Publications by authors named "Alpesh N Amin"

99 Publications

Effectiveness and Safety of Dabigatran Compared to Vitamin K Antagonists in Non-Asian Patients with Atrial Fibrillation: A Systematic Review and Meta-Analysis.

Clin Drug Investig 2021 Oct 13. Epub 2021 Oct 13.

Grup de Recerca d'Epidemiologia Clínica i Serveis Sanitaris, Institut d'Investigació Biomèdica Sant Pau (IIB Sant Pau), Barcelona, Spain.

Background And Objective: Real-life data about the use of dabigatran in patients with non-valvular atrial fibrillation are warranted. The objective of this systematic review and meta-analysis was to assess the effectiveness and safety of dabigatran, globally and stratified by dose (110/150 mg twice daily), vs vitamin K antagonists in non-Asian patients with non-valvular atrial fibrillation from "real-world" studies.

Methods: A systematic review was performed according to Cochrane methodological standards. The results were reported according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses Statement) statement. The ROBINS-I tool was used to assess bias risk. MEDLINE and EMBASE, from inception up to May 2021, using appropriate controlled vocabulary and free search terms, were searched.  RESULTS: A total of 34 studies, corresponding to 37 articles involving 1,600,722 participants (1,154,283 exposed to vitamin K antagonists and 446,439 to dabigatran) were eligible for this review. Dabigatran 150 mg reduced the risk of ischemic stroke compared with vitamin K antagonists, with a 14% risk reduction (hazard ratio [HR] 0.86, 95% confidence interval [CI] 0.74-0.98). Globally, dabigatran reduced the risk of all-cause mortality compared with vitamin K antagonists (HR 0.76, 95% CI 0.69-0.84), with a greater effect observed with dabigatran 150 mg (HR 0.65, 95% CI 0.58-0.73). There was a trend towards a lower risk of myocardial infarction with dabigatran 150 mg (HR 0.86, 95% CI 0.71-1.04). Regarding the primary safety outcomes, dabigatran (either at a dose of 150 mg or 110 mg) reduced the risk of major bleeding compared with vitamin K antagonists (HR 0.77, 95% CI 0.70-0.83), as well as the risk of intracranial bleeding (HR 0.44, 95% CI 0.39-0.50) and fatal bleeding (HR 0.76, 95% CI 0.60-0.95), but with a slight increase in gastrointestinal bleeding risk (HR 1.16, 95% CI 1.08-1.26).

Conclusions: Dabigatran has a favorable impact on effectiveness and safety outcomes compared with vitamin K antagonists in real-world populations.
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http://dx.doi.org/10.1007/s40261-021-01091-wDOI Listing
October 2021

Continuous glucose monitoring in an end-stage renal disease patient with diabetes receiving hemodialysis.

Semin Dial 2021 Sep 10;34(5):388-393. Epub 2021 Aug 10.

Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine School of Medicine, Orange, California, USA.

Diabetes is the leading cause of end-stage renal disease (ESRD) and contributes to heightened morbidity and mortality in dialysis patients. Given that ESRD patients are susceptible to hypoglycemia and hyperglycemia via multiple pathways, adequate glycemic monitoring and control is a cornerstone in diabetic kidney disease management. In ESRD, existing glycemic metrics such as glycated hemoglobin, self-monitored blood glucose, fructosamine, and glycated albumin have limitations in accuracy, convenience, and accessibility. In contrast, continuous glucose monitoring (CGM) provides automated, less invasive glucose measurements and more comprehensive glycemic data versus conventional metrics. Here, we report a 48-year-old male with ESRD due to diabetes receiving thrice-weekly hemodialysis who experienced decreased patient-burden, greater glucose monitoring adherence, improved glycemic parameters, and reduction in hypoglycemia after transitioning to CGM. Through this case, we discuss how CGM is a practical, convenient patient-centered tool that may improve metabolic outcomes and quality of life in ESRD patients with diabetes.
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http://dx.doi.org/10.1111/sdi.13009DOI Listing
September 2021

Improved outcomes over time for adult COVID-19 patients with acute respiratory distress syndrome or acute respiratory failure.

PLoS One 2021 25;16(6):e0253767. Epub 2021 Jun 25.

Department of Surgery, University of California Irvine, Orange, California, United States of America.

Background: COVID-19's pulmonary manifestations are broad, ranging from pneumonia with no supplemental oxygen requirements to acute respiratory distress syndrome (ARDS) with acute respiratory failure (ARF). In response, new oxygenation strategies and therapeutics have been developed, but their large-scale effects on outcomes in severe COVID-19 patients remain unknown. Therefore, we aimed to examine the trends in mortality, mechanical ventilation, and cost over the first six months of the pandemic for adult COVID-19 patients in the US who developed ARDS or ARF.

Methods And Findings: The Vizient Clinical Data Base, a national database comprised of administrative, clinical, and financial data from academic medical centers, was queried for patients ≥ 18-years-old with COVID-19 and either ARDS or ARF admitted between 3/2020-8/2020. Demographics, mechanical ventilation, length of stay, total cost, mortality, and discharge status were collected. Mann-Kendall tests were used to assess for significant monotonic trends in total cost, mechanical ventilation, and mortality over time. Chi-square tests were used to compare mortality rates between March-May and June-August. 110,223 adult patients with COVID-19 ARDS or ARF were identified. Mean length of stay was 12.1±13.3 days and mean total cost was $35,991±32,496. Mechanical ventilation rates were 34.1% and in-hospital mortality was 22.5%. Mean cost trended downward over time (p = 0.02) from $55,275 (March) to $18,211 (August). Mechanical ventilation rates trended down (p<0.01) from 53.8% (March) to 20.3% (August). Overall mortality rates also decreased (p<0.01) from 28.4% (March) to 13.7% (August). Mortality rates in mechanically ventilated patients were similar over time (p = 0.45), but mortality in patients not requiring mechanical ventilation decreased from March-May compared to June-July (13.5% vs 4.6%, p<0.01).

Conclusions: This study describes the outcomes of a large cohort with COVID-19 ARDS or ARF and the subsequent decrease in cost, mechanical ventilation, and mortality over the first 6 months of the pandemic in the US.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0253767PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8232521PMC
July 2021

Stratifying Deterioration Risk by Acuity at Admission Offers Triage Insights for Coronavirus Disease 2019 Patients.

Crit Care Explor 2021 Apr 5;3(4):e0400. Epub 2021 Apr 5.

PeraHealth, Inc., Charlotte, NC.

Objectives: Triaging patients at admission to determine subsequent deterioration risk can be difficult. This is especially true of coronavirus disease 2019 patients, some of whom experience significant physiologic deterioration due to dysregulated immune response following admission. A well-established acuity measure, the Rothman Index, is evaluated for stratification of patients at admission into high or low risk of subsequent deterioration.

Design: Multicenter retrospective study.

Setting: One academic medical center in Connecticut, and three community hospitals in Connecticut and Maryland.

Patients: Three thousand four hundred ninety-nine coronavirus disease 2019 and 14,658 noncoronavirus disease 2019 adult patients admitted to a medical service between January 1, 2020, and September 15, 2020.

Interventions: None.

Measurements And Main Results: Performance of the Rothman Index at admission to predict in-hospital mortality or ICU utilization for both general medical and coronavirus disease 2019 populations was evaluated using the area under the curve. Precision and recall for mortality prediction were calculated, high- and low-risk thresholds were determined, and patients meeting threshold criteria were characterized. The Rothman Index at admission has good to excellent discriminatory performance for in-hospital mortality in the coronavirus disease 2019 (area under the curve, 0.81-0.84) and noncoronavirus disease 2019 (area under the curve, 0.90-0.92) populations. We show that for a given admission acuity, the risk of deterioration for coronavirus disease 2019 patients is significantly higher than for noncoronavirus disease 2019 patients. At admission, Rothman Index-based thresholds segregate the majority of patients into either high- or low-risk groups; high-risk groups have mortality rates of 34-45% (coronavirus disease 2019) and 17-25% (noncoronavirus disease 2019), whereas low-risk groups have mortality rates of 2-5% (coronavirus disease 2019) and 0.2-0.4% (noncoronavirus disease 2019). Similarly large differences in ICU utilization are also found.

Conclusions: Acuity level at admission may support rapid and effective risk triage. Notably, in-hospital mortality risk associated with a given acuity at admission is significantly higher for coronavirus disease 2019 patients than for noncoronavirus disease 2019 patients. This insight may help physicians more effectively triage coronavirus disease 2019 patients, guiding level of care decisions and resource allocation.
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http://dx.doi.org/10.1097/CCE.0000000000000400DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8084057PMC
April 2021

Baricitinib plus Remdesivir for Hospitalized Adults with Covid-19.

N Engl J Med 2021 03 11;384(9):795-807. Epub 2020 Dec 11.

From the University of Nebraska Medical Center, Omaha (A.C.K., L.L.); University of Texas Health San Antonio, University Health, and the South Texas Veterans Health Care System, San Antonio (T.F.P., P.O.P., B.S.T.), UT Southwestern Medical Center, Parkland Health and Hospital System (M.K.J.) and Baylor Scott and White Health (U.S.), Dallas, and Baylor College of Medicine, Houston (H.M.E.S.) - all in Texas; Emory University (A.K.M., N.G.R., Y.S., V.C.M., V.D.C.) and Grady Memorial Hospital (V.D.C.), Atlanta, and Atlanta Veterans Affairs Medical Center, Decatur (V.C.M.) - both in Georgia; the National Institute of Allergy and Infectious Diseases, National Institutes of Health (K.M.T., V.G., R.T.D., M.P., G.A.D., W.D., S.U.N., L.E.D., J.H.B.), and the Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences (T.H.B.), Bethesda, and Emmes (J.F., M.G., M.M.) and Clinical Monitoring Research Program Directorate, Frederick National Laboratory (T.B.), Rockville - both in Maryland; Duke University, Durham, NC (C.R.W., E.R.K., J.J.E.); Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, (G.M.R.-P.) and Instituto Nacional de Enfermedades Respiratorias (J.R.P.), Mexico City; University of California Irvine, Irvine (L.H., A.N.A., M.W.), Cedars-Sinai Medical Center, Los Angeles (V.T.), University of California, San Diego, La Jolla (D.A.S.), University of California, San Francisco, San Francisco (A.F.L.), University of California, Davis, Davis (S.H.C.), and Stanford University, Stanford (N.A.) - all in California; University of Minnesota Medical School, Minneapolis (S.K., J.B.); University of Florida, Gainesville (N.M.I., M.-C.E.); University of Rochester, Rochester, NY (A.R.B.); National Center for Infectious Diseases, Tan Tock Seng Hospital, Lee Kong Chian School of Medicine, and Yong Loo Lin School of Medicine (D.C.L.), and Changi General Hospital (S.Y.T.), Singapore; University of Massachusetts Medical School, Worcester (R.W.F.); University of Virginia, Charlottesville (P.E.H.J.); Northwestern University, Chicago (B.T.); Penn State Health Milton S. Hershey Medical Center, Hershey, PA (C.I.P.); Providence Sacred Heart Medical Center, Spokane, WA (H.A.); University of Alabama at Birmingham, Birmingham (N.E.); Denver Health and Hospital Authority, Denver (M.F.); Seoul National University Hospital, Seoul (M.O.), and Seoul National University Bundang Hospital, Seongnam (E.-S.K.) - both in South Korea; Kaiser Permanente Northwest, Portland, OR (R.A.M.); Aalborg University Hospital, Aalborg, Denmark (H.N.); and Eli Lilly, Indianapolis (A.C., S.B.).

Background: Severe coronavirus disease 2019 (Covid-19) is associated with dysregulated inflammation. The effects of combination treatment with baricitinib, a Janus kinase inhibitor, plus remdesivir are not known.

Methods: We conducted a double-blind, randomized, placebo-controlled trial evaluating baricitinib plus remdesivir in hospitalized adults with Covid-19. All the patients received remdesivir (≤10 days) and either baricitinib (≤14 days) or placebo (control). The primary outcome was the time to recovery. The key secondary outcome was clinical status at day 15.

Results: A total of 1033 patients underwent randomization (with 515 assigned to combination treatment and 518 to control). Patients receiving baricitinib had a median time to recovery of 7 days (95% confidence interval [CI], 6 to 8), as compared with 8 days (95% CI, 7 to 9) with control (rate ratio for recovery, 1.16; 95% CI, 1.01 to 1.32; P = 0.03), and a 30% higher odds of improvement in clinical status at day 15 (odds ratio, 1.3; 95% CI, 1.0 to 1.6). Patients receiving high-flow oxygen or noninvasive ventilation at enrollment had a time to recovery of 10 days with combination treatment and 18 days with control (rate ratio for recovery, 1.51; 95% CI, 1.10 to 2.08). The 28-day mortality was 5.1% in the combination group and 7.8% in the control group (hazard ratio for death, 0.65; 95% CI, 0.39 to 1.09). Serious adverse events were less frequent in the combination group than in the control group (16.0% vs. 21.0%; difference, -5.0 percentage points; 95% CI, -9.8 to -0.3; P = 0.03), as were new infections (5.9% vs. 11.2%; difference, -5.3 percentage points; 95% CI, -8.7 to -1.9; P = 0.003).

Conclusions: Baricitinib plus remdesivir was superior to remdesivir alone in reducing recovery time and accelerating improvement in clinical status among patients with Covid-19, notably among those receiving high-flow oxygen or noninvasive ventilation. The combination was associated with fewer serious adverse events. (Funded by the National Institute of Allergy and Infectious Diseases; ClinicalTrials.gov number, NCT04401579.).
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http://dx.doi.org/10.1056/NEJMoa2031994DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7745180PMC
March 2021

Development and external validation of a prognostic tool for COVID-19 critical disease.

PLoS One 2020 9;15(12):e0242953. Epub 2020 Dec 9.

Department of Radiological Sciences, University of California, Irvine, California, United States of America.

Background: The rapid spread of coronavirus disease 2019 (COVID-19) revealed significant constraints in critical care capacity. In anticipation of subsequent waves, reliable prediction of disease severity is essential for critical care capacity management and may enable earlier targeted interventions to improve patient outcomes. The purpose of this study is to develop and externally validate a prognostic model/clinical tool for predicting COVID-19 critical disease at presentation to medical care.

Methods: This is a retrospective study of a prognostic model for the prediction of COVID-19 critical disease where critical disease was defined as ICU admission, ventilation, and/or death. The derivation cohort was used to develop a multivariable logistic regression model. Covariates included patient comorbidities, presenting vital signs, and laboratory values. Model performance was assessed on the validation cohort by concordance statistics. The model was developed with consecutive patients with COVID-19 who presented to University of California Irvine Medical Center in Orange County, California. External validation was performed with a random sample of patients with COVID-19 at Emory Healthcare in Atlanta, Georgia.

Results: Of a total 3208 patients tested in the derivation cohort, 9% (299/3028) were positive for COVID-19. Clinical data including past medical history and presenting laboratory values were available for 29% (87/299) of patients (median age, 48 years [range, 21-88 years]; 64% [36/55] male). The most common comorbidities included obesity (37%, 31/87), hypertension (37%, 32/87), and diabetes (24%, 24/87). Critical disease was present in 24% (21/87). After backward stepwise selection, the following factors were associated with greatest increased risk of critical disease: number of comorbidities, body mass index, respiratory rate, white blood cell count, % lymphocytes, serum creatinine, lactate dehydrogenase, high sensitivity troponin I, ferritin, procalcitonin, and C-reactive protein. Of a total of 40 patients in the validation cohort (median age, 60 years [range, 27-88 years]; 55% [22/40] male), critical disease was present in 65% (26/40). Model discrimination in the validation cohort was high (concordance statistic: 0.94, 95% confidence interval 0.87-1.01). A web-based tool was developed to enable clinicians to input patient data and view likelihood of critical disease.

Conclusions And Relevance: We present a model which accurately predicted COVID-19 critical disease risk using comorbidities and presenting vital signs and laboratory values, on derivation and validation cohorts from two different institutions. If further validated on additional cohorts of patients, this model/clinical tool may provide useful prognostication of critical care needs.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0242953PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7725393PMC
December 2020

Novel therapeutic approaches for COVID-19 in chronic kidney disease and transplant.

Curr Opin Nephrol Hypertens 2021 01;30(1):47-53

Department of Medicine, University of California Irvine School of Medicine, Orange, California, USA.

Purpose Of Review: Severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) is the novel virus responsible for the current worldwide pandemic. The scientific and healthcare communities have made every effort to discover and implement treatment options at a historic pace. Patients with kidney disease are uniquely vulnerable to an infectious pandemic because of their need to be in frequent contact with the healthcare system for life-sustaining renal replacement therapy whether it be by dialysis or transplant.

Recent Findings: The use of targeted viral therapies, extracorporeal therapies, immunosuppressive therapy and public health interventions are important in the management of patients with COVID-19 but require special consideration in patients with kidney disease because of the complexity of their condition.

Summary: Here, we discuss some of the major efforts made to prevent spread and emerging treatment options for this virus, as they pertain to patients with kidney disease.
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http://dx.doi.org/10.1097/MNH.0000000000000671DOI Listing
January 2021

Awareness, Knowledge, and Utility of RCT Data vs RWE: Results From a Survey of US Cardiologists: Real-world Evidence in Clinical Decision Making.

Clin Med Insights Cardiol 2020 2;14:1179546820953410. Epub 2020 Sep 2.

Department of Medicine, School of Medicine, University of California Irvine, Irvine, CA, USA.

Real-world evidence (RWE) provides a potential rich source of additional information to the body of data available from randomized clinical trials (RCTs), but there is a need to understand the strengths and limitations of RWE before it can be applied to clinical practice. To gain insight into current thinking in clinical decision making and utility of different data sources, a representative sampling of US cardiologists selected from the current, active Fellows of the American College of Cardiology (ACC) were surveyed to evaluate their perceptions of findings from RCTs and RWE studies and their application in clinical practice. The survey was conducted online via the ACC web portal between 12 July and 11 August 2017. Of the 548 active ACC Fellows invited as panel members, 173 completed the survey (32% response), most of whom were board certified in general cardiology (n = 119, 69%) or interventional cardiology (n = 40, 23%). The survey results indicated a wide range of familiarity with and utilization of RWE amongst cardiologists. Most cardiologists were familiar with RWE and considered RWE in clinical practice at least some of the time. However, a significant minority of survey respondents had rarely or never applied RWE learnings in their clinical practice, and many did not feel confident in the results of RWE other than registry data. These survey findings suggest that additional education on how to assess and interpret RWE could help physicians to integrate data and learnings from RCTs and RWE to best guide clinical decision making.
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http://dx.doi.org/10.1177/1179546820953410DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7476349PMC
September 2020

Mortality Risk in Chronic Kidney Disease Patients Transitioning to Dialysis: Impact of Opiate and Non-Opiate Use.

Am J Nephrol 2020 10;51(9):715-725. Epub 2020 Aug 10.

Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine, Orange, California, USA,

Background: Population-based studies show there is a high prevalence of chronic kidney disease (CKD) patients suffering from chronic pain. While opiates are frequently prescribed in non-dialysis-dependent CKD (NDD-CKD) patients, there may be toxic accumulation of metabolites, particularly among those progressing to end-stage renal disease (ESRD). We examined the association of opiate versus other analgesic use during the pre-ESRD period with post-ESRD mortality among NDD-CKD patients transitioning to dialysis.

Methods: We examined a national cohort of US Veterans with NDD-CKD who transitioned to dialysis over 2007-14. Among patients who received ≥1 prescription(s) in the Veterans Affairs (VA) Healthcare System within 1 year of transitioning to dialysis, we examined associations of pre-ESRD analgesic status, defined as opiate, gabapentin/pregabalin, other non-opiate analgesic, versus no analgesic use, with post-ESRD mortality using multivariable Cox models.

Results: Among 57,764 patients who met eligibility criteria, pre-ESRD opiate and gabapentin/pregabalin use were each associated with higher post-ESRD mortality (ref: no analgesic use), whereas non-opiate analgesic use was not associated with higher mortality in expanded case-mix analyses: HRs (95% CIs) 1.07 (1.05-1.10), 1.07 (1.01-1.13), and 1.00 (0.94-1.06), respectively. In secondary analyses, increasing frequency of opiate prescriptions exceeding 1 opiate prescription in the 1-year pre-ESRD period was associated with incrementally higher post-ESRD mortality (ref: no analgesic use).

Conclusions: In NDD-CKD patients transitioning to dialysis, pre-ESRD opiate and gabapentin/pregabalin use were associated with higher post-ESRD mortality, whereas non-opiate analgesic use was not associated with death. There was a graded association between increasing frequency of pre-ESRD opiate use and incrementally higher mortality.
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http://dx.doi.org/10.1159/000509451DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8123720PMC
July 2021

Comparing Randomized Controlled Trials and Real-World Studies in Chronic Obstructive Pulmonary Disease Pharmacotherapy.

Int J Chron Obstruct Pulmon Dis 2020 2;15:1225-1243. Epub 2020 Jun 2.

Crisor, LLC Clinical Research Institute of Southern Oregon, Medford, OR, USA.

Analytic epidemiological studies cover a large spectrum of study methodologies, ranging from noninterventional observational studies (population-based, case-control, or cohort studies) to interventional studies (clinical trials). Herein, we review the different research methodologies or study designs and discuss their advantages and disadvantages in the context of chronic obstructive pulmonary disease (COPD) pharmacotherapy. Although randomized controlled trials (RCTs) are considered the "gold standard" for evaluating the efficacy and safety of an intervention, observational studies conducted in a real-world scenario are useful in providing evidence on the effectiveness of the intervention in clinical practice; understanding both efficacy and effectiveness is important from the clinician's perspective. Pragmatic clinical trials that use real-world data while retaining randomization bridge the gap between explanatory RCTs and noninterventional observational studies. Overall, different study designs have their associated advantages and disadvantages; together, findings from all types of studies bring about progress in clinical research as elucidated through examples from COPD research in this paper.
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http://dx.doi.org/10.2147/COPD.S244942DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7276323PMC
June 2021

A Case of Novel Coronavirus Disease 19 in a Chronic Hemodialysis Patient Presenting with Gastroenteritis and Developing Severe Pulmonary Disease.

Am J Nephrol 2020 28;51(5):337-342. Epub 2020 Mar 28.

Department of Medicine, Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine Medical Center, Orange, California, USA,

Novel coronavirus disease 2019 (COVID-19) is a highly infectious, rapidly spreading viral disease with an alarming case fatality rate up to 5%. The risk factors for severe presentations are concentrated in patients with chronic kidney disease, particularly patients with end-stage renal disease (ESRD) who are dialysis dependent. We report the first US case of a 56-year-old nondiabetic male with ESRD secondary to IgA nephropathy undergoing thrice-weekly maintenance hemodialysis for 3 years, who developed COVID-19 infection. He has hypertension controlled with angiotensin receptor blocker losartan 100 mg/day and coronary artery disease status-post stent placement. During the first 5 days of his febrile disease, he presented to an urgent care, 3 emergency rooms, 1 cardiology clinic, and 2 dialysis centers in California and Utah. During this interval, he reported nausea, vomiting, diarrhea, and low-grade fevers but was not suspected of COVID-19 infection until he developed respiratory symptoms and was admitted to the hospital. Imaging studies upon admission were consistent with bilateral interstitial pneumonia. He was placed in droplet-eye precautions while awaiting COVID-19 test results. Within the first 24 h, he deteriorated quickly and developed acute respiratory distress syndrome (ARDS), requiring intubation and increasing respiratory support. Losartan was withheld due to hypotension and septic shock. COVID-19 was reported positive on hospital day 3. He remained in critical condition being treated with hydroxychloroquine and tocilizumab in addition to the standard medical management for septic shock and ARDS. Our case is unique in its atypical initial presentation and highlights the importance of early testing.
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http://dx.doi.org/10.1159/000507417DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7179539PMC
May 2020

Efficacy and safety of sodium zirconium cyclosilicate in patients with baseline serum potassium level ≥ 5.5 mmol/L: pooled analysis from two phase 3 trials.

BMC Nephrol 2019 12 2;20(1):440. Epub 2019 Dec 2.

Division of General Medicine, University of Washington, Seattle, WA, USA.

Background: Reliable, timely-onset, oral treatments with an acceptable safety profile for patients with hyperkalemia are needed. We examined the efficacy and safety of sodium zirconium cyclosilicate (SZC; formerly ZS-9) treatment for ≤ 48 h in patients with baseline serum potassium level ≥ 5.5 mmol/L.

Methods: Data were pooled from two phase 3 studies (ZS-003 and HARMONIZE) among patients receiving SZC 10 g three times daily. Outcomes included mean and absolute change from baseline, median time to potassium level ≤ 5.5 and ≤ 5.0 mmol/L, and proportion achieving potassium level ≤ 5.5 and ≤ 5.0 mmol/L at 4, 24, and 48 h. Outcomes were stratified by baseline potassium. Safety outcomes were evaluated.

Results: At baseline, 125 of 170 patients (73.5%) had potassium level 5.5-< 6.0, 39 (22.9%) had potassium level 6.0-6.5, and 6 (3.5%) had potassium level > 6.5 mmol/L. Regardless of baseline potassium, mean potassium decreased at 1 h post-initial dose. By 4 and 48 h, 37.5% and 85.0% of patients achieved potassium level ≤ 5.0 mmol/L, respectively. Median (95% confidence interval) times to potassium level ≤ 5.5 and ≤ 5.0 mmol/L were 2.0 (1.1-2.0) and 21.6 (4.1-22.4) h, respectively. Fifteen patients (8.8%) experienced adverse events; none were serious.

Conclusions: SZC 10 g three times daily achieved serum potassium reduction and normokalemia, with a favorable safety profile.

Trial Registration: ClinicalTrials.gov identifiers: ZS-003: NCT01737697 and HARMONIZE: NCT02088073.
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http://dx.doi.org/10.1186/s12882-019-1611-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6889520PMC
December 2019

Impact of a Central-Line Insertion Site Assessment (CLISA) score on localized insertion site infection to prevent central-line-associated bloodstream infection (CLABSI).

Infect Control Hosp Epidemiol 2020 01 8;41(1):59-66. Epub 2019 Nov 8.

Epidemiology & Infection Prevention Program, University of California, Irvine Health, Orange, California.

Objective: To assess the impact of a newly developed Central-Line Insertion Site Assessment (CLISA) score on the incidence of local inflammation or infection for CLABSI prevention.

Design: A pre- and postintervention, quasi-experimental quality improvement study.

Setting And Participants: Adult inpatients with central venous catheters (CVCs) hospitalized in an intensive care unit or oncology ward at a large academic medical center.

Methods: We evaluated CLISA score impact on insertion site inflammation and infection (CLISA score of 2 or 3) incidence in the baseline period (June 2014-January 2015) and the intervention period (April 2015-October 2017) using interrupted times series and generalized linear mixed-effects multivariable analyses. These were run separately for days-to-line removal from identification of a CLISA score of 2 or 3. CLISA score interrater reliability and photo quiz results were evaluated.

Results: Among 6,957 CVCs assessed 40,846 times, percentage of lines with CLISA score of 2 or 3 in the baseline and intervention periods decreased by 78.2% (from 22.0% to 4.7%), with a significant immediate decrease in the time-series analysis (P < .001). According to the multivariable regression, the intervention was associated with lower percentage of lines with a CLISA score of 2 or 3, after adjusting for age, gender, CVC body location, and hospital unit (odds ratio, 0.15; 95% confidence interval, 0.06-0.34; P < .001). According to the multivariate regression, days to removal of lines with CLISA score of 2 or 3 was 3.19 days faster after the intervention (P < .001). Also, line dwell time decreased 37.1% from a mean of 14 days (standard deviation [SD], 10.6) to 8.8 days (SD, 9.0) (P < .001). Device utilization ratios decreased 9% from 0.64 (SD, 0.08) to 0.58 (SD, 0.06) (P = .039).

Conclusions: The CLISA score creates a common language for assessing line infection risk and successfully promotes high compliance with best practices in timely line removal.
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http://dx.doi.org/10.1017/ice.2019.291DOI Listing
January 2020

Using Team Census Caps to Optimize Education, Patient Care, and Wellness: A Survey of Internal Medicine Residency Program Directors.

Acad Med 2020 04;95(4):567-573

J.S. Catalanotti is associate professor, Department of Medicine, and internal medicine residency program director, The George Washington University School of Medicine and Health Sciences, Washington, DC; ORCID: http://orcid.org/0000-0003-3603-1493. A.N. Amin is professor and chair, Department of Medicine, School of Medicine, University of California, Irvine, Irvine, California. S.F. Vinciguerra is business administrator, Department of Medicine, College of Medicine, Medical University of South Carolina, Charleston, South Carolina. K. Walsh is clinical associate professor, Department of Medicine, The Ohio State University College of Medicine, Columbus, Ohio. J. Gilden is professor, Department of Medicine, chief of endocrinology, and endocrinology fellowship program director, Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, Illinois. M. Kisielewski is survey and data manager, Alliance for Academic Internal Medicine, Alexandria, Virginia. H.S. Laird-Fick is professor, Department of Medicine, and director of assessment, College of Human Medicine, Michigan State University, East Lansing, Michigan; ORCID: https://orcid.org/0000-0001-9215-8152.

Purpose: To discover whether internal medicine (IM) residency program directors use lower-than-required caps on general medicine wards, critical care units, and inpatient subspecialty wards; describe justifications for lower-than-required general medicine ward caps and strategies for when caps have been exceeded or the number of patients is a detriment to critical thinking or education; and assess whether caps were associated with program characteristics.

Method: From August to December 2016, the Association of Program Directors in Internal Medicine surveyed all member program directors about team caps and their effects on the learning environment. Responses were appended with publicly available or licensed third-party data. Programs were categorized by type, size, and region.

Results: Overall response rate was 65.7% (251/382 programs). Nearly all (244/248; 98.4%) reported caps for general medicine ward teams (mean = 17.0 [standard deviation (SD) = 4.2]). Fewer (171/247; 69.2%) had caps for critical care teams (mean = 13.8 [SD = 5.4]). Fewer still (131/225; 58.2%) had caps for inpatient subspecialty ward teams (mean = 14.8 [SD = 6.0]). Fewer first-quartile programs (0-28 residents) reported having caps on inpatient subspecialty teams (P < .001). Directors reported higher caps compromised education (109/130; 83.8%), patient care (89/130; 68.5%), and/or resident wellness (77/130; 59.2%). Nonteaching services (181/249; 72.7%), patient transfers (110/249; 44.2%), or "backup" residents (67/249; 26.9%) were used when caps are reached or the number of patients is detrimental to critical thinking or education.

Conclusions: IM program directors frequently exercise discretion when setting caps. Accrediting bodies should explicitly encourage such adjustments and allow differentiation by setting.
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http://dx.doi.org/10.1097/ACM.0000000000003016DOI Listing
April 2020

Costs associated with unplanned readmissions among patients with heart failure with and without hyponatremia.

Am J Health Syst Pharm 2019 02;76(6):374-380

Field Medical Affairs, Otsuka Pharmaceutical Development and Commercialization, Princeton, NJ.

Purpose: Costs associated with unplanned readmissions among patients with heart failure with and without hyponatremia were studied.

Methods: This study estimated the costs of patients hospitalized for heart failure (HF) discharged with or without corrected sodium. A model was developed to monetize the 30-day readmission risk based on hyponatremia correction. Costs of discharging patient with corrected versus uncorrected hyponatremia were estimated using readmission rates from a previously published study and hospitalization costs from the Healthcare Costs and Utilization Cost Project and the Premier Healthcare Database.

Results: Discharging patients with HF and hyponatremia increased costs from $488-$569 per discharge compared to patients with corrected hyponatremia. This range reflected differences in readmission rates and sources of hospitalization costs. Sensitivity analyses showed hospitalization costs and readmission rates had the largest impact on model results.

Conclusion: A retrospective study supports the value of upfront monitoring and correction of low serum sodium levels before discharge among patients with HF and hyponatremia by presenting an economic argument in addition to the clinical rational for reducing risk of readmission.
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http://dx.doi.org/10.1093/ajhp/zxy064DOI Listing
February 2019

Tackling the Problem of Ambulatory Faculty Recruitment in Undergraduate Medical Education: An AAIM Position Paper.

Am J Med 2019 10 19;132(10):1242-1246. Epub 2019 Jul 19.

University of California, Irvine School of Medicine, Irvine.

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http://dx.doi.org/10.1016/j.amjmed.2019.06.035DOI Listing
October 2019

Glycemic Status and Mortality in Chronic Kidney Disease According to Transition Versus Nontransition to Dialysis.

J Ren Nutr 2019 03 15;29(2):82-90. Epub 2018 Nov 15.

Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, California; Tibor Rubin Veterans Affairs Medical Center, Long Beach, California.

Objective: The impact of glycemic control in diabetic patients with chronic kidney disease (CKD) who may or may not transition to dialysis remains uncertain, given recent interest in the conservative management of advanced CKD without dialysis therapy, which may benefit from alternative glycemic control strategies.

Design And Methods: Among a national cohort of US Veterans, we examined the association of glycemic status, defined by averaged random blood glucose and hemoglobin A1c (HbA1c), with mortality after transitioning to dialysis over 2007-2011 (Transition Cohort) compared with patients in a one-to-one matched cohort of CKD patients with diabetes who did not transition to dialysis (Nontransition Cohort).

Results: Among 17,121 patients in the Transition Cohort, averaged random glucose ≥200 mg/dL was associated with higher mortality in expanded case-mix analyses (reference: 100-<120 mg/dL): adjusted hazard ratio (95% confidence interval) 1.26 (1.13-1.40). In the transition cohort, HbA1c 8-<10% and ≥10% were associated with higher mortality (reference: 6-<8%): adjusted hazard ratios (95% confidence interval) 1.21 (1.11-1.33) and 1.43 (1.21-1.69), respectively. Among 8,711 patients in the Nontransition Cohort, averaged random glucose <100 mg/dl and ≥160 mg/dl were associated with higher death risk, whereas HbA1c was not associated with mortality.

Conclusion: In diabetic CKD patients transitioning to dialysis, higher averaged random glucose and HbA1c were associated with early dialysis mortality, whereas in matched CKD patients who did not transition, both lower and higher glucose levels were associated with higher mortality. These data suggest the need for different glycemic strategies based on whether there are plans to transition to dialysis versus pursue conservative management among diabetic patients with CKD.
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http://dx.doi.org/10.1053/j.jrn.2018.07.003DOI Listing
March 2019

Antibiotic use in patients hospitalized with chronic obstructive pulmonary disease.

Am J Health Syst Pharm 2018 09;75(17):1268-1269

Agile Outcomes ResearchRochester, MN.

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http://dx.doi.org/10.2146/ajhp180178DOI Listing
September 2018

Hypoglycemia-Related Hospitalizations and Mortality Among Patients With Diabetes Transitioning to Dialysis.

Am J Kidney Dis 2018 11 20;72(5):701-710. Epub 2018 Jul 20.

Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA; Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA.

Rationale & Objective: Diabetic patients with declining kidney function are at heightened risk for hypoglycemia. We sought to determine whether hypoglycemia-related hospitalizations in the interval before dialysis therapy initiation are associated with post-end-stage renal disease (ESRD) mortality among incident patients with ESRD with diabetes.

Study Design: Observational cohort study.

Setting & Participants: US veterans from the national Veterans Affairs database with diabetes and chronic kidney disease transitioning to dialysis therapy from October 2007 to September 2011.

Exposure: Hypoglycemia-related hospitalizations during the pre-ESRD period and antidiabetic medication regimens.

Outcome: The outcome of post-ESRD all-cause mortality was evaluated relative to pre-ESRD hypoglycemia. The outcome of pre-ESRD hypoglycemia-related hospitalization was evaluated relative to antidiabetic medication regimens.

Analytic Approach: We examined whether the occurrence and frequency of pre-ESRD hypoglycemia-related hospitalizations are associated with post-ESRD mortality using Cox regression models adjusted for case-mix covariates. In a subcohort of patients prescribed 0 to 2 oral antidiabetic drugs and/or insulin, we examined the 12 most commonly prescribed antidiabetic medication regimens and risk for pre-ESRD hypoglycemia-related hospitalization using logistic regression models adjusted for case-mix covariates.

Results: Among 30,156 patients who met eligibility criteria, the occurrence of pre-ESRD hypoglycemia-related hospitalization(s) was associated with higher post-ESRD mortality risk: adjusted HR (aHR), 1.25; 95% CI, 1.17-1.34 (reference group: no hypoglycemia hospitalization). Increasing frequency of hypoglycemia-related hospitalizations was independently associated with incrementally higher mortality risk: aHRs of 1.21 (95% CI, 1.12-1.30), 1.47 (95% CI, 1.19-1.82), and 2.07 (95% CI, 1.46-2.95) for 1, 2, and 3 or more hypoglycemia-related hospitalizations, respectively (reference group: no hypoglycemia hospitalization). Compared with patients who were prescribed neither oral antidiabetic drugs nor insulin, medication regimens that included sulfonylureas and/or insulin were associated with higher risk for hypoglycemia.

Limitations: Residual confounding cannot be excluded.

Conclusions: Among incident patients with ESRD with diabetes, a dose-dependent relationship between frequency of pre-ESRD hypoglycemia-related hospitalizations and post-ESRD mortality was observed. Further study of diabetic management strategies that prevent hypoglycemia as patients with chronic kidney disease transition to ESRD are warranted.
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http://dx.doi.org/10.1053/j.ajkd.2018.04.022DOI Listing
November 2018

Developing Faculty in Emerging Areas of Interdisciplinary Research.

Am J Med 2018 10 5;131(10):1257-1262. Epub 2018 Jul 5.

University of Illinois College of Medicine, Chicago.

The availability of new techniques and technologies to answer important medical questions is accelerating at a breathtaking pace. In response to these exciting new opportunities, clinical departments, in general, and departments of medicine, in particular, have broadened their research portfolios. Organization of the traditional structures of clinical departments, research infrastructure, training programs, and rewards for faculty has only begun to catalyze emerging research areas such as artificial intelligence, bioinformatics, bioengineering, cell and tissue engineering, cost effectiveness, health services, implementation science, integrative epidemiology, medical informatics, nanomedicine, and quality improvement. Success in these emerging areas of research requires interdisciplinary collaboration on a much larger scale than in the past. The effectiveness of efforts to recruit, develop, mentor, and promote faculty in these exciting areas will be critical to the success of departmental and institutional research programs. We describe examples of initiatives from our 5 departments of medicine designed to develop and promote faculty conducting research in emerging interdisciplinary areas. We focus on core resources, training, organizational structures, and recognition and promotion. Faculty have a compelling opportunity and obligation to pursue emerging research areas that have the potential to further improve the prevention, diagnosis, and treatment of disease. As departments prepare to meet this exciting opportunity in the future, the lessons learned must inform investments in faculty development. Although many of the strategies outlined herein could and should expand beyond any individual department, departments of medicine have a distinct obligation and opportunity to lead this effort.
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http://dx.doi.org/10.1016/j.amjmed.2018.06.009DOI Listing
October 2018

Dialysis Provider and Outcomes among United States Veterans Who Transition to Dialysis.

Clin J Am Soc Nephrol 2018 07 14;13(7):1055-1062. Epub 2018 Jun 14.

Harold Simmons Program in Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension and

Background And Objectives: Veterans with ESKD initiate dialysis under the Veterans Health Administration (VHA), an integrated health system, or are outsourced to non-VHA providers. It is unknown whether outcomes differ according to their dialysis provider at initiation. We sought to evaluate the association between dialysis provider and mortality and hospitalization among United States veterans initiating dialysis.

Design, Setting, Participants, & Measurements: Among 68,727 United States veterans who initiated dialysis in 2007-2014, we examined the association of dialysis provider (VHA versus non-VHA) at initiation with mortality and hospitalization rates in the first 12 months post-initiation. Associations were examined across adjusted models, accounting for demographics and comorbidities.

Results: Patients were 72±11 years, 5% were women, 24% were black, and 10% (=7584) initiated at VHA dialysis centers. VHA dialysis center patients were younger, more likely to be black, had fewer cardiovascular comorbidities, and lower eGFR at dialysis initiation. VHA provider patients were more likely to be hospitalized in the first 12 months (adjusted incidence rate ratio, 1.10; 95% confidence interval, 1.07 to 1.14), but had lower all-cause mortality risk (adjusted hazard ratio, 0.87; 95% confidence interval, 0.83 to 0.93) in fully adjusted models.

Conclusions: Veteran patients initiating dialysis with a VHA dialysis provider appear to have a lower mortality risk but higher hospitalization rates than veterans initiating dialysis at non-VHA dialysis units.
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http://dx.doi.org/10.2215/CJN.12951117DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6032569PMC
July 2018

Treatment patterns for patients hospitalized with chronic obstructive pulmonary disease.

Am J Health Syst Pharm 2018 Mar;75(6):359-366

Sunovion Pharmaceuticals, Marlborough, MA.

Purpose: Medication treatment patterns for chronic obstructive pulmonary disease (COPD) in inpatient settings were examined, as were the characteristics of patients treated with long-acting bronchodilators (LABDs) during hospitalization.

Methods: This retrospective study was conducted using inpatient administrative data from hospitals and medical centers nationwide. All patients discharged from the hospital from January 1, 2010, through December 31, 2012, who were at least 40 years of age, had a primary discharge diagnosis of COPD or a secondary diagnosis of COPD with a primary diagnosis of a respiratory condition, and treatment with a bronchodilator were included. Treatment patterns were described for inpatient use of medications, including short-acting β-agonists (SABAs), long-acting β-agonists (LABAs), short-acting muscarinic antagonists (SAMAs), and long-acting muscarinic antagonists. Logistic regression predicted characteristics of patients receiving LABDs.

Results: Only 5.5% of patients did not receive an SABA during the hospitalization: 71.7% received a single-product SABA, and 46.4% received an SABA-SAMA combination product, with some patients switching between or using SABA and SABA-SAMA combinations concurrently. Most patients (80.9%) received systemic corticosteroids, and nearly all (91.6%) were treated with antibiotics. Only 52.2% of patients received LABDs (39.3% LABAs). Patients treated with LABDs were more likely to have a primary COPD diagnosis, prior hospitalizations, spirometry use, and fewer comorbidities.

Conclusion: A review of COPD-related inpatient admissions found that the majority of patients received the primary recommended treatments for acute exacerbations of COPD (SABAs, systemic corticosteroids, and antibiotics). However, maintenance therapy had been initiated for only about half of patients before discharge.
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http://dx.doi.org/10.2146/ajhp160979DOI Listing
March 2018

Utilization and budget impact of tolvaptan in the inpatient setting among patients with heart failure and hyponatremia.

Curr Med Res Opin 2018 03 22;34(3):559-566. Epub 2018 Jan 22.

c Otsuka Pharmaceutical Development & Commercialization Inc. , Princeton , NJ , USA.

Objective: Assess characteristics of patients with heart failure (HF) and hyponatremia (HN) using tolvaptan, a selective vasopressin V2-receptor antagonist, for sodium correction, and estimate the budget impact of tolvaptan use in a hospital.

Methods: The Premier hospital database was analyzed to assess the utilization of tolvaptan, characteristics of users and non-users, and hospitalization costs among patients with HF and HN. Using these findings, a model was developed to estimate tolvaptan costs in proportion to total medical costs of managing patients with HF and HN, and the budget impact of tolvaptan use. Results were regenerated using data from the Healthcare Cost and Utilization Project (HCUP) database, and robustness was assessed in sensitivity analyses.

Results: Tolvaptan was used in 4.96% of inpatient visits among patients with HF and HN, more commonly among sicker patients as reflected in high utilization during intensive care stays (30.46%). Additionally, utilization increased by length of stay, which can serve as a proxy for disease severity. The model estimated that tolvaptan costs accounted for 0.3% of total hospitalization-related costs for patients with HF and HN, and the budget impact was $52.42 per visit.

Conclusions: Results demonstrate that tolvaptan is used infrequently among patients with HF and HN, and is utilized among sicker patients. Tolvaptan accounted for 0.3% of total spending on management of inpatient visits with HF and HN, and had a marginal impact on hospital budget when compared with fluid restriction for HN correction. Availability of tolvaptan can provide an additional therapeutic option for sodium correction.
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http://dx.doi.org/10.1080/03007995.2018.1423958DOI Listing
March 2018

Using an online quiz-based reinforcement system to teach healthcare quality and patient safety and care transitions at the University of California.

Int J Qual Health Care 2017 Oct;29(5):735-739

Department of Medicine, University of California San Francisco, 533 Parnassus Avenue, Box 0131, San Francisco, CA 94143-0131, USA.

Quality Issue: Implementing quality improvement (QI) education during clinical training is challenging due to time constraints and inadequate faculty development in these areas.

Initial Assessment: Quiz-based reinforcement systems show promise in fostering active engagement, collaboration, healthy competition and real-time formative feedback, although further research on their effectiveness is required.

Choice Of Solution: An online quiz-based reinforcement system to increase resident and faculty knowledge in QI, patient safety and care transitions.

Implementation: Experts in QI and educational assessment at the 5 University of California medical campuses developed a course comprised of 3 quizzes on Introduction to QI, Patient Safety and Care Transitions. Each quiz contained 20 questions and utilized an online educational quiz-based reinforcement system that leveraged spaced learning.

Evaluation: Approximately 500 learners completed the course (completion rate 66-86%). Knowledge acquisition scores for all quizzes increased after completion: Introduction to QI (35-73%), Patient Safety (58-95%), and Care Transitions (66-90%). Learners reported that the quiz-based system was an effective teaching modality and preferred this type of education to classroom-based lectures. Suggestions for improvement included reducing frequency of presentation of questions and utilizing more questions that test learners on application of knowledge instead of knowledge acquisition.

Lessons Learned: A multi-campus online quiz-based reinforcement system to train residents in QI, patient safety and care transitions was feasible, acceptable, and increased knowledge. The course may be best utilized to supplement classroom-based and experiential curricula, along with increased attention to optimizing frequency of presentation of questions and enhancing application skills.
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http://dx.doi.org/10.1093/intqhc/mzx093DOI Listing
October 2017

Current Management of Hyponatremia in Acute Heart Failure: A Report From the Hyponatremia Registry for Patients With Euvolemic and Hypervolemic Hyponatremia (HN Registry).

J Am Heart Assoc 2017 Aug 3;6(8). Epub 2017 Aug 3.

The University of Texas at Austin College of Pharmacy, Hutto, TX.

Background: Hyponatremia (HN) occurs commonly in patients with acute heart failure and confers a worse prognosis. Current HN treatment varies widely, with no consensus. This study recorded treatment practices currently used for patients hospitalized with acute heart failure and HN.

Methods And Results: Data were collected prospectively from 146 US sites on patients hospitalized with acute heart failure and HN (serum sodium concentration [Na] ≤130 mEq/L) present at admission or developing in the hospital. Baseline variables, HN treatment, and laboratory values were recorded. Of 762 patients, median [Na] was 126 mEq/L (interquartile range, 7) at baseline and increased to 130 mEq/L at discharge. Fluid restriction was the most commonly prescribed therapy (44%), followed by no specific HN treatment beyond therapy for congestion (23%), isotonic saline (5%), tolvaptan (4%), and hypertonic saline (2%). Median rate of change in [Na] varied by treatment (0.5 [interquartile range, 1.0] to 2.3 [8.0] mEq/L/d) and median treatment duration ranged from 1 (interquartile range, 1) to 6 (5) days. Fluid restriction and no specific HN treatment resulted in similar changes in [Na], and were least effective in correcting HN. Few patients (19%) had [Na] ≥135 mEq/L at discharge.

Conclusions: The most commonly used treatment approaches for HN (fluid restriction and no specific treatment) in acute heart failure increased [Na] minimally, and most patients remained hyponatremic at discharge.
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http://dx.doi.org/10.1161/JAHA.116.005261DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5586406PMC
August 2017

Confidence in correct inhaler technique and its association with treatment adherence and health status among US patients with chronic obstructive pulmonary disease.

Patient Prefer Adherence 2017 12;11:1205-1212. Epub 2017 Jul 12.

Respiratory Research, Adelphi Real World, Bollington, UK.

Background: Improper use of bronchodilators is associated with poor disease control, nonadherence to long-term therapy, and poor clinical outcomes. Our current understanding of factors associated with correct inhaler use and adherence is limited. We measured physician-and patient-reported confidence in device usage and associations with treatment adherence and COPD-related health status.

Methods: This was an analysis of a US observational, point-in-time survey of physicians and patients. Physicians who met study eligibility criteria completed surveys for 5 consecutive, eligible patients who were then invited to respond to questionnaires. We assessed patient demographics, type of prescribed inhaler device(s), device training, COPD severity, comorbidities, physician-and patient self-reported confidence in device usage, treatment adherence, and health status.

Results: Completed questionnaires for 373 patients were provided by 134 physicians. Complete confidence in device usage was observed for 22% and 17% of patients as reported by patients and physicians, respectively. Greater confidence was associated with higher self-reported adherence to inhaler usage. Physicians were more likely than patients to report lower levels of patient confidence in device usage. High physician- and patient-reported confidence were associated with more favorable health status. Predictors of confidence in device usage included fewer comorbidities, no depression, and higher education levels.

Conclusion: Low confidence in inhaler usage was associated with lower adherence and poor COPD-related health status. Choice of inhaler device tailored to patients' ability to use specific devices and ongoing education to support optimal inhaler usage may improve patient confidence and enhance both adherence and health status.
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http://dx.doi.org/10.2147/PPA.S140139DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5513874PMC
July 2017

Feasibility Study of a Mobile Health Intervention for Older Adults on Oral Anticoagulation Therapy.

Gerontol Geriatr Med 2016 Jan-Dec;2:2333721416672970. Epub 2016 Oct 7.

Department of Medicine, University of California Irvine, Irvine, CA, USA.

Oral anticoagulation treatment (OAT) such as warfarin therapy is recommended for older adults with atrial fibrillation, heart failure, or who are at risk for venous thromboembolism. Despite its proven benefits, older adults report both dissatisfaction with OAT and reduced quality of life that can potentially lead to low adherence to OAT and decreased treatment efficacy. To test the feasibility of Mobile Applications for Seniors to enhance Safe anticoagulation therapy (MASS), a mobile-based health technology intervention designed to promote independence and self-care. s: This pilot study used a single-arm experimental pre-post design to test the feasibility of a 3-month intervention using MASS in 18 older adults (male: = 14; White: = 9; Hispanic: = 7; Other: = 2; age = 67). MASS was available in English or Spanish. Participants completed surveys about their OAT knowledge, attitudes, quality of life with OAT, and adherence at baseline and at a 3-month follow-up. Satisfaction with the MASS intervention was also assessed at follow-up. Anticoagulation knowledge significantly improved from baseline to follow-up ( = 12.5 ± 5.51, = 14.78 ± 3.93, = .007). Other outcomes were not different, pre- and post-tests. Participants reported they were generally satisfied with MASS, its ease of use and its usefulness. The results showed use of MASS improved older adults' knowledge of OAT. Using mHealth apps may enhance self-care among older adults with chronic conditions who are also taking oral anticoagulants.
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http://dx.doi.org/10.1177/2333721416672970DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5486482PMC
October 2016
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