pennsylvania, Philadelphia, PA
| | - John P Fischer
- Division of Plastic Surgery, University of Pennsylvania, Philadelphia, PA
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McCoy IE, Hsu JY, Bonventre JV, Parikh CR, Go AS, Liu KD, Ricardo AC, Srivastava A, Cohen DL, He J, Chen J, Rao PS, Muiru AN, Hsu CY. Absence of long-term changes in urine biomarkers after AKI: findings from the CRIC study. BMC Nephrol 2022; 23:311. [PMID: 36100915 PMCID: PMC9472364 DOI: 10.1186/s12882-022-02937-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Accepted: 08/31/2022] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Mechanisms by which AKI leads to CKD progression remain unclear. Several urine biomarkers have been identified as independent predictors of progressive CKD. It is unknown whether AKI may result in long-term changes in these urine biomarkers, which may mediate the effect of AKI on CKD progression. METHODS We selected 198 episodes of hospitalized AKI (defined as peak/nadir inpatient serum creatinine values ≥ 1.5) among adult participants in the Chronic Renal Insufficiency Cohort (CRIC) Study. We matched the best non-AKI hospitalization (unique patients) for each AKI hospitalization using pre-hospitalization characteristics including eGFR and urine protein/creatinine ratio. Biomarkers were measured in banked urine samples collected at annual CRIC study visits. RESULTS Urine biomarker measurements occurred a median of 7 months before and 5 months after hospitalization. There were no significant differences in the change in urine biomarker-to-creatinine ratio between the AKI and non-AKI groups: KIM-1/Cr + 9% vs + 7%, MCP-1/Cr + 4% vs + 1%, YKL-40/Cr + 7% vs -20%, EGF/Cr -11% vs -8%, UMOD/Cr -2% vs -7% and albumin/Cr + 17% vs + 13% (all p > 0.05). CONCLUSION In this cohort of adults with CKD, AKI did not associate with long-term changes in urine biomarkers.
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Affiliation(s)
- Ian E McCoy
- Division of Nephrology, University of California San Francisco, Box 0532, 500 Parnassus Ave., MUW418, 94143-0532, San Francisco, CA, USA.
| | - Jesse Y Hsu
- Division of Biostatistics, University of Pennsylvania, Philadelphia, PA, USA
| | - Joseph V Bonventre
- Division of Renal Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Chirag R Parikh
- Division of Nephrology, Johns Hopkins University, Baltimore, MD, USA
| | - Alan S Go
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Kathleen D Liu
- Division of Nephrology, University of California San Francisco, Box 0532, 500 Parnassus Ave., MUW418, 94143-0532, San Francisco, CA, USA
| | - Ana C Ricardo
- Division of Nephrology, University of Illinois, Chicago, IL, USA
| | - Anand Srivastava
- Division of Nephrology and Hypertension, Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Debbie L Cohen
- Division of Nephrology, University of Pennsylvania, Philadelphia, PA, USA
| | - Jiang He
- Department of Epidemiology, Tulane University, New Orleans, Louisiana, USA
| | - Jing Chen
- Department of Epidemiology, Tulane University, New Orleans, Louisiana, USA
- Division of Nephrology, Tulane University, New Orleans, Louisiana, USA
| | - Panduranga S Rao
- Division of Nephrology, University of Michigan, Ann Arbor, MI, USA
| | - Anthony N Muiru
- Division of Nephrology, University of California San Francisco, Box 0532, 500 Parnassus Ave., MUW418, 94143-0532, San Francisco, CA, USA
| | - Chi-Yuan Hsu
- Division of Nephrology, University of California San Francisco, Box 0532, 500 Parnassus Ave., MUW418, 94143-0532, San Francisco, CA, USA
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
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20
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Kellier DJ, de Prado BM, Haagen D, Grabner P, Raj N, Lechtenberg L, Velasquez G, Hsu JY, Farrar JT, Hershey AD, Szperka CL. Development of a text message-based headache diary in adolescents and children. Cephalalgia 2022; 42:1013-1021. [PMID: 35400198 PMCID: PMC10120392 DOI: 10.1177/03331024221090206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND International guidelines recommend diaries in migraine trials for prospective collection of headache symptoms. Studies in other patient populations suggest higher adherence with electronic diaries instead of pen-and-paper. This study examines the feasibility of a text message-based (texting) diary for children and adolescents with headache. METHODS This is a secondary analysis of data from a study validating a pediatric scale of treatment expectancy. We developed a Health Insurance Portability and Accountability Act-compliant texting diary collecting headache characteristics, medication use, and disability with 3-5 core daily questions for 4 or 12 weeks depending on headache treatment. Adherence was incentivized. RESULTS 93 participants consented to the expectancy study. Five participants opted for a paper diary for follow-up. 88 participants chose the texting diary with 28 4-week and 60 12-week participants. Five participants did not complete the enrollment visit. Of those remaining 83, 89% of 4-week and 93% of 12-week participants responded on at least 80% of days. On average, participants fully completed 88% (4-week cohort) and 90% (12-week) of diary entries. CONCLUSIONS Text messages are a promising method for collecting patient-reported data. Adherence was similar to that reported for paper diaries in other pediatric migraine trials, but time-stamped entries ensure real-time data collection.
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Affiliation(s)
- Danielle J. Kellier
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | | | - Dana Haagen
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | | | - Nichelle Raj
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Lara Lechtenberg
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Gerardo Velasquez
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jesse Y. Hsu
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - John T. Farrar
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Andrew D. Hershey
- Cincinnati Children’s Hospital, Cincinnati, Ohio, USA
- University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Christina L. Szperka
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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21
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Rios-Diaz AJ, Morris MP, Christopher AN, Patel V, Broach RB, Heniford BT, Hsu JY, Fischer JP. National epidemiologic trends (2008-2018) in the United States for the incidence and expenditures associated with incisional hernia in relation to abdominal surgery. Hernia 2022; 26:1355-1368. [PMID: 36006563 DOI: 10.1007/s10029-022-02644-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 06/04/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE It is unknown whether the trend of rising incisional hernia (IH) repair (IHR) incidence and costs until 2011 currently persists. We aimed to evaluate how the IHR procedure incidence, cost and patient risk-profile have changed over the last decade relative to all abdominal surgeries (AS). METHODS Repeated cross-sectional analysis of 38,512,737 patients undergoing inpatient 4AS including IHR within the 2008-2018 National Inpatient Sample. Yearly incidence (procedures/1,000,000 people [PMP]), hospital costs, surgical and patient characteristics were compared between IHR and AS using generalized linear and multinomial regression. RESULTS Between 2008-2018, 3.1% of AS were IHR (1,200,568/38,512,737). There was a steeper decrease in the incidence of AS (356.5 PMP/year) compared to IHR procedures (12.0 PMP/year) which resulted in the IHR burden relative to AS (2008-2018: 12,576.3 to 9,113.4 PMP; trend difference P < 0.01). National costs averaged $47.9 and 1.7 billion/year for AS and IHR, respectively. From 2008-2018, procedure costs increased significantly for AS (68.2%) and IHR (74.6%; trends P < 0.01). Open IHR downtrended (42.2%), whereas laparoscopic (511.1%) and robotic (19,301%) uptrended significantly (trends P < 0.01). For both AS and IHR, the proportion of older (65-85y), Black and Hispanic, publicly-insured, and low-income patients, with higher comorbidity burden, undergoing elective procedures at small- and medium-sized hospitals uptrended significantly (all P < 0.01). CONCLUSION IH persists as a healthcare burden as demonstrated by the increased proportion of IHR relative to all AS, disproportionate presence of high-risk patients that undergo these procedures, and increased costs. Targeted efforts for IH prevention have the potential of decreasing $17 M/year in costs for every 1% reduction.
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Affiliation(s)
- A J Rios-Diaz
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, 51 North 39th Street, Wright Saunders Building, Philadelphia, PA, 19104, USA
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - M P Morris
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, 51 North 39th Street, Wright Saunders Building, Philadelphia, PA, 19104, USA
| | - A N Christopher
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, 51 North 39th Street, Wright Saunders Building, Philadelphia, PA, 19104, USA
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - V Patel
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, 51 North 39th Street, Wright Saunders Building, Philadelphia, PA, 19104, USA
| | - R B Broach
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, 51 North 39th Street, Wright Saunders Building, Philadelphia, PA, 19104, USA
| | - B T Heniford
- Division of Gastrointestinal and Minimally Invasive Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - J Y Hsu
- Center for Clinical Epidemiology and Biostatistics (CCEB), University of Pennsylvania, Philadelphia, PA, USA
| | - J P Fischer
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, 51 North 39th Street, Wright Saunders Building, Philadelphia, PA, 19104, USA.
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22
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Rios-Diaz AJ, Cunning JR, Talwar AA, Christopher A, Broach RB, Hsu JY, Morris JB, Fischer JP. Reoperation Through a Prosthetic-Reinforced Abdominal Wall and Its Association With Postoperative Outcomes and Longitudinal Health Care Utilization. JAMA Surg 2022; 157:908-916. [PMID: 35921101 PMCID: PMC9350843 DOI: 10.1001/jamasurg.2022.3320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Prosthetic reinforcement of critically sized incisional hernias is necessary to decrease hernia recurrence, but long-term prosthetic-mesh footprint may increase complication risk during subsequent abdominal operations. Objective To investigate the association of prior incisional hernia repair with mesh (IHRWM) with postoperative outcomes and health care utilization after common abdominal operations. Design, Setting, and Participants This was a population-based, retrospective cohort study of patients undergoing inpatient abdominal surgical procedures during the period of January 2009 to December 2016, with at least 1 year of follow-up within 5 geographically diverse statewide inpatient/ambulatory databases (Florida, Iowa, Nebraska, New York, Utah). History of an abdominal operation was ascertained within the 3-year period preceding the index operation. Patients admitted to the hospital with a history of an abdominal operation (ie, bariatric, cholecystectomy, small- or large-bowel resection, prostatectomy, gynecologic) were identified using the International Classification of Diseases, Ninth Revision and Tenth Revision, Clinical Modification procedure codes. Patients with prior IHRWM were propensity score matched (1:1) to controls both with and without a history of an abdominal surgical procedure based on clinical and operative characteristics. Data analysis was conducted from March 1 to November 27, 2021. Main Outcomes and Measures The primary outcome was a composite of adverse postoperative outcomes (surgical and nonsurgical). Secondary outcomes included health care utilization determined by length of hospital stay, hospital charges, and 1-year readmissions. Logistic and Cox regression determined the association of prior IHRWM with the outcomes of interest. Additional subanalyses matched and compared patients with prior IHR without mesh (IHRWOM) to those with a history of an abdominal operation. Results Of the 914 105 patients undergoing common abdominal surgical procedures (81 123 bariatric [8.9%], 284 450 small- or large-bowel resection [31.1%], 223 768 cholecystectomy [24.5%], 33 183 prostatectomy [3.6%], and 291 581 gynecologic [31.9%]), all 3517 patients (age group: 46-55 years, 1547 [44.0%]; 2396 majority sex [68.1%]) with prior IHRWM were matched to patients without a history of abdominal surgical procedures. After matching, prior IHRWM was associated with increased overall complications (odds ratio [OR], 1.43; 95% CI, 1.27-1.60), surgical complications (OR, 1.51; 95% CI, 1.34-1.70), length of hospital stay (mean increase of 1.03 days; 95% CI, 0.56-1.49 days; P < .001), index admission charges (predicted mean difference of $11 896.10; 95% CI, $6096.80-$17 695.40; P < .001), and 1-year unplanned readmissions (hazard ratio, 1.14; 95% CI, 1.05-1.25; P = .002). This trend persisted even when comparing matched patients with prior IHRWM to patients with a history of abdominal surgical procedures, and the treatment outcome disappeared when comparing patients with prior IHRWOM to those without a previous abdominal operation. Conclusions and Relevance Reoperation through a previously prosthetic-reinforced abdominal wall was associated with increased surgical complications and health care utilization. This risk appeared to be independent of a history of abdominal surgical procedures and was magnified by the presence of a prosthetic-mesh footprint in the abdominal wall.
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Affiliation(s)
- Arturo J Rios-Diaz
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia.,Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Jessica R Cunning
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Ankoor A Talwar
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Adrienne Christopher
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia.,Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Robyn B Broach
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Jesse Y Hsu
- Division of Biostatistics, Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia
| | - Jon B Morris
- Division of Gastrointestinal Surgery, Department of Surgery, University of Pennsylvania, Philadelphia
| | - John P Fischer
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia
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23
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Foglia EE, Weinberg DD, te Pas AB, Dekker J, Hsu JY. Reliability of respiratory function monitor interpretation for neonatal resuscitation. Arch Dis Child Fetal Neonatal Ed 2022; 108:321-322. [PMID: 35835540 PMCID: PMC9844082 DOI: 10.1136/archdischild-2022-324369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/28/2022] [Indexed: 01/19/2023]
Affiliation(s)
- Elizabeth E. Foglia
- Division of Neonatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA USA
| | - Danielle D. Weinberg
- Division of Neonatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA USA
| | - Arjan B. te Pas
- Department of Pediatrics, Leiden University Medical Center, Leiden, the Netherlands
| | - Janneke Dekker
- Department of Pediatrics, Leiden University Medical Center, Leiden, the Netherlands
| | - Jesse Y. Hsu
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA USA
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Miller-Patterson C, Hsu JY, Chahine LM. Early Autonomic Symptoms Predict Functional Decline in Parkinson's Disease Independent of Dopaminergic Therapy. NEURODEGENER DIS 2022; 22:15-23. [PMID: 35785765 DOI: 10.1159/000525664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 06/13/2022] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Parkinson's disease (PD) has variable progression; identifying determinants of functional decline in PD is needed for accurate prognostication. Autonomic symptoms can result from dopaminergic therapy, but may also independently predict functional decline. METHODS The sample included individuals with newly-diagnosed PD in Parkinson's Progression Markers Initiative. Autonomic symptoms were measured with the Scales-for-Outcomes-in-Parkinson's-Disease-Autonomic (SCOPA-AUT). Presence/absence of autonomic symptoms for SCOPA-AUT total scale and seven subscales was defined and baseline demographic/clinical data were compared between groups with and without autonomic symptoms. Time-to-functional-dependence, or Schwab-and-England Activities-of-Daily-Living (SE-ADL) ≤70, was compared between groups using hazard models, adjusting for covariates including time-varying levodopa-equivalent daily dosage (LEDD). If a subscale was associated with a significant subhazard ratio (SHR), hazard models for items in that subscale were generated and gender was evaluated as an effect modifier. RESULTS 399 participants were included. Over a median of 72 months (range 6-84), 91 (22.81%) reached SE-ADL≤70. SCOPA-AUT total/gastrointestinal/urinary/pupillomotor scales were associated with SE-ADL≤70; respective multivariable SHRs (95% CI, p-value) were 1.98 (1.06-3.70, .03), 1.71 (1.04-2.81, .03), 1.94 (1.25-3.01, <.01), 2.56 (1.24-5.31, .01). Individual items in the gastrointestinal and urinary scales drove associations. Urinary scale associations were seen in males only. CONCLUSIONS Symptoms of gastrointestinal, urinary, pupillomotor dysfunction are associated with functional decline risk in PD, independent of dopaminergic therapy. Detailed assessments of autonomic symptomatology should be utilized in studies attempting to refine predictive models of PD progression.
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Affiliation(s)
- Cameron Miller-Patterson
- Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jesse Y Hsu
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lana M Chahine
- Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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McCoy IE, Hsu JY, Bonventre JV, Parikh CR, Go AS, Liu KD, Ricardo AC, Srivastava A, Cohen DL, He J, Chen J, Rao PS, Hsu CY. Acute Kidney Injury Associates with Long-Term Increases in Plasma TNFR1, TNFR2, and KIM-1: Findings from the CRIC Study. J Am Soc Nephrol 2022; 33:1173-1181. [PMID: 35296554 PMCID: PMC9161789 DOI: 10.1681/asn.2021111453] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 02/28/2022] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Some markers of inflammation-TNF receptors 1 and 2 (TNFR1 and TNFR2)-are independently associated with progressive CKD, as is a marker of proximal tubule injury, kidney injury molecule 1 (KIM-1). However, whether an episode of hospitalized AKI may cause long-term changes in these biomarkers is unknown. METHODS Among adult participants in the Chronic Renal Insufficiency Cohort (CRIC) study, we identified 198 episodes of hospitalized AKI (defined as peak/nadir inpatient serum creatinine values ≥1.5). For each AKI hospitalization, we found the best matched non-AKI hospitalization (unique patients), using prehospitalization characteristics, including eGFR and urine protein/creatinine ratio. We measured TNFR1, TNFR2, and KIM-1 in banked plasma samples collected at annual CRIC study visits before and after the hospitalization (a median of 7 months before and 5 months after hospitalization). RESULTS In the AKI and non-AKI groups, we found similar prehospitalization median levels of TNFR1 (1373 pg/ml versus 1371 pg/ml, for AKI and non-AKI, respectively), TNFR2 (47,141 pg/ml versus 46,135 pg/ml, respectively), and KIM-1 (857 pg/ml versus 719 pg/ml, respectively). Compared with matched study participants who did not experience AKI, study participants who did experience AKI had greater increases in TNFR1 (23% versus 10%, P<0.01), TNFR2 (10% versus 3%, P<0.01), and KIM-1 (13% versus -2%, P<0.01). CONCLUSIONS Among patients with CKD, AKI during hospitalization was associated with increases in plasma TNFR1, TNFR2, and KIM-1 several months after their hospitalization. These results highlight a potential mechanism by which AKI may contribute to more rapid loss of kidney function months to years after the acute insult.
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Affiliation(s)
- Ian E McCoy
- Division of Nephrology, University of California San Francisco, San Francisco, California
| | - Jesse Y Hsu
- Division of Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joseph V Bonventre
- Division of Renal Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Chirag R Parikh
- Division of Nephrology, Johns Hopkins University, Baltimore, Maryland
| | - Alan S Go
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Kathleen D Liu
- Division of Nephrology, University of California San Francisco, San Francisco, California
| | - Ana C Ricardo
- Division of Nephrology, University of Illinois, Chicago, Illinois
| | - Anand Srivastava
- Division of Nephrology, Northwestern University, Chicago, Illinois
| | - Debbie L Cohen
- Division of Nephrology and Hypertension, Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jiang He
- Department of Epidemiology, Tulane University, New Orleans, Louisiana
| | - Jing Chen
- Department of Epidemiology, Tulane University, New Orleans, Louisiana
- Division of Nephrology, Tulane University, New Orleans, Louisiana
| | - Panduranga S Rao
- Division of Nephrology, University of Michigan, Ann Arbor, Michigan
| | - Chi-Yuan Hsu
- Division of Nephrology, University of California San Francisco, San Francisco, California
- Division of Research, Kaiser Permanente Northern California, Oakland, California
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McAuliffe PB, Hsu JY, Broach RB, Borovskiy Y, Christopher AN, Morris MP, Fischer JP. Systematic variable reduction for simplification of incisional hernia risk prediction instruments. Am J Surg 2022; 224:576-583. [DOI: 10.1016/j.amjsurg.2022.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 02/14/2022] [Accepted: 03/01/2022] [Indexed: 11/29/2022]
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Fujii N, Hamano T, Hsu JY, Imai E, Akizawa T, Nitta K, Watanabe T, Iimuro S, Ohashi Y, Matsuo S, Makino H, Hishida A, Alper AB, Horwitz EJ, Hsu CY, Porter AC, Wolf M, Yang W, Nessel L, Feldman HI. A Comparative Study of Serum Phosphate and Related Parameters in Chronic Kidney Disease between the USA and Japan. Am J Nephrol 2022; 53:226-239. [PMID: 35226897 PMCID: PMC9210453 DOI: 10.1159/000521386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 11/29/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Recent studies have suggested a higher incidence of cardiovascular disease (CVD) among patients with chronic kidney disease (CKD) in the USA than in Japan. Hyperphosphatemia, a possible risk for CVD, may explain this difference; however, international differences in phosphate parameters in CKD have not been well elaborated. METHODS By using the baseline data from the USA and the Japanese nation-wide, multicenter, CKD cohort studies; the Chronic Renal Insufficiency Cohort Study (CRIC, N = 3,870) and the Chronic Kidney Disease-Japan Cohort Study (CKD-JAC, N = 2,632), we harmonized the measures and compared clinical parameters regarding phosphate metabolism or serum phosphate, fibroblast growth factor-23 (FGF23), and parathyroid hormone (PTH), in the cross-sectional model. RESULTS Multivariable linear regression analyses revealed that serum phosphate levels were significantly higher in CRIC across all levels of estimated glomerular filtration rate (eGFR) with the greatest difference being observed at lower levels of eGFR. Serum FGF23 and 25-hydroxy vitamin D (25OHD) levels were higher in CRIC, while PTH levels were higher in CKD-JAC at all levels of eGFR. Adjustments for demographics, 25OHD, medications, dietary intake or urinary excretion of phosphate, PTH, and FGF23 did not eliminate the difference in serum phosphate levels between the cohorts (0.43, 0.46, 0.54, 0.64, and 0.78 mg/dL higher in CRIC within eGFR strata of >50, 41-50, 31-40, 21-30, and ≤20 mL/min/1.73 m2, respectively). These findings were consistent when only Asian CRIC participants (N = 105) were included in the analysis. CONCLUSION Serum phosphate levels in CRIC were significantly higher than those of CKD-JAC across all stages of CKD, which may shed light on the international variations in phosphate parameters and thus in cardiovascular risk among CKD patients. The key mechanisms for the substantial differences in phosphate parameters need to be elucidated.
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Affiliation(s)
- Naohiko Fujii
- Department of Nephrology, Hyogo Prefectural Nishinomiya Hospital, Nishinomiya, Japan,
| | - Takayuki Hamano
- Department of Nephrology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Jesse Y Hsu
- Department of Biostatistics and Epidemiology, Leonard Davis Institute of Health Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Enyu Imai
- Nakayamadera Imai Clinic, Takarazuka, Japan
| | - Tadao Akizawa
- Department of Nephrology, Showa University School of Medicine, Tokyo, Japan
| | - Kosaku Nitta
- Department of Nephrology, Tokyo Women's Medical University, Tokyo, Japan
| | - Tsuyoshi Watanabe
- Department of General Medicine, Tokyo-Kita Medical Center, Tokyo, Japan
| | - Satoshi Iimuro
- International University of Health and Welfare Graduate School of Public Health, Tokyo, Japan
| | - Yasuo Ohashi
- Department of Integrated Science and Engineering for Sustainable Society, Chuo University, Tokyo, Japan
| | - Seiichi Matsuo
- Department of Integrated Molecular Medicine, Nagoya University, Nagoya, Japan
| | - Hirofumi Makino
- University Hospital of Medicine and Dentistry, Okayama University, Okayama, Japan
| | - Akira Hishida
- Department of Nephrology, Yaizu City Hospital, Yaizu, Japan
| | - Arnold B Alper
- Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Edward J Horwitz
- Division of Nephrology, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Chi-Yuan Hsu
- Division of Nephrology, University of California, San Francisco, California, USA
| | - Anna C Porter
- Division of Nephrology, Department of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Myles Wolf
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Wei Yang
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lisa Nessel
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Harold I Feldman
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Toth-Manikowski SM, Hsu JY, Fischer MJ, Cohen JB, Lora CM, Tan TC, He J, Greer RC, Weir MR, Zhang X, Schrauben SJ, Saunders MR, Ricardo AC, Lash JP. Emergency Department/ Urgent Care as Usual Source of Care and Clinical Outcomes in CKD: Findings From the CRIC (Chronic Renal Insufficiency Cohort) Study. Kidney Med 2022; 4:100424. [PMID: 35372819 PMCID: PMC8971310 DOI: 10.1016/j.xkme.2022.100424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Rationale & Objective Having a usual source of care increases use of preventive services and is associated with improved survival in the general population. We evaluated this association in adults with chronic kidney disease (CKD). Study Design Prospective, observational cohort study. Setting & Participants Adults with CKD enrolled in the Chronic Renal Insufficiency Cohort (CRIC) Study. Predictor Usual source of care was self-reported as: 1) clinic, 2) emergency department (ED)/urgent care, 3) other. Outcomes Primary outcomes included incident end-stage kidney disease (ESKD), atherosclerotic events (myocardial infarction, stroke, or peripheral artery disease), incident heart failure, hospitalization events, and all-cause death. Analytical Approach Multivariable regression analyses to evaluate the association between usual source of care (ED/urgent care vs clinic) and primary outcomes. Results Among 3,140 participants, mean age was 65 years, 44% female, 45% non-Hispanic White, 43% non-Hispanic Black, and 9% Hispanic, mean estimated glomerular filtration rate 50 mL/min/1.73 m2. Approximately 90% identified clinic as usual source of care, 9% ED/urgent care, and 1% other. ED/urgent care reflected a more vulnerable population given lower baseline socioeconomic status, higher comorbid condition burden, and poorer blood pressure and glycemic control. Over a median follow-up time of 3.6 years, there were 181 incident end-stage kidney disease events, 264 atherosclerotic events, 263 incident heart failure events, 288 deaths, and 7,957 hospitalizations. Compared to clinic as usual source of care, ED/urgent care was associated with higher risk for all-cause death (HR, 1.53; 95% CI, 1.05-2.23) and hospitalizations (RR, 1.41; 95% CI, 1.32-1.51). Limitations Cannot be generalized to all patients with CKD. Causal relationships cannot be established. Conclusions In this large, diverse cohort of adults with moderate-to-severe CKD, those identifying ED/urgent care as usual source of care were at increased risk for death and hospitalizations. These findings highlight the need to develop strategies to improve health care access for this high-risk population.
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George MD, Hsu JY, Hennessy S, Chen L, Xie F, Curtis JR, Baker JF. Risk of Serious Infection With Low-dose Glucocorticoids in Patients With Rheumatoid Arthritis: An Instrumental Variable Analysis. Epidemiology 2022; 33:65-74. [PMID: 34561348 PMCID: PMC8633063 DOI: 10.1097/ede.0000000000001422] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Low-dose glucocorticoids are commonly used in the treatment of rheumatoid arthritis (RA). Observational studies have found an increased risk of serious infection associated with low-dose glucocorticoids, but concerns about residual confounding remain. METHODS We identified adults with RA on stable immunomodulatory therapy for >6 months receiving no glucocorticoids or ≤5 mg/day using Medicare data from 2006 to 2015. We used provider preference for glucocorticoids as an instrumental variable (IV) to assess associations between low-dose glucocorticoid use and the risk of infection requiring hospitalization using a cause-specific proportional hazards model. RESULTS We identified 163,603 qualifying treatment episodes among 120,656 patients. Glucocorticoids ≤5 mg/day were used by 25,373/81,802 (31.0%) of patients seen by a rheumatologist with low provider preference for glucocorticoids and by 36,087/81,801 (44.1%) of patients seen by a rheumatologist with high provider preference for glucocorticoids (adjusted odds ratio 1.81, 95% confidence interval 1.77, 1.84 for association between provider preference and glucocorticoids). Chronic obstructive pulmonary disease, opioids, antibiotics, previous emergency department visits, hospitalizations, and infections requiring hospitalization infections were unbalanced with regard to exposure but not to the IV. The incidence of infection requiring hospitalization was 8.0/100 person-years among patients unexposed to glucocorticoids versus 11.7/100 person-years among those exposed. The association between glucocorticoids and infection requiring hospitalization from IV analysis (hazard ratio 1.26 [1.02-1.56]) was similar to results from a standard multivariable model (hazard ratio 1.24 [1.21-1.28]). CONCLUSIONS Among patients with RA on stable immunomodulatory therapy, IV analysis based on provider preference demonstrated an increased risk of infection requiring hospitalization associated with low-dose glucocorticoids, similar to a traditional analysis.
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Affiliation(s)
- Michael D. George
- University of Pennsylvania, Division of Rheumatology, Philadelphia, Pennsylvania, UA
- University of Pennsylvania, Department of Biostatistics, Epidemiology, and Informatics, Philadelphia, Pennsylvania, UA
| | - Jesse Y. Hsu
- University of Pennsylvania, Department of Biostatistics, Epidemiology, and Informatics, Philadelphia, Pennsylvania, UA
| | - Sean Hennessy
- University of Pennsylvania, Department of Biostatistics, Epidemiology, and Informatics, Philadelphia, Pennsylvania, UA
| | - Lang Chen
- University of Alabama at Birmingham, Division of Clinical Immunology and Rheumatology, Birmingham, Alabama, UA
| | - Fenglong Xie
- University of Alabama at Birmingham, Division of Clinical Immunology and Rheumatology, Birmingham, Alabama, UA
| | - Jeffrey R. Curtis
- University of Alabama at Birmingham, Division of Clinical Immunology and Rheumatology, Birmingham, Alabama, UA
| | - Joshua F. Baker
- University of Pennsylvania, Division of Rheumatology, Philadelphia, Pennsylvania, UA
- University of Pennsylvania, Department of Biostatistics, Epidemiology, and Informatics, Philadelphia, Pennsylvania, UA
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Zebrowski AM, Hsu JY, Holena DN, Wiebe DJ, Carr BG. Developing a measure of overall intensity of injury care: A latent class analysis. J Trauma Acute Care Surg 2022; 92:193-200. [PMID: 34225349 PMCID: PMC8692337 DOI: 10.1097/ta.0000000000003321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND While injury is a leading cause of death and debility in older adults, the relationship between intensity of care and trauma remains unknown. The focus of this analysis is to measure the overall intensity of care delivered to injured older adults during hospitalization. METHODS We used Centers for Medicare and Medicaid Services Medicare fee-for-service claims data (2013-2014), to identify emergency department-based claims for moderate and severe blunt trauma in age-eligible beneficiaries. Medical procedures associated with care intensity were identified using a modified Delphi method. A latent class model was estimated using the identified procedures, intensive care unit length of stay, demographics, and injury characteristics. Clinical phenotypes for each class were explored. RESULTS A total of 683,398 cases were classified as low- (73%), moderate- (23%), and high-intensity care (4%). Greater age and reduced injury severity were indicators of lower intensity, while males, non-Whites, and nonfall mechanisms were more common with high intensity. Intubation/mechanical ventilation was an indicator of high intensity and often occurred with at least one other procedure or an extended intensive care unit stay. CONCLUSION This work demonstrates that, although heterogeneous, care for blunt trauma can be evaluated using a single novel measure. LEVEL OF EVIDENCE For prognostic/epidemiological studies, level III.
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Affiliation(s)
- Alexis M. Zebrowski
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Jesse Y. Hsu
- Department of Epidemiology, Biostatistics, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Daniel N. Holena
- Department of Epidemiology, Biostatistics, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, 19104, USA
- Department of Surgery, Division of Traumatology, Perelman School of Medicine, University of Pennsylvania
| | - Douglas J. Wiebe
- Department of Epidemiology, Biostatistics, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Brendan G. Carr
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, 19104, USA
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Morris MP, Christopher AN, Patel V, Mellia JA, Liu T, Hsu JY, Broach RB, Ungar LH, Fischer JP. Feasibility of Natural Language Processing in Surgery: Sensitivity and Specificity Compared to Manual Extraction. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.07.173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Rios-Diaz AJ, Morris MP, Christopher AN, Patel V, Broach RB, Hsu JY, Serletti JM, Fischer JP. Trends in Incisional Hernia Repair and Abdominal Surgery: A Nationwide Analysis of Hospitalization and Hospital Cost. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.08.191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Kaufmann TL, Getz KD, Hsu JY, Bennett AV, Takvorian SU, Kamal AH, DeMichele A. Identification of Patient-Reported Outcome Phenotypes Among Oncology Patients With Palliative Care Needs. JCO Oncol Pract 2021; 17:e1473-e1488. [PMID: 33760637 PMCID: PMC8791824 DOI: 10.1200/op.20.00849] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
PURPOSE Despite evidence-based guidelines recommending early palliative care, it remains unclear how to identify and refer oncology patients, particularly in settings with constrained access to palliative care. We hypothesize that patient-reported outcome (PRO) data can be used to characterize patients with palliative care needs. To determine if PRO data can identify latent phenotypes that characterize indications for specialty palliative care referral. METHODS We conducted a retrospective study of self-reported symptoms on the Edmonton Symptom Assessment System collected from solid tumor oncology patients (n = 745) referred to outpatient palliative care. Data were collected as part of routine clinical care from October 2012 to March 2018 at eight community and academic sites. We applied latent profile analysis to identify PRO phenotypes and examined the association of phenotypes with clinical and demographic characteristics using multinomial logistic regression. RESULTS We identified four PRO phenotypes: (1) Low Symptoms (n = 295, 39.6%), (2) Moderate Pain/Fatigue + Mood (n = 180, 24.2%), (3) Moderate Pain/Fatigue + Appetite + Dyspnea (n = 201, 27.0%), and (4) High Symptoms (n = 69, 9.3%). In a secondary analysis of 421 patients, we found that two brief items assessing social and existential needs aligned with higher severity symptom and psychological distress phenotypes. CONCLUSION Oncology patients referred to outpatient palliative care in a real-world setting can be differentiated into clinically meaningful phenotypes using brief, routinely collected PRO measures. Latent modeling provides a mechanism to use patient-reported data on a population level to identify distinct subgroups of patients with unmet palliative needs.
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Affiliation(s)
- Tara L. Kaufmann
- Division of Hematology and Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Penn Center for Cancer Care Innovation, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA,Livestrong Cancer Institutes, Dell Medical School, The University of Texas at Austin, Austin, TX,Tara L. Kaufmann, MD, MSCE, The University of Texas at Austin, Livestrong Cancer Institutes, Dell Medical School, 1601 Trinity St, Bldg B, Stop Z1100, Austin, TX 78712; e-mail:
| | - Kelly D. Getz
- Division of Hematology and Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,University of Pennsylvania, Philadelphia, PA,The Children's Hospital of Philadelphia, Philadelphia, PA
| | | | - Antonia V. Bennett
- Cancer Outcomes Research Program, Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC
| | - Samuel U. Takvorian
- Division of Hematology and Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Penn Center for Cancer Care Innovation, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | | | - Angela DeMichele
- Division of Hematology and Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Rios-Diaz AJ, Cunning J, Hsu JY, Elfanagely O, Marks JA, Grenda TR, Reilly PM, Broach RB, Fischer JP. Incidence, Burden on the Health Care System, and Factors Associated With Incisional Hernia After Trauma Laparotomy. JAMA Surg 2021; 156:e213104. [PMID: 34259810 DOI: 10.1001/jamasurg.2021.3104] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Importance The evidence provided supports routine and systematic capture of long-term outcomes after trauma, lengthening the follow-up for patients at risk for incisional hernia (IH) after trauma laparotomy (TL), counseling on the risk of IH during the postdischarge period, and consideration of preventive strategies before future abdominal operations to lessen IH prevalence as well as the patient and health care burden. Objective To determine burden of and factors associated with IH formation following TL at a population-based level across health care settings. Design, Setting, and Participants This population-based cohort study included adult patients who were admitted with traumatic injuries and underwent laparotomy with follow-up of 2 or more years. The study used 18 statewide databases containing data collected from January 2006 through December 2016 and corresponding to 6 states in diverse regions of the US. Longitudinal outcomes were identified within the Statewide Inpatient, Ambulatory, and Emergency Department Databases. Patients admitted with International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes for traumatic injuries with 1 or more concurrent open abdominal operations were included. Data analysis was conducted from March 2020 through June 2020. Main Outcomes and Measures The primary outcome was IH after TL. Risk-adjusted Cox regression allowed identification of patient-level, operative, and postoperative factors associated with IH. Results Of 35 666 patients undergoing TL, 3127 (8.8%) developed IH (median [interquartile range] follow-up, 5.6 [3.4-8.6] years). Patients had a median age of 49 (interquartile range, 31-67) years, and most were male (21 014 [58.9%]), White (21 584 [60.5%]), and admitted for nonpenetrating trauma (28 909 [81.1%]). The 10-year IH rate and annual incidence were 11.1% (95% CI, 10.7%-11.5%) and 15.6 (95% CI, 15.1-16.2) cases per 1000 people, respectively. Within risk-adjusted analyses, reoperation (adjusted hazard ratio [aHR], 1.28 [95% CI, 1.2-1.37]) and subsequent abdominal surgeries (aHR, 1.71 [95% CI, 1.56-1.88]), as well as obesity (aHR, 1.88 [95% CI, 1.69-2.10]), intestinal procedures (aHR, 1.47 [95% CI, 1.36-1.59]), and public insurance (aHRs: Medicare, 1.38 [95% CI, 1.20-1.57]; Medicaid, 1.35 [95% CI, 1.21-1.51]) were among the variables most strongly associated with IH. Every additional reoperation at the index admission and subsequently resulted in a 28% (95% CI, 20%-37%) and 71% (95% CI, 56%-88%) increased risk for IH, respectively. Repair of IH represented an additional $36.1 million in aggregate costs (39.9%) relative to all index TL admissions. Conclusions and Relevance Incisional hernia after TL mirrors the epidemiology and patient profile characteristics seen in the elective setting. We identified patient-level, perioperative, and novel postoperative factors associated with IH, with obesity, intestinal procedures, and repeated disruption of the abdominal wall among the factors most strongly associated with this outcome. These data support preemptive strategies at the time of reoperation to lessen IH incidence. Longer follow-up may be considered after TL for patients at high risk for IH.
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Affiliation(s)
- Arturo J Rios-Diaz
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia.,Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Jessica Cunning
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Jesse Y Hsu
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Pennsylvania
| | - Omar Elfanagely
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Joshua A Marks
- Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Tyler R Grenda
- Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Patrick M Reilly
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Robyn B Broach
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia
| | - John P Fischer
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia
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Srivastava A, Cai X, Mehta R, Lee J, Chu DI, Mills KT, Shafi T, Taliercio JJ, Hsu JY, Schrauben SJ, Saunders MR, Diamantidis CJ, Hsu CY, Waikar SS, Lash JP, Isakova T. Hospitalization Trajectories and Risks of ESKD and Death in Individuals With CKD. Kidney Int Rep 2021; 6:1592-1602. [PMID: 34169199 PMCID: PMC8207467 DOI: 10.1016/j.ekir.2021.03.883] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 02/10/2021] [Accepted: 03/08/2021] [Indexed: 01/13/2023] Open
Abstract
INTRODUCTION Management of chronic kidney disease (CKD) entails high medical complexity and often results in high hospitalization burden. There are limited data on the associations of longitudinal hospital utilization patterns with adverse clinical outcomes in individuals with CKD. METHODS We derived cumulative all-cause hospitalization trajectory groups using latent class trajectory analysis in 3012 participants of the Chronic Renal Insufficiency Cohort (CRIC) Study who were alive and did not reach end-stage kidney disease (ESKD) within 4 years of study entry. Cox proportional hazards models tested the associations between hospitalization trajectory groups and risks of ESKD and death prior to the onset of ESKD (ESKD-censored death). RESULTS Within 4 years of study entry, there were 5658 hospitalizations among 3012 participants. We identified 3 distinct subgroups of individuals with CKD based on cumulative all-cause hospitalization trajectories over 4 years: low-utilizer (n = 1066), intermediate-utilizer (n = 1802), and high-utilizer (n = 144). High-utilizers represented a patient population of lower socioeconomic status who had a greater prevalence of comorbid conditions and lower kidney function compared with intermediate- and low-utilizers. After the 4-year ascertainment period to form the trajectory subgroups, there were 544 ESKD events and 437 ESKD-censored deaths during a median follow-up time of 5.1 years. Compared with low-utilizers, intermediate-utilizers and high-utilizers were at 1.49-fold (95% confidence interval [CI] 1.22-1.84) and 1.75-fold (95% CI 1.20-2.56) higher risk of ESKD in adjusted analyses, respectively. Compared with low-utilizers, intermediate-utilizers and high-utilizers were at 1.48-fold (95% CI 1.17-1.87) and 2.58-fold (95% CI 1.74-3.83) higher risk of ESKD-censored death in adjusted analyses, respectively. CONCLUSIONS Trajectories of cumulative all-cause hospitalization identify subgroups of individuals with CKD who are at high risk of ESKD and death.
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Affiliation(s)
- Anand Srivastava
- Division of Nephrology and Hypertension, Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Xuan Cai
- Division of Nephrology and Hypertension, Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Rupal Mehta
- Division of Nephrology and Hypertension, Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jungwha Lee
- Division of Biostatistics, Department of Preventative Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - David I. Chu
- Division of Urology, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Katherine T. Mills
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, and Tulane University Translational Science Institute, New Orleans, Louisiana, USA
| | - Tariq Shafi
- Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Jonathan J. Taliercio
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jesse Y. Hsu
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sarah J. Schrauben
- Division of Renal-Electrolyte and Hypertension, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Pennsylvania, USA
| | - Milda R. Saunders
- General Internal Medicine, Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Clarissa J. Diamantidis
- Divisions of General Internal Medicine and Nephrology and Department of Population Health Science, Duke University School of Medicine, Durham, North Carolina, USA
| | - Chi-yuan Hsu
- Department of Medicine, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Sushrut S. Waikar
- Section of Nephrology, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, USA
| | - James P. Lash
- Division of Nephrology, Department of Medicine, University of Illinois Hospital and Health Sciences Center, University of Illinois College of Medicine, Chicago, Illinois, USA
| | - Tamara Isakova
- Division of Nephrology and Hypertension, Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Schrauben SJ, Hsu JY, Amaral S, Anderson AH, Feldman HI, Dember LM. Effect of Kidney Function on Relationships between Lifestyle Behaviors and Mortality or Cardiovascular Outcomes: A Pooled Cohort Analysis. J Am Soc Nephrol 2021; 32:663-675. [PMID: 33547215 PMCID: PMC7920187 DOI: 10.1681/asn.2020040394] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 11/12/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Adherence to healthy behaviors reduces risks of cardiovascular disease and death in the general population. However, among people with kidney disease, a group at higher risk for cardiovascular disease, such benefits have not been established. METHODS We pooled data from three cohort studies with a total of 27,271 participants. Kidney function was categorized on the basis of eGFR (≥60, 45 to <60, and <45 ml/min per 1.73 m2). We used proportional hazard frailty models to estimate associations between healthy behaviors (not smoking, at recommended body mass index [BMI], physical activity, healthy diet, and moderate to no alcohol intake) and outcomes (all-cause death, major coronary events, ischemic stroke, and heart failure events). RESULTS All recommended lifestyle behaviors were significantly associated with lower risks of death, regardless of eGFR. Not smoking (versus current) and any moderate to vigorous physical activity (versus none) was significantly associated with reduced risks of major coronary and heart failure events, regardless of eGFR. Any (versus no) moderate or vigorous physical activity significantly associated with decreased risk of ischemic stroke events only among those with eGFR ≥60. Moderate to no daily alcohol intake (versus excessive) was significantly associated with an increased risk of major coronary events, regardless of eGFR. For heart failure events, a BMI of 18.5 to 30 associated with decreased risk, regardless of eGFR. Across all eGFR categories, the magnitude of risk reduction for death and all cardiovascular outcomes increased with greater numbers of recommended lifestyle behaviors. CONCLUSIONS Recommended lifestyle behaviors are associated with lower risk of death and cardiovascular disease events among individuals with or without reduced kidney function, supporting lifestyle behaviors as potentially modifiable risk factors for people with kidney disease.
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Affiliation(s)
- Sarah J. Schrauben
- Renal, Electrolyte-Hypertension Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jesse Y. Hsu
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sandra Amaral
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania,Division of Nephrology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Amanda H. Anderson
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania,Department of Epidemiology, School of Public Health and Tropical Medicine, Tulane University, New Orleans, Louisiana
| | - Harold I. Feldman
- Renal, Electrolyte-Hypertension Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Laura M. Dember
- Renal, Electrolyte-Hypertension Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Raj DS, Sohn MB, Charytan DM, Himmelfarb J, Ikizler TA, Mehrotra R, Ramezani A, Regunathan-Shenk R, Hsu JY, Landis JR, Li H, Kimmel PL, Kliger AS, Dember LM. The Microbiome and p-Inulin in Hemodialysis: A Feasibility Study. Kidney360 2021; 2:445-455. [PMID: 35369018 PMCID: PMC8786005 DOI: 10.34067/kid.0006132020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 01/14/2021] [Indexed: 02/08/2023]
Abstract
Background The intestinal microbiome is an appealing target for interventions in ESKD because of its likely contribution to uremic toxicity. Before conducting clinical trials of microbiome-altering treatments, it is necessary to understand the within-person and between-person variability in the composition and function of the gut microbiome in patients with ESKD. Methods We conducted a multicenter, nonrandomized, crossover feasibility study of patients on maintenance hemodialysis consisting of three phases: pretreatment (8 weeks); treatment, during which the prebiotic, p-inulin, was administered at a dosage of 8 g twice daily (12 weeks); and post-treatment (8 weeks). Stool samples were collected 1-2 times per week and blood was collected weekly for 28 weeks. The gut microbiome was characterized using 16S ribosomal-RNA sequencing and metabolomic profiling. Results A total of 11 of the 13 participants completed the 28-week study. Interparticipant variability was greater than intraparticipant variability for microbiome composition (P<0.001 by UniFrac distances) and metabolomic composition (P<0.001 by Euclidean distances). p-Inulin was well tolerated by 12 of 13 participants. Adherence to the frequent sample collection and self-aliquoting of stool samples were both 96%. A change in the microbiome composition from pretreatment to post-treatment was evident by the overall shifts in weighted UniFrac distances (P=0.004) and a progressive decrease in prevalence of high intraclass correlations, indicating an increase in intraparticipant microbiome diversity during and after p-inulin treatment. An effect of p-inulin on the metabolomic profile was not evident. Conclusions The intraparticipant stability of the gut microbiome under no-treatment conditions, the tolerability of p-inulin, the signals of increased diversity of the microbiome with p-inulin treatment, and the willingness of participants to provide stool samples all support the feasibility of a larger trial to investigate interventions targeting the gut microbiome in patients with ESKD. Whether or not p-inulin has sufficient efficacy as an intervention requires evaluation in larger studies. Clinical Trial registry name and registration number Gut Microbiome and p-Inulin in Hemodialysis, NCT02572882.
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Affiliation(s)
- Dominic S. Raj
- Division of Renal Diseases and Hypertension, George Washington University School of Medicine, Washington, DC
| | - Michael B. Sohn
- Department of Biostatistics and Computational Biology, University of Rochester Medical Center, Rochester, New York
| | - David M. Charytan
- Division of Nephrology, Department of Medicine, New York University Grossman School of Medicine, New York, New York
| | - Jonathan Himmelfarb
- Division of Nephrology, Department of Medicine, Kidney Research Institute, University of Washington, Seattle, Washington
| | - T. Alp Ikizler
- Division of Nephrology and Hypertension, Department of Medicine, and Vanderbilt Center for Kidney Disease, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Rajnish Mehrotra
- Division of Nephrology, Department of Medicine, Kidney Research Institute and Harborview Medical Center, University of Washington, Seattle, Washington
| | - Ali Ramezani
- Division of Renal Diseases and Hypertension, George Washington University School of Medicine, Washington, DC
| | - Renu Regunathan-Shenk
- Division of Renal Diseases and Hypertension, George Washington University School of Medicine, Washington, DC
| | - Jesse Y. Hsu
- Department of Biostatistics, Epidemiology and Informatics, and Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - J. Richard Landis
- Department of Biostatistics, Epidemiology and Informatics, and Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Hongzhe Li
- Department of Biostatistics, Epidemiology and Informatics, and Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Paul L. Kimmel
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Alan S. Kliger
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Laura M. Dember
- Renal-Electrolyte and Hypertension Division, Department of Medicine, and Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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McCauley MD, Hsu JY, Ricardo AC, Darbar D, Kansal M, Kurella Tamura M, Feldman HI, Kusek JW, Taliercio JJ, Rao PS, Shafi T, He J, Wang X, Sha D, Lamar M, Go AS, Yaffe K, Lash JP. Atrial Fibrillation and Longitudinal Change in Cognitive Function in CKD. Kidney Int Rep 2021; 6:669-674. [PMID: 33732981 PMCID: PMC7938064 DOI: 10.1016/j.ekir.2020.12.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 12/11/2020] [Accepted: 12/22/2020] [Indexed: 11/01/2022] Open
Abstract
Background Studies in the general population suggest that atrial fibrillation (AF) is an independent risk factor for decline in cognitive function, but this relationship has not been examined in adults with chronic kidney disease (CKD). We investigated the association between incident AF and changes in cognitive function over time in this population. Methods and Results We studied a subgroup of 3254 adults participating in the Chronic Renal Insufficiency Cohort Study. Incident AF was ascertained by 12-lead electrocardiogram (ECG) obtained at a study visit and/or identification of a hospitalization with AF during follow-up. Cognitive function was assessed biennially using the Modified Mini-Mental State Exam. Linear mixed effects regression was used to evaluate the association between incident AF and longitudinal change in cognitive function. Compared with individuals without incident AF (n = 3158), those with incident AF (n = 96) were older, had a higher prevalence of cardiovascular disease and hypertension, and lower estimated glomerular filtration rate. After median follow-up of 6.8 years, we observed no significant multivariable association between incident AF and change in cognitive function test score. Conclusion In this cohort of adults with CKD, incident AF was not associated with a decline in cognitive function.
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Affiliation(s)
- Mark D McCauley
- Department of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA.,Jesse Brown VA Medical Center, Chicago, Illinois, USA
| | - Jesse Y Hsu
- Center for Clinical Epidemiology & Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ana C Ricardo
- Department of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Dawood Darbar
- Department of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA.,Jesse Brown VA Medical Center, Chicago, Illinois, USA
| | - Mayank Kansal
- Department of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA.,Jesse Brown VA Medical Center, Chicago, Illinois, USA
| | - Manjula Kurella Tamura
- Departments of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Philadelphia, Pennsylvania, USA.,Department of Medicine, Stanford University, Palo Alto, California, USA
| | - Harold I Feldman
- Center for Clinical Epidemiology & Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Departments of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Philadelphia, Pennsylvania, USA
| | - John W Kusek
- Center for Clinical Epidemiology & Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Departments of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Philadelphia, Pennsylvania, USA
| | | | - Panduranga S Rao
- Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Tariq Shafi
- Department of Medicine, University of Mississippi, Jackson, Mississippi, USA
| | - Jiang He
- Department of Epidemiology, Tulane School of Public Health and Tropical Medicine, New Orleans, Louisiana, USA
| | - Xue Wang
- Center for Clinical Epidemiology & Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Departments of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Philadelphia, Pennsylvania, USA
| | - Daohang Sha
- Center for Clinical Epidemiology & Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Melissa Lamar
- Rush Alzheimer's Disease Center and the Department of Psychiatry and Behavioral Sciences, Rush University, Chicago, Illinois, USA
| | - Alan S Go
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA.,Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA.,Department of Medicine, University of California, San Francisco, San Francisco, California, USA.,Departments of Medicine, Health Research and Policy, Stanford University, Stanford, California, USA
| | - Kristine Yaffe
- Departments of Psychiatry and Neurology, University of California, San Francisco, San Francisco, California, USA
| | - James P Lash
- Department of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
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Charytan DM, Hsu JY, Mc Causland FR, Waikar SS, Ikizler TA, Raj DS, Landis JR, Mehrotra R, Williams M, DiCarli M, Skali H, Kimmel PL, Kliger AS, Dember LM. Combination Hydralazine and Isosorbide Dinitrate in Dialysis-Dependent ESRD (HIDE): A Randomized, Placebo-Controlled, Pilot Trial. Kidney360 2020; 1:1380-1389. [PMID: 35372900 DOI: 10.34067/kid.0004342020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 10/05/2020] [Indexed: 11/27/2022]
Abstract
Background Combination therapy with isosorbide dinitrate (ISD) and hydralazine (HY) reduces heart failure mortality. The safety and tolerability in individuals requiring maintenance hemodialysis (HD) is unknown. Methods Single-center, randomized, placebo-controlled, double-blind pilot trial to explore safety and tolerability of ISD/HY in maintenance HD. Participants were randomized to placebo or combination ISD/HY. Dose was escalated over 3 weeks from ISD 10 mg/HY 10 mg to ISD 40 mg/HY 75 mg three times per day with the maximum tolerated dose maintained for the subsequent 21 weeks. Primary endpoints included adverse events, adverse events precluding further treatment with study medication, serious hypotension (i.e., requiring hospitalization or emergency room visit), and recurrent intra-dialytic hypotension. Efficacy signals included change in mitral annular E' velocity by tissue Doppler echocardiography and change in left ventricular coronary flow reserve on positron emission tomography. Results A total of 17 individuals were randomized to ISD/HY (N=7) or placebo (N=10). All participants assigned to ISD/HY completed dose escalation to 40/75 mg, but dose reductions were required in two participants. No participants discontinued therapy. There were no serious hypotension events. Recurrent intradialytic hypotension was less frequent with ISD/HY (0.47 events/patient-year) than placebo (1.83 events/patient-year, P=0.04). In contrast, nausea (ISD/HY, 1.90 events/patient-year; placebo, 0.50 events/patient-year, P=0.03) was significantly more frequent, and headache and diarrhea were numerically but not significantly more frequent with ISD/HY. Adverse events were more frequent with ISD/HY (11.4 events/patient-year) than placebo (6.31 events/patient-year). We did not detect between-group differences in the change in E' (P=0.34); ISD/HY showed a mean increase of 0.6 cm/s (SD 1.1), and placebo showed a mean decrease of 0.04 cm/s (SD 0.9). Changes in coronary flow reserve were minimal, -0.3 (0.2) with ISD/HY and -0.03 (0.5) in the placebo group, P=0.19. Conclusions ISD/HY appears to be well tolerated in patients being treated with maintenance HD, but headache and gastrointestinal side effects occur more frequently with ISD/HY compared with placebo.
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Affiliation(s)
- David M Charytan
- Division of Nephrology, Department of Medicine, New York University Grossman School of Medicine, New York, New York
| | - Jesse Y Hsu
- Department of Biostatistics, Epidemiology and Informatics, and Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Finnian R Mc Causland
- Renal Division, Department of Medicine, Harvard Medical School and Brigham and Women's Hospital, Boston, Massachusetts
| | - Sushrut S Waikar
- Renal Section, Department of Medicine, Boston University Medical Center, Boston, Massachusetts
| | - T Alp Ikizler
- Division of Nephrology and Hypertension, Department of Medicine, and Vanderbilt Center for Kidney Disease, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Dominic S Raj
- Division of Renal Diseases and Hypertension, George Washington University School of Medicine, Washington, DC
| | - J Richard Landis
- Department of Biostatistics, Epidemiology and Informatics, and Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rajnish Mehrotra
- Division of Nephrology, Department of Medicine, Kidney Research Institute, University of Washington, Seattle, Washington
| | - Mark Williams
- Renal Division, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Marcelo DiCarli
- Departments of Radiology and Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Hicham Skali
- Cardiovascular Division, Department of Medicine, Harvard Medical School and Brigham and Women's Hospital, Boston, Massachusetts
| | - Paul L Kimmel
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Alan S Kliger
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Laura M Dember
- Renal, Electrolyte and Hypertension Division, and Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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George MD, Baker JF, Winthrop K, Hsu JY, Wu Q, Chen L, Xie F, Yun H, Curtis JR. Risk for Serious Infection With Low-Dose Glucocorticoids in Patients With Rheumatoid Arthritis : A Cohort Study. Ann Intern Med 2020; 173:870-878. [PMID: 32956604 PMCID: PMC8073808 DOI: 10.7326/m20-1594] [Citation(s) in RCA: 80] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Low-dose glucocorticoids are frequently used for the management of rheumatoid arthritis (RA) and other chronic conditions, but the safety of long-term use remains uncertain. OBJECTIVE To quantify the risk for hospitalized infection with long-term use of low-dose glucocorticoids in patients with RA receiving stable disease-modifying antirheumatic drug (DMARD) therapy. DESIGN Retrospective cohort study. SETTING Medicare claims data and Optum's deidentified Clinformatics Data Mart database from 2006 to 2015. PATIENTS Adults with RA receiving a stable DMARD regimen for more than 6 months. MEASUREMENTS Associations between glucocorticoid dose (none, ≤5 mg/d, >5 to 10 mg/d, and >10 mg/d) and hospitalized infection were evaluated using inverse probability-weighted analyses, with 1-year cumulative incidence predicted from weighted models. RESULTS 247 297 observations were identified among 172 041 patients in Medicare and 58 279 observations among 44 118 patients in Optum. After 6 months of stable DMARD use, 47.1% of Medicare patients and 39.5% of Optum patients were receiving glucocorticoids. The 1-year cumulative incidence of hospitalized infection in Medicare patients not receiving glucocorticoids was 8.6% versus 11.0% (95% CI, 10.6% to 11.5%) for glucocorticoid dose of 5 mg or less per day, 14.4% (CI, 13.8% to 15.1%) for greater than 5 to 10 mg/d, and 17.7% (CI, 16.5% to 19.1%) for greater than 10 mg/d (all P < 0.001 vs. no glucocorticoids). The 1-year cumulative incidence of hospitalized infection in Optum patients not receiving glucocorticoids was 4.0% versus 5.2% (CI, 4.7% to 5.8%) for glucocorticoid dose of 5 mg or less per day, 8.1% (CI, 7.0% to 9.3%) for greater than 5 to 10 mg/d, and 10.6% (CI, 8.5% to 13.2%) for greater than 10 mg/d (all P < 0.001 vs. no glucocorticoids). LIMITATION Potential for residual confounding and misclassification of glucocorticoid dose. CONCLUSION In patients with RA receiving stable DMARD therapy, glucocorticoids were associated with a dose-dependent increase in the risk for serious infection, with small but significant risks even at doses of 5 mg or less per day. Clinicians should balance the benefits of low-dose glucocorticoids with this potential risk. PRIMARY FUNDING SOURCE National Institute of Arthritis and Musculoskeletal and Skin Diseases.
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Affiliation(s)
- Michael D George
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania (M.D.G., J.Y.H., Q.W.)
| | - Joshua F Baker
- University of Pennsylvania and Philadelphia Veterans Affairs Medical Center, Philadelphia, Pennsylvania (J.F.B.)
| | - Kevin Winthrop
- Oregon Health & Science University, Portland, Oregon (K.W.)
| | - Jesse Y Hsu
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania (M.D.G., J.Y.H., Q.W.)
| | - Qufei Wu
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania (M.D.G., J.Y.H., Q.W.)
| | - Lang Chen
- University of Alabama at Birmingham, Birmingham, Alabama (L.C., F.X., H.Y., J.R.C.)
| | - Fenglong Xie
- University of Alabama at Birmingham, Birmingham, Alabama (L.C., F.X., H.Y., J.R.C.)
| | - Huifeng Yun
- University of Alabama at Birmingham, Birmingham, Alabama (L.C., F.X., H.Y., J.R.C.)
| | - Jeffrey R Curtis
- University of Alabama at Birmingham, Birmingham, Alabama (L.C., F.X., H.Y., J.R.C.)
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Sonnenberg EM, Hsu JY, Reese PP, Goldberg D, Abt PL. Wide Variation in the Percentage of Donation After Circulatory Death Donors Across Donor Service Areas: A Potential Target for Improvement. Transplantation 2020; 104:1668-1674. [PMID: 32732846 PMCID: PMC7170761 DOI: 10.1097/tp.0000000000003019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Substantial differences exist in the clinical characteristics of donors across the 58 donor service areas (DSAs). Organ procurement organization (OPO) performance metrics incorporate organs donated after circulatory determination of death (DCDD) donors but do not measure potential DCDD donors. METHODS Using 2011-2016 United Network for Organ Sharing data, we examined the variability in DCDD donors/all deceased donors (%DCDD) across DSAs. We supplemented United Network for Organ Sharing data with CDC death records and OPO statistics to characterize underlying process and system factors that may correlate with donors and utilization. RESULTS Among 52 184 deceased donors, the %DCDD varied widely across DSAs, with a median of 15.1% (interquartile range [9.3%, 20.9%]; range 0.0%-32.0%). The %DCDD had a modest positive correlation with 4 DSA factors: median match model for end-stage liver disease, proportion of white deaths out of total deaths, kidney center competition, and %DCDD livers by a local transplant center (all Spearman coefficients 0.289-0.464), and negative correlation with 1 factor: mean kidney waiting time (Spearman coefficient -0.388). Adjusting for correlated variables in linear regression explained 46.3% of the variability in %DCDD. CONCLUSIONS Donor pool demographics, waitlist metrics, center competition, and DCDD utilization explain only a portion of the variability of DCDD donors. This requires further studies and policy changes to encourage consideration of all possible organ donors.
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Affiliation(s)
- Elizabeth M. Sonnenberg
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- National Clinician Scholars Program, University of Pennsylvania, Philadelphia, PA, USA
| | - Jesse Y. Hsu
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA
| | - Peter P. Reese
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA
- Division of Renal-Electrolyte and Hypertension, University of Pennsylvania, Philadelphia, PA, USA
| | - David Goldberg
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA
- Division of Gastroenterology, University of Pennsylvania, Philadelphia, PA, USA
| | - Peter L. Abt
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
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Saunders MR, Ricardo AC, Chen J, Anderson AH, Cedillo-Couvert EA, Fischer MJ, Hernandez-Rivera J, Hicken MT, Hsu JY, Zhang X, Hynes D, Jaar B, Kusek JW, Rao P, Feldman HI, Go AS, Lash JP. Neighborhood socioeconomic status and risk of hospitalization in patients with chronic kidney disease: A chronic renal insufficiency cohort study. Medicine (Baltimore) 2020; 99:e21028. [PMID: 32664108 PMCID: PMC7360239 DOI: 10.1097/md.0000000000021028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Patients with chronic kidney disease (CKD) experience significantly greater morbidity than the general population. The hospitalization rate for patients with CKD is significantly higher than the general population. The extent to which neighborhood-level socioeconomic status (SES) is associated with hospitalization has been less explored, both in the general population and among those with CKD.We evaluated the relationship between neighborhood SES and hospitalizations for adults with CKD participating in the Chronic Renal Insufficiency Cohort Study. Neighborhood SES quartiles were created utilizing a validated neighborhood-level SES summary measure expressed as z-scores for 6 census-derived variables. The relationship between neighborhood SES and hospitalizations was examined using Poisson regression models after adjusting for demographic characteristics, individual SES, lifestyle, and clinical factors while taking into account clustering within clinical centers and census block groups.Among 3291 participants with neighborhood SES data, mean age was 58 years, 55% were male, 41% non-Hispanic white, 49% had diabetes, and mean estimated glomerular filtration rate (eGFR) was 44 ml/min/1.73 m. In the fully adjusted model, compared to individuals in the highest SES neighborhood quartile, individuals in the lowest SES neighborhood quartile had higher risk for all-cause hospitalization (rate ratio [RR], 1.28, 95% CI, 1.09-1.51) and non-cardiovascular hospitalization (RR 1.30, 95% CI, 1.10-1.55). The association with cardiovascular hospitalization was in the same direction but not statistically significant (RR 1.21, 95% CI, 0.97-1.52).Neighborhood SES is associated with risk for hospitalization in individuals with CKD even after adjusting for individual SES, lifestyle, and clinical factors.
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Affiliation(s)
| | - Ana C. Ricardo
- Department of Medicine, University of Illinois at Chicago, Chicago, IL
| | - Jinsong Chen
- Department of Medicine, University of Illinois at Chicago, Chicago, IL
| | - Amanda H. Anderson
- Center for Clinical Epidemiology and Biostatistics
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | | | - Michael J. Fischer
- Department of Medicine, University of Illinois at Chicago, Chicago, IL
- Center of Innovation for Complex Chronic Healthcare, Jesse Brown VAMC, Chicago, IL
| | | | | | - Jesse Y. Hsu
- Center for Clinical Epidemiology and Biostatistics
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Xiaoming Zhang
- Center for Clinical Epidemiology and Biostatistics
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Denise Hynes
- Department of Medicine, University of Illinois at Chicago, Chicago, IL
- College of Public Health and Human Sciences, Oregon State University, and US Department of Veterans Affairs, Portland, OR
| | - Bernard Jaar
- Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - John W. Kusek
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
| | - Panduranga Rao
- Department of Medicine, University of Michigan, Ann Arbor, MI
| | - Harold I. Feldman
- Center for Clinical Epidemiology and Biostatistics
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Alan S. Go
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - James P. Lash
- Department of Medicine, University of Illinois at Chicago, Chicago, IL
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Saraf SL, Hsu JY, Ricardo AC, Mehta R, Chen J, Chen TK, Fischer MJ, Hamm L, Sondheimer J, Weir MR, Zhang X, Wolf M, Lash JP. Anemia and Incident End-Stage Kidney Disease. ACTA ACUST UNITED AC 2020; 1:623-630. [PMID: 33117990 DOI: 10.34067/kid.0000852020] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Background Chronic kidney disease (CKD) progression can be a cause and potentially a consequence of anemia. Previous studies suggesting that anemia is associated with CKD progression have not utilized methodologic approaches to address time-dependent confounding. Methods We evaluated the association of anemia (defined using World Health Organization criteria of hemoglobin <12 g/dL in women and <13 g/dL in men) with incident ESRD and all-cause death in individuals with CKD using data from the Chronic Renal Insufficiency Cohort Study. Marginal structural models were used to account for time-dependent confounding. Results Among 3919 participants, 1859 (47.4%) had anemia at baseline. Over median follow up of 7.8 years, we observed 1,010 ESRD events and 994 deaths. In multivariable analyses, individuals with anemia had higher risk for ESRD compared to those without (HR 1.62, 95% CI 1.24-2.11). In stratified analyses, the increased risk for incident ESRD with anemia was observed in males (HR 2.15, 95% CI: 1.53-3.02) but not females (HR 1.20, 95% CI 0.82-1.78. The association between anemia and ESRD was significant among all racial/ethnic groups except non-Hispanic blacks (non-Hispanic white, HR 2.16, 95% CI 1.53-3.06; Hispanic, HR 1.92, 1.04-3.51; others, HR 2.94; 95% CI 1.16-7.44; non-Hispanic black, HR 1.39; 95% CI 0.95-2.02). There was no association between anemia and all-cause death. Conclusions In this cohort, anemia was independently associated with increased risk for incident ESRD. Future work is needed to evaluate the mechanisms by which anemia leads to CKD progression as well as the impact of novel therapeutic agents to treat anemia.
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Affiliation(s)
- Santosh L Saraf
- Department of Medicine, University of Illinois at Chicago, Chicago, IL
| | - Jesse Y Hsu
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA
| | - Ana C Ricardo
- Department of Medicine, University of Illinois at Chicago, Chicago, IL
| | - Rupal Mehta
- Department of Medicine, Northwestern University, Chicago, IL.,Medical Service, Jesse Brown VA Medical Center, Chicago, Illinois
| | - Jing Chen
- Department of Medicine, Tulane University, New Orleans, LA
| | - Teresa K Chen
- Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Michael J Fischer
- Department of Medicine, University of Illinois at Chicago, Chicago, IL.,Medical Service, Jesse Brown VA Medical Center, Chicago, Illinois.,Research Service, Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr., VA Hospital, Hines, Illinois
| | - Lee Hamm
- Department of Medicine, Tulane University, New Orleans, LA
| | | | - Matthew R Weir
- Department of Medicine, University of Maryland, Baltimore, MD
| | - Xiaoming Zhang
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA
| | - Myles Wolf
- Division of Nephrology, Department of Medicine, and Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - James P Lash
- Department of Medicine, University of Illinois at Chicago, Chicago, IL
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Herrick HM, Lorch S, Hsu JY, Catchpole K, Foglia EE. Impact of flow disruptions in the delivery room. Resuscitation 2020; 150:29-35. [PMID: 32194162 PMCID: PMC7205586 DOI: 10.1016/j.resuscitation.2020.02.037] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 02/20/2020] [Accepted: 02/26/2020] [Indexed: 11/21/2022]
Abstract
AIM Flow disruptions (FDs) are deviations from the progression of care that compromise safety and efficiency of a specific process. The study aim was to identify the impact of FDs during neonatal resuscitation and determine their association with key process and outcome measures. METHODS Prospective observational study of video recorded delivery room resuscitations of neonates <32 weeks gestational age. FDs were classified using an adaptation of Wiegmann's FD tool. The primary outcome was target oxygenation saturation achievement at 5 min. Secondary outcomes included achieving target saturation at 10 min, time to positive pressure ventilation for initially apnoeic/bradycardic neonates, time to electrocardiogram signal, time to pulse oximetry signal, and time to stable airway. Multivariable logistic regression assessed association between FDs and achieving target saturations adjusting for gestational age and leader. Associations between FDs and time to event outcomes were assessed using Cox proportional hazards models. RESULTS Between 10/2017-7/2018, 32 videos were included. A mean of 52.6 FDs (standard deviation 17.9) occurred per resuscitation. Extraneous FDs were the most common FDs. FDs were associated with an adjusted odds ratio of 0.92 (95% confidence interval [CI] 0.80-1.05) of achieving target saturation at 5 min and 0.94 (95% CI 0.84-1.05) at 10 min. There was no significant evidence to show FDs were associated with time to event outcomes. CONCLUSIONS FDs occurred frequently during neonatal resuscitation. Measuring FDs is a feasible method to assess the impact of human factors in the delivery room and identify modifiable factors and practices to improve patient care.
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Affiliation(s)
- Heidi M Herrick
- Department of Pediatrics, Division of Neonatology, The Children's Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Division of Neonatology, 2(nd) Floor, Main Building, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA.
| | - Scott Lorch
- Department of Pediatrics, Division of Neonatology, The Children's Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Division of Neonatology, 2(nd) Floor, Main Building, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA.
| | - Jesse Y Hsu
- Department of Biostatistics, Epidemiology, and Informatics at The University of Pennsylvania Perelman School of Medicine, 629 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104, USA.
| | - Kenneth Catchpole
- Department of Anesthesia and Perioperative Medicine & College of Nursing at The Medical University of South Carolina, Storm Eye Building, 167 Ashley Avenue, Suite 301, MSC 912, Charleston, SC 29425-9120, USA.
| | - Elizabeth E Foglia
- Department of Pediatrics, Division of Neonatology, The Children's Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Division of Neonatology, 2(nd) Floor, Main Building, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA.
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Baker JF, England BR, Mikuls TR, Hsu JY, George MD, Pedro S, Sayles H, Michaud K. Changes in Alcohol Use and Associations With Disease Activity, Health Status, and Mortality in Rheumatoid Arthritis. Arthritis Care Res (Hoboken) 2020; 72:301-308. [PMID: 30891938 DOI: 10.1002/acr.23847] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 02/05/2019] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Better disease activity and quality of life have been observed among patients with rheumatoid arthritis (RA) who drink alcohol. This association might be explained by reverse causality. We undertook this study to identify predictors of change in alcohol use and to evaluate independent associations between alcohol use and RA activity and mortality. METHODS Participants in Forward, The National Databank for Rheumatic Diseases, were asked about alcohol use (any versus none), and disease activity was collected through the Patient Activity Scale-II (PAS-II) on semiannual surveys. We identified factors associated with changes in alcohol use and determined associations between alcohol use and disease activity and mortality using linear and logistic regression models, Cox proportional hazards models, and marginal structural models. RESULTS A total of 121,280 observations were studied among 16,762 unique participants. Discontinuation and initiation of alcohol were common among drinkers and abstainers (8.2% and 9.2% of observations, respectively). Greater discontinuation and less initiation were observed with greater disease activity, older age, female sex, nonwhite race, obesity, greater comorbidity, low quality of life, low educational level, low income, and work disability. While alcohol users had lower PAS-II (β = -0.15 [95% confidence interval (95% CI) -0.18, -0.11], P < 0.001) and a lower mortality (odds ratio 0.87 [95% CI 0.76, 0.98], P = 0.03) in traditional models, associations were not seen in marginal structural models. CONCLUSION Higher disease activity, disability, comorbidity, and poor quality of life contribute to reductions in alcohol use. Active use and changes in use were not associated with disease activity or mortality when adjusting for confounding, suggesting no clear benefit of alcohol consumption in RA.
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Affiliation(s)
- Joshua F Baker
- Philadelphia VA Medical Center and University of Pennsylvania, Philadelphia
| | - Bryant R England
- VA Nebraska-Western Iowa Health Care System and University of Nebraska Medical Center, Omaha
| | - Ted R Mikuls
- VA Nebraska-Western Iowa Health Care System and University of Nebraska Medical Center, Omaha
| | | | | | - Sofia Pedro
- Forward, The National Databank for Rheumatic Diseases, Wichita, Kansas
| | | | - Kaleb Michaud
- University of Nebraska Medical Center, Omaha, and Forward, The National Databank for Rheumatic Diseases, Wichita, Kansas
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46
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Kaufmann TL, Hsu JY, Getz KD, Kamal A, DeMichele A. Patient-reported symptom profiles: A tool to direct palliative care referral. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.31_suppl.93] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
93 Background: Both routine PRO monitoring and specialty palliative care are associated with a survival benefit in advanced cancer patients, yet the integration of these efforts has not been described. As PRO collection becomes standard of care, there is a need to understand how PROs may be leveraged to identify patients who could benefit from palliative care referral. Methods: We applied latent profile analysis (LPA) to PROs from a national palliative care registry collected from 2008 – 2017 on 745 solid tumor patients at the time of initial outpatient palliative care visit. LPA is an established method to identify unobserved groups from variables of interest. We used patients’ responses to 11 questions across 4 palliative care domains (9 ESAS items and 2 items for social and existential distress) to generate “PRO profiles” and examined their clinical and demographic correlates using multinomial logistic regression. Results: Four PRO profiles were identified using 9 ESAS items (Table). Young age, metastatic disease, and tumor type (including breast, GYN, GI) differed across PRO profiles compared to lung. Patients with PPS < 70% were 4.5 times more likely to be in the High vs. Low symptom profile compared to those with PPS > 70%. Subgroup analyses showed correlation of social and existential distress PROs with Mood and High profiles. Conclusions: Cancer patients referred to outpatient palliative care can be differentiated into clinically meaningful PRO profiles using brief, routinely collected data in the real-world setting. PRO profiles provide richer data on patient needs compared to prognosis estimates or cancer stage, and synthesize big data for use in clinical practice and epidemiologic research. PRO profiles should include comprehensive palliative domains and be tested as screening thresholds for palliative care referral. [Table: see text]
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Affiliation(s)
- Tara L. Kaufmann
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Jesse Y. Hsu
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA
| | - Kelly D. Getz
- The Children's Hospital of Philadelphia, Philadelphia, PA
| | | | - Angela DeMichele
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
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47
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George MD, Baker JF, Winthrop K, Alemao E, Chen L, Connolly S, Hsu JY, Simon TA, Wu Q, Xie F, Yang S, Curtis JR. Timing of Abatacept Before Elective Arthroplasty and Risk of Postoperative Outcomes. Arthritis Care Res (Hoboken) 2019; 71:1224-1233. [PMID: 30740938 DOI: 10.1002/acr.23843] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 02/05/2019] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Guidelines recommend withholding biologic therapies before hip and knee arthroplasty, yet evidence to inform optimal timing is limited. The aim of this study was to determine whether withholding abatacept infusions is associated with lower risk of adverse postoperative outcomes. METHODS This retrospective cohort study, which used US Medicare and Truven MarketScan administrative data from January 2006 to September 2015, evaluated adults with rheumatoid arthritis who received intravenous abatacept (precisely dated in claims data) within 6 months of elective primary or revision hip or knee arthroplasty. Propensity weighted analyses using inverse probability weights compared the risk of 30-day hospitalized infection and 1-year prosthetic joint infection (PJI) between patients with different abatacept stop timing (time between last infusion and surgery). Secondary analyses evaluated nonurinary hospitalized infections and 30-day readmissions. RESULTS After 1,939 surgeries among 1,780 patients, there were 175 hospitalized infections (9.0%), 115 nonurinary hospitalized infections (5.9%), 39 PJIs (2.4/100 person-years), and 114/1,815 30-day readmissions (6.3%). There were no significant differences in outcomes with abatacept stop timing <4 weeks (1 dosing interval) versus 4-8 weeks (hospitalized infection odds ratio [OR] 0.93 [95% confidence interval (95% CI) 0.65-1.34]; nonurinary hospitalized infection OR 0.93 [95% CI 0.60-1.44]; PJI hazard ratio 1.29 [95% CI 0.62-2.69]; 30-day readmission OR 1.00 [95% CI 0.65-1.54]). Similarly, there were no significant differences in outcomes with abatacept stop timing <4 weeks versus ≥8 weeks. Glucocorticoid use >7.5 mg/day was associated with greater risk of hospitalized infection (OR 2.19 [95% CI 1.28-3.77]) and nonurinary hospitalized infection (OR 2.38 [95% CI 1.22-4.64]). CONCLUSION Compared to continuing intravenous abatacept, withholding abatacept for ≥4 weeks (one dosing interval) before surgery was not associated with a lower risk of hospitalized infection, nonurinary hospitalized infection, PJI, or 30-day readmission.
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Affiliation(s)
- Michael D George
- University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Joshua F Baker
- Philadelphia Veterans Affairs Medical Center, Philadelphia, Pennyslvania
| | | | - Evo Alemao
- Bristol-Myers Squibb, Princeton, New Jersey
| | | | | | - Jesse Y Hsu
- University of Pennsylvania Perelman School of Medicine, Philadelphia
| | | | - Qufei Wu
- University of Pennsylvania Perelman School of Medicine, Philadelphia
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George MD, Baker JF, Winthrop K, Alemao E, Chen L, Connolly S, Hsu JY, Simon TA, Wu Q, Xie F, Yang S, Curtis JR. Risk of Biologics and Glucocorticoids in Patients With Rheumatoid Arthritis Undergoing Arthroplasty: A Cohort Study. Ann Intern Med 2019; 170:825-836. [PMID: 31108503 PMCID: PMC7197029 DOI: 10.7326/m18-2217] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Patients with rheumatoid arthritis (RA) are at increased risk for infection after arthroplasty, yet risks of specific biologic medications are unknown. OBJECTIVE To compare risk for postoperative infection among biologics and to evaluate the risk associated with glucocorticoids. DESIGN Retrospective cohort study. SETTING Medicare and Truven MarketScan administrative data from January 2006 through September 2015. PATIENTS Adults with RA who were having elective inpatient total knee or hip arthroplasty, either primary or revision, and had a recent infusion of or prescription for abatacept, adalimumab, etanercept, infliximab, rituximab, or tocilizumab before surgery. MEASUREMENTS Propensity-adjusted analyses using inverse probability weights evaluated comparative risks for hospitalized infection within 30 days and prosthetic joint infection (PJI) within 1 year after surgery between biologics or with different dosages of glucocorticoids. Secondary analyses evaluated non-urinary tract hospitalized infections and 30-day readmissions. RESULTS Among 9911 patients treated with biologics, 10 923 surgical procedures were identified. Outcomes were similar in patients who received different biologics. Compared with an 8.16% risk for hospitalized infection with abatacept, predicted risk from propensity-weighted models ranged from 6.87% (95% CI, 5.30% to 8.90%) with adalimumab to 8.90% (CI, 5.70% to 13.52%) with rituximab. Compared with a 2.14% 1-year cumulative incidence of PJI with abatacept, predicted incidence ranged from 0.35% (CI, 0.11% to 1.12%) with rituximab to 3.67% (CI, 1.69% to 7.88%) with tocilizumab. Glucocorticoids were associated with a dose-dependent increase in postoperative risk for all outcomes. Propensity-weighted models showed that use of more than 10 mg of glucocorticoids per day (vs. no glucocorticoid use) resulted in a predicted risk for hospitalized infection of 13.25% (CI, 9.72% to 17.81%) (vs. 6.78%) and a predicted 1-year cumulative incidence of PJI of 3.83% (CI, 2.13% to 6.87%) (vs. 2.09%). LIMITATION Residual confounding is possible, and sample sizes for rituximab and tocilizumab were small. CONCLUSION Risks for hospitalized infection, PJI, and readmission after arthroplasty were similar across biologics. In contrast, glucocorticoid use, especially with dosages above 10 mg/d, was associated with greater risk for adverse outcomes. PRIMARY FUNDING SOURCE Rheumatology Research Foundation, National Institutes of Health, and Bristol-Myers Squibb.
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Affiliation(s)
- Michael D George
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania (M.D.G., J.Y.H., Q.W.)
| | - Joshua F Baker
- University of Pennsylvania Perelman School of Medicine and Philadelphia Veterans Affairs Medical Center, Philadelphia, Pennsylvania (J.F.B.)
| | - Kevin Winthrop
- Oregon Health & Science University, Portland, Oregon (K.W.)
| | - Evo Alemao
- Bristol-Myers Squibb, New York, New York (E.A., S.C., T.A.S.)
| | - Lang Chen
- University of Alabama at Birmingham, Birmingham, Alabama (L.C., F.X., S.Y., J.R.C.)
| | - Sean Connolly
- Bristol-Myers Squibb, New York, New York (E.A., S.C., T.A.S.)
| | - Jesse Y Hsu
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania (M.D.G., J.Y.H., Q.W.)
| | - Teresa A Simon
- Bristol-Myers Squibb, New York, New York (E.A., S.C., T.A.S.)
| | - Qufei Wu
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania (M.D.G., J.Y.H., Q.W.)
| | - Fenglong Xie
- University of Alabama at Birmingham, Birmingham, Alabama (L.C., F.X., S.Y., J.R.C.)
| | - Shuo Yang
- University of Alabama at Birmingham, Birmingham, Alabama (L.C., F.X., S.Y., J.R.C.)
| | - Jeffrey R Curtis
- University of Alabama at Birmingham, Birmingham, Alabama (L.C., F.X., S.Y., J.R.C.)
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Sonnenberg EM, Cohen JB, Hsu JY, Potluri VS, Levine MH, Abt PL, Reese PP. Association of Kidney Transplant Center Volume With 3-Year Clinical Outcomes. Am J Kidney Dis 2019; 74:441-451. [PMID: 31076173 DOI: 10.1053/j.ajkd.2019.02.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Accepted: 02/26/2019] [Indexed: 12/29/2022]
Abstract
RATIONALE & OBJECTIVE A robust relationship between procedure volume and clinical outcomes has been demonstrated across many surgical fields. This study assessed whether a center volume-outcome relationship exists for contemporary kidney transplantation, specifically for diabetic recipients, older recipients (aged ≥65 years), and recipients of high kidney donor profile index (KDPI ≥ 85) kidneys. STUDY DESIGN Retrospective cohort study. SETTING & PARTICIPANTS Adult kidney-only transplant recipients who underwent transplantation between 2009 and 2013 (N = 79,581). EXPOSURES The primary exposure variable was center volume, categorized into quartiles based on the total kidney transplantation volume. Quartile 1 (Q1) centers performed a mean of fewer than 66 kidney transplantations per year, whereas Q4 centers performed a mean of more than 196 kidney transplantations per year. OUTCOMES All-cause graft failure and mortality within 3 years of transplantation. ANALYTICAL APPROACH Multivariable Cox frailty models were used to adjust for donor characteristics, recipient characteristics, and cold ischemia time. RESULTS Minor differences in rates of 3-year deceased donor all-cause graft failure across quartiles of center volume were observed (14.9% for Q1 vs 16.7% for Q4), including in subgroups (diabetic recipients, 18.4% for Q1 vs 19.7% for Q4; older recipients, 19.4% for Q1 vs 22.5% for Q4; recipients of high KDPI kidneys, 26.5% for Q1 vs 26.5% for Q4). Results were similar for 3-year mortality. After adjustment for donor, recipient, and graft characteristics using Cox regression, center volume was not significantly associated with all-cause graft failure or mortality within 3 years, except that diabetic recipients at Q3 centers had slightly lower mortality (compared with Q1 centers, adjusted HR of 0.85 [95% CI, 0.73-0.99]). LIMITATIONS Potential unmeasured confounding from patient comorbid conditions and organ selection. CONCLUSIONS These findings provide little evidence that care in higher volume centers is associated with better adjusted outcomes for kidney transplant recipients, even in populations anticipated to be at increased risk for graft failure or death.
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Affiliation(s)
- Elizabeth M Sonnenberg
- Department of Surgery, University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; National Clinician Scholars Program, University of Pennsylvania, Philadelphia, PA
| | - Jordana B Cohen
- Renal-Electrolyte and Hypertension Division, University of Pennsylvania, Philadelphia, PA; Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA
| | - Jesse Y Hsu
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA
| | - Vishnu S Potluri
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; Renal-Electrolyte and Hypertension Division, University of Pennsylvania, Philadelphia, PA
| | - Matthew H Levine
- Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Peter L Abt
- Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Peter P Reese
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; Renal-Electrolyte and Hypertension Division, University of Pennsylvania, Philadelphia, PA; Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA.
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50
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Dember LM, Lacson E, Brunelli SM, Hsu JY, Cheung AK, Daugirdas JT, Greene T, Kovesdy CP, Miskulin DC, Thadhani RI, Winkelmayer WC, Ellenberg SS, Cifelli D, Madigan R, Young A, Angeletti M, Wingard RL, Kahn C, Nissenson AR, Maddux FW, Abbott KC, Landis JR. The TiME Trial: A Fully Embedded, Cluster-Randomized, Pragmatic Trial of Hemodialysis Session Duration. J Am Soc Nephrol 2019; 30:890-903. [PMID: 31000566 DOI: 10.1681/asn.2018090945] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Accepted: 02/11/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Data from clinical trials to inform practice in maintenance hemodialysis are limited. Incorporating randomized trials into dialysis clinical care delivery should help generate practice-guiding evidence, but the feasibility of this approach has not been established. METHODS To develop approaches for embedding trials into routine delivery of maintenance hemodialysis, we performed a cluster-randomized, pragmatic trial demonstration project, the Time to Reduce Mortality in ESRD (TiME) trial, evaluating effects of session duration on mortality (primary outcome) and hospitalization rate. Dialysis facilities randomized to the intervention adopted a default session duration ≥4.25 hours (255 minutes) for incident patients; those randomized to usual care had no trial-driven approach to session duration. Implementation was highly centralized, with no on-site research personnel and complete reliance on clinically acquired data. We used multiple strategies to engage facility personnel and participating patients. RESULTS The trial enrolled 7035 incident patients from 266 dialysis units. We discontinued the trial at a median follow-up of 1.1 years because of an inadequate between-group difference in session duration. For the primary analysis population (participants with estimated body water ≤42.5 L), mean session duration was 216 minutes for the intervention group and 207 minutes for the usual care group. We found no reduction in mortality or hospitalization rate for the intervention versus usual care. CONCLUSIONS Although a highly pragmatic design allowed efficient enrollment, data acquisition, and monitoring, intervention uptake was insufficient to determine whether longer hemodialysis sessions improve outcomes. More effective strategies for engaging clinical personnel and patients are likely required to evaluate clinical trial interventions that are fully embedded in care delivery.
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Affiliation(s)
- Laura M Dember
- Renal, Electrolyte and Hypertension Division, Department of Medicine, .,Department of Biostatistics, Epidemiology, and Informatics
| | - Eduardo Lacson
- Division of Nephrology, Fresenius Medical Care North America, Waltham, Massachusetts
| | | | - Jesse Y Hsu
- Department of Biostatistics, Epidemiology, and Informatics, and
| | - Alfred K Cheung
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Utah and Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, Utah
| | - John T Daugirdas
- Division of Nephrology, Department of Medicine, University of Illinois College of Medicine at Chicago, Chicago, Illinois
| | - Tom Greene
- Departments of Population Health Science and Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Csaba P Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Dana C Miskulin
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Ravi I Thadhani
- Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts.,Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | | | - Denise Cifelli
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rosemary Madigan
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Amy Young
- DaVita Clinical Research, Minneapolis, Minnesota
| | - Michael Angeletti
- Division of Nephrology, Fresenius Medical Care North America, Waltham, Massachusetts
| | - Rebecca L Wingard
- Division of Nephrology, Fresenius Medical Care North America, Waltham, Massachusetts
| | - Christina Kahn
- Division of Nephrology, Fresenius Medical Care North America, Waltham, Massachusetts
| | - Allen R Nissenson
- DaVita Kidney Care, El Segundo, California.,David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California; and
| | - Franklin W Maddux
- Division of Nephrology, Fresenius Medical Care North America, Waltham, Massachusetts
| | - Kevin C Abbott
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
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