Publications by authors named "John D Sorkin"

126 Publications

Repetitive Traumatic Brain Injury Among Older Adults.

J Head Trauma Rehabil 2021 Jul 26. Epub 2021 Jul 26.

Departments of Epidemiology and Public Health (Drs Chauhan, Guralnik, and Albrecht) and Neurology (Dr Badjatia), University of Maryland School of Medicine, Baltimore; Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore (Dr dosReis); Baltimore VA Geriatric Research, Education and Clinical Center (Dr Sorkin); and Department of Medicine, Division of Gerontology and Geriatrics, University of Maryland School of Medicine, Baltimore (Dr Sorkin).

Objective: To determine the incidence of and assess risk factors for repetitive traumatic brain injury (TBI) among older adults in the United States.

Design: Retrospective cohort study.

Setting: Administrative claims data obtained from the Centers for Medicare & Medicaid Services' Chronic Conditions Data Warehouse.

Participants: Individuals 65 years or older and diagnosed with TBI between July 2008 and September 2012 drawn from a 5% random sample of US Medicare beneficiaries.

Main Measures: Repetitive TBI was identified as a second TBI occurring at least 90 days after the first occurrence of TBI following an 18-month TBI-free period. We identified factors associated with repetitive TBI using a log-binomial model.

Results: A total of 38 064 older Medicare beneficiaries experienced a TBI. Of these, 4562 (12%) beneficiaries sustained at least one subsequent TBI over up to 5 years of follow-up. The unadjusted incidence rate of repetitive TBI was 3022 (95% CI, 2935-3111) per 100 000 person-years. Epilepsy was the strongest predictor of repetitive TBI (relative risk [RR] = 1.44; 95% CI, 1.25-1.56), followed by Alzheimer disease and related dementias (RR = 1.32; 95% CI 1.20-1.45), and depression (RR = 1.30; 95% CI, 1.21-1.38).

Conclusions: Injury prevention and fall-reduction interventions could be targeted to identify groups of older adults at an increased risk of repetitive head injury. Future work should focus on injury-reduction initiatives to reduce the risk of repetitive TBI as well as assessment of outcomes related to repetitive TBI.
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http://dx.doi.org/10.1097/HTR.0000000000000719DOI Listing
July 2021

A guide for authors and readers of the American Society for Nutrition Journals on the proper use of P values and strategies that promote transparency and improve research reproducibility.

Am J Clin Nutr 2021 Jul 13. Epub 2021 Jul 13.

Division of Preventive Medicine, Brigham and Women's Hospital, Boston, MA, USA.

Two questions regarding the scientific literature have become grist for public discussion: 1) what place should P values have in reporting the results of studies? 2) How should the perceived difficulty in replicating the results reported in published studies be addressed? We consider these questions to be 2 sides of the same coin; failing to address them can lead to an incomplete or incorrect message being sent to the reader. If P values (which are derived from the estimate of the effect size and a measure of the precision of the estimate of the effect) are used improperly, for example reporting only significant findings, or reporting P values without account for multiple comparisons, or failing to indicate the number of tests performed, the scientific record can be biased. Moreover, if there is a lack of transparency in the conduct of a study and reporting of study results, it will not be possible to repeat a study in a manner that allows inferences from the original study to be reproduced or to design and conduct a different experiment whose aim is to confirm the original study's findings. The goal of this article is to discuss how P values can be used in a manner that is consistent with the scientific method, and to increase transparency and reproducibility in the conduct and analysis of nutrition research.
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http://dx.doi.org/10.1093/ajcn/nqab223DOI Listing
July 2021

Excess Mortality in COVID-19-Positive Versus COVID-19-Negative Inpatients With Diabetes: A Nationwide Study.

Diabetes Care 2021 Jul 7. Epub 2021 Jul 7.

Geriatric Research, Education, and Clinical Center, Baltimore Veterans Affairs Medical Center, Baltimore, MD.

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http://dx.doi.org/10.2337/dc20-2350DOI Listing
July 2021

A Nation-wide Review of Elective Surgery and COVID-Surge Capacity.

J Surg Res 2021 Jun 19;267:211-216. Epub 2021 Jun 19.

Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland; Surgery Service, Veterans Affairs Medical Centre, Baltimore, Maryland. Electronic address:

Background: The COVID-19 pandemic has resulted in over 225,000 excess deaths in the United States. A moratorium on elective surgery was placed early in the pandemic to reduce risk to patients and staff and preserve critical care resources. This report evaluates the impact of the elective surgical moratorium on case volumes and intensive care unit (ICU) bed utilization.

Methods: This retrospective review used a national convenience sample to correlate trends in the weekly rates of surgical cases at 170 Veterans Affairs Hospitals around the United States from January 1 to September 30, 2020 to national trends in the COVID-19 pandemic. We reviewed data on weekly number of procedures performed and ICU bed usage, stratified by level of urgency (elective, urgent, emergency), and whether an ICU bed was required within 24 hours of surgery. National data on the proportion of COVID-19 positive test results and mortality rates were obtained from the Center for Disease Control website.

Results: 198,911 unique surgical procedures performed during the study period. The total number of cases performed from January 1 to March 16 was 86,004 compared with 15,699 from March 17 to May 17. The reduction in volume occurred before an increase in the percentage of COVID-19 positive test results and deaths nationally. There was a 91% reduction from baseline in the number of elective surgeries performed allowing 78% of surgical ICU beds to be available for COVID-19 positive patients.

Conclusion: The moratorium on elective surgical cases was timely and effective in creating bed capacity for critically ill COVID-19 patients. Further analyses will allow targeted resource allocation for future pandemic planning.
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http://dx.doi.org/10.1016/j.jss.2021.05.028DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8213966PMC
June 2021

Prevalence and clinical outcomes of hospitalized patients with upper extremity deep vein thrombosis.

J Vasc Surg Venous Lymphat Disord 2021 Jun 2. Epub 2021 Jun 2.

Division of Vascular Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, Md; Vascular Service, Veterans Affairs Medical Center, Baltimore, Md. Electronic address:

Objective: Upper extremity (UE) deep vein thrombosis (DVT) is a common and increasing complication in hospitalized patients. The objective of the present study was to determine the prevalence, treatment strategies, complications, and outcomes of UE-DVT.

Methods: We performed a retrospective single-institution study of patients with a diagnosis of UE-DVT from January 2016 through February 2018 (26 months). Patients aged ≥18 years who had been admitted to the hospital and who had had positive UE duplex ultrasound findings for acute UE-DVT were included in the present study. The outcomes were in-hospital mortality, major bleeding, pulmonary embolism (PE), and recurrent UE-DVT.

Results: Among 63,045 patients admitted to the hospital, 1000 (1.6%) had been diagnosed with UE-DVT. Of 3695 UE venous duplex ultrasound examinations performed during the study period, almost one third (27.0%) were positive for acute UE-DVT. The mean age was 55.0 ± 17.2 years, and most patients were men (58.3%), white (49.2%), and overweight (mean body mass index, 29.4 ± 10.3 kg/m). The most affected vein was the right internal jugular vein (54.8%). Most of the patients (96.9%) has been receiving venous thromboembolism prophylaxis or anticoagulation therapy at the diagnosis. Most patients (77.8%) had had an intravenous device (IVD) in place at the diagnosis. Most of the patients (84.4%) were treated with anticoagulation therapy in the hospital but only one half (54.5%) were discharged with anticoagulation therapy. In-hospital mortality was 12.1% unrelated to UE-DVT, major bleeding occurred in 47.6% of the patients during hospitalization (fatal bleeding, 1%), PE was diagnosed in 4.8% of the patients, and 0.7% were fatal. Recurrent UE-DVT occurred in 6.1% of the patients. On multivariable analysis, the risk of death was increased by older age, cancer, intensive care unit admission, concomitant lower extremity DVT, and bleeding before the UE-DVT diagnosis. The presence of an IVD increased the risk of PE and the risk of recurrent UE-DVT. The risk of major bleeding was increased by the presence of an IVD, female sex, and concomitant lower extremity DVT.

Conclusions: UE-DVT is a common complication in hospitalized patients (1.6%). Consequent acute PE and recurrent DVT remain important complications, as does bleeding. It is unclear whether standard thromboprophylaxis effectively protects against UE-DVT. More studies dedicated to UE-DVT are required to provide appropriate guidance on prophylaxis and treatment.
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http://dx.doi.org/10.1016/j.jvsv.2021.05.007DOI Listing
June 2021

Revascularization for asymptomatic carotid artery stenosis improves balance and mobility.

J Vasc Surg 2021 May 19. Epub 2021 May 19.

Department of Vascular Surgery, University of Maryland School of Medicine, Baltimore, Md; Vascular Service, Veterans Affairs Medical Center, Baltimore, Md. Electronic address:

Objective: Balance and mobility function worsen with age, more so for those with underlying chronic diseases. We recently found that asymptomatic carotid artery stenosis (ACAS) restricts blood flow to the brain and might also contribute to balance and mobility impairment. In the present study, we tested the hypothesis that ACAS is a modifiable risk factor for balance and mobility impairment. Our goal was to assess the effect of restoring blood flow to the brain by carotid revascularization on the balance and mobility of patients with high-grade ACAS (≥70% diameter-reducing stenosis).

Methods: Twenty adults (age, 67.0 ± 9.4 years) undergoing carotid endarterectomy for high-grade stenosis were enrolled. Balance and mobility assessments were performed before and 6 weeks after revascularization. These included the Short Physical Performance Battery, the Berg Balance Scale, the Four Square Step Test, the Dynamic Gait Index (DGI), the Timed Up and Go test, gait speed, the Mini-Balance Evaluation Systems Test (Mini-BESTest), and the Walking While Talking complex test.

Results: Consistent with our previous findings, patients demonstrated reduced scores on the Short Physical Performance Battery, Berg Balance Scale, DGI, and Timed Up and Go test and in gait speed. Depending on the outcome measure, 25% to 90% of the patients had scored in the impaired range at baseline. After surgery, significant improvements were observed in the outcome measures that combined walking with dynamic movements, including the DGI (P = .02) and Mini-BESTest (P = .002). The proportion of patients with Mini-BESTest scores indicating a high fall risk had decreased significantly from 90% (n = 18) at baseline to 40% (n = 8) after surgery (P = .02). We used Pearson's correlations to examine the relationship between balance and mobility before surgery and the change after surgery. Patients with lower baseline DGI and Mini-BESTest scores demonstrated the most improvement after surgery (r = -0.59, P = .006; and r = -0.70, P = .001, respectively).

Conclusions: Carotid revascularization improved patients' balance and mobility, especially for measures that combine walking and dynamic movements. The greatest improvements were observed for the patients who had been most impaired at baseline.
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http://dx.doi.org/10.1016/j.jvs.2021.04.056DOI Listing
May 2021

Catheter-based interventions versus medical and surgical approaches in acute pulmonary embolism.

J Vasc Surg Venous Lymphat Disord 2021 May 7. Epub 2021 May 7.

Department of Surgery, University of Maryland School of Medicine, Baltimore, Md.

Objective: Catheter-based intervention (CBI) has become an increasingly popular option for treating pulmonary embolism (PE); however, the real benefits are unknown. The purpose of the present study was to compare the outcomes of patients treated with CBI with the outcomes of those treated with medical or surgical approaches.

Methods: We performed a retrospective analysis of patients admitted from October 2015 to December 2017 with a diagnosis of acute PE. We compared patients aged ≥18 years with a diagnosis of acute PE treated with CBI against a control group identified by propensity score matching. The control group was divided into those who had undergone surgical pulmonary embolectomy (SPE) as the surgical group and those who had not undergone SPE as the medical group. The primary outcome was mortality (in-hospital and overall mortality). The secondary outcomes were major bleeding, length of hospital stay, thrombus resolution, right ventricle improvement in systolic function and dilatation, and recurrent PE.

Results: Of the 108 patients, 30 were in the CBI group and 78 were in the control group (62 in the medical group and 16 in the surgical group). The patient characteristics on admission were similar, except for the body mass index, which was greater in the CBI group (P = .03). No difference was found in clinical severity, clot burden, right ventricle function, or biomarkers. Recurrent PE was less frequent in the CBI group than in the medical group (0% vs 6.4%). Otherwise, no significant differences were found in the outcomes between the CBI and medical groups. When CBI was compared with the surgical group, SPE was associated with improved mortality (0% vs 16.6%) but a longer median length of hospital stay (median, 7 days; interquartile range, 3-12 days; vs median, 8 days; interquartile range, 6.5-17 days).

Conclusions: The use of CBI reduced the number of recurrent PE events compared with the medically treated patients; however, the mortality was higher than that in the surgical group.
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http://dx.doi.org/10.1016/j.jvsv.2021.02.015DOI Listing
May 2021

Increased complications in patients who test COVID-19 positive after elective surgery and implications for pre and postoperative screening.

Am J Surg 2021 Apr 14. Epub 2021 Apr 14.

Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA; Surgery Service, Veterans Affairs Medical Center, Baltimore, MD, USA. Electronic address:

Background: The COVID-19 pandemic has necessitated the adoption of protocols to minimize risk of periprocedural complications associated with SARS-CoV-2 infection. This typically involves a preoperative symptom screen and nasal swab RT-PCR test for viral RNA. Asymptomatic patients with a negative COVID-19 test are cleared for surgery. However, little is known about the rate of postoperative COVID-19 positivity among elective surgical patients, risk factors for this group and rate of complications.

Methods: This prospective multicenter study included all patients undergoing elective surgery at 170 Veterans Health Administration (VA) hospitals across the United States. Patients were divided into groups based on first positive COVID-19 test within 30 days after surgery (COVID[-/+]), before surgery (COVID[+/-]) or negative throughout (COVID[-/-]). The cumulative incidence, risk factors for and complications of COVID[-/+], were estimated using univariate analysis, exact matching, and multivariable regression.

Results: Between March 1 and December 1, 2020 90,093 patients underwent elective surgery. Of these, 60,853 met inclusion criteria, of which 310 (0.5%) were in the COVID[-/+] group. Adjusted multivariable logistic regression identified female sex, end stage renal disease, chronic obstructive pulmonary disease, congestive heart failure, cancer, cirrhosis, and undergoing neurosurgical procedures as risk factors for being in the COVID[-/+] group. After matching on current procedural terminology code and month of procedure, multivariable Poisson regression estimated the complication rate ratio for the COVID[-/+] group vs. COVID[-/-] to be 8.4 (C.I. 4.9-14.4) for pulmonary complications, 3.0 (2.2, 4.1) for major complications, and 2.6 (1.9, 3.4) for any complication.

Discussion: Despite preoperative COVID-19 screening, there remains a risk of COVID infection within 30 days after elective surgery. This risk is increased for patients with a high comorbidity burden and those undergoing neurosurgical procedures. Higher intensity preoperative screening and closer postoperative monitoring is warranted in such patients because they have a significantly elevated risk of postoperative complications.
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http://dx.doi.org/10.1016/j.amjsurg.2021.04.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8045424PMC
April 2021

Low Back Pain and Substance Use: Diagnostic and Administrative Coding for Opioid Use and Dependence Increased in U.S. Older Adults with Low Back Pain.

Pain Med 2021 04;22(4):836-847

Geriatric Research Education and Clinical Center, VA Maryland Health Care System, Baltimore, Maryland.

Objective: Low back pain (LBP) is a leading cause of pain and disability. Substance use complicates the management of LBP, and potential risks increase with aging. Despite implications for an aging, diverse U.S. population, substance use and LBP comorbidity remain poorly defined. The objective of this study was to characterize LBP and substance use diagnoses in older U.S. adults by age, gender, and race.

Design: Cross-sectional study of a random national sample.

Subjects: Older adults including 1,477,594 U.S. Medicare Part B beneficiaries.

Methods: Bayesian analysis of 37,634,210 claims, with 10,775,869 administrative and 92,903,649 diagnostic code assignments.

Results: LBP was diagnosed in 14.8±0.06% of those more than 65 years of age, more in females than in males (15.8±0.08% vs. 13.4±0.09%), and slightly less in those more than 85 years of age (13.3±0.2%). Substance use diagnosis varied by substance: nicotine, 9.6±0.02%; opioid, 2.8±0.01%; and alcohol, 1.3±0.01%. Substance use diagnosis declined with advancing age cohort. Opioid use diagnosis was markedly higher for those in whom LBP was diagnosed (10.5%) than for those not diagnosed with LBP (1.5%). Most older adults (54.9%) with an opioid diagnosis were diagnosed with LBP. Gender differences were modest. Relative rates of substance use diagnoses in LBP were modest for nicotine and alcohol.

Conclusions: Older adults with LBP have high relative rates of opioid diagnoses, irrespective of gender or age. Most older adults with opioid-related diagnoses have LBP, compared with a minority of those not opioid diagnosed. In caring for older adults with LBP or opioid-related diagnoses, health systems must anticipate complexity and support clinicians, patients, and caregivers in managing pain comorbidities. Older adults may benefit from proactive incorporation of non-opioid pain treatments. Further study is needed.
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http://dx.doi.org/10.1093/pm/pnaa428DOI Listing
April 2021

Comparison of Lateral Perturbation-Induced Step Training and Hip Muscle Strengthening Exercise on Balance and Falls in Community Dwelling Older Adults: A Blinded Randomized Controlled Trial.

J Gerontol A Biol Sci Med Sci 2021 Jan 25. Epub 2021 Jan 25.

Division of Gerontology and Geriatric Medicine, University of Maryland School of Medicine, Baltimore, MD, USA.

Background: This factorial, assessor-blinded, randomized, and controlled study compared the effects of perturbation-induced step training (lateral waist-pulls), hip muscle strengthening, and their combination, on balance performance, muscle strength, and prospective falls among older adults.

Methods: community-dwelling older adults were randomized to four training groups. Induced-step training (IST, n=25) involved 43 progressive perturbations. Hip abduction strengthening (HST, n=25) utilized progressive resistance exercises. Combined training (CMB, n=25) included IST and HST, and the control performed seated flexibility/relaxation exercises (SFR, n=27). Training involved 36 sessions over 12-weeks. The primary outcomes were the number of recovery steps and first step length, and maximum hip abduction torque. Fall frequency during 12 months after training was determined.

Results: Overall, the number of recovery steps was reduced by 31%, and depended upon the first step type. IST and CMB increased the rate of more stable single lateral steps pre-post training than HST and SFR who used more multiple crossover and sequential steps. The improved rate of lateral steps for CMB exceeded the control (CMB/SFR rate ratio 2.68). First step length was unchanged, and HST alone increased hip torque by 25%. Relative to SFR, the fall rate ratios (falls/person/year) [95% confidence interval] were: CMB 0.26 [0.07 to 0.90], IST 0.44 [0.18 to 1.08], HST 0.30 (0.10 to 0.91).

Conclusions: Balance performance through stepping was best improved by combining perturbation and strength training and not strengthening alone. The interventions reduced future falls by 56% -74% over the control. Lateral balance perturbation training may enhance traditional programs for fall prevention.
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http://dx.doi.org/10.1093/gerona/glab017DOI Listing
January 2021

Telehealth Exercise Intervention in Older Adults With HIV: Protocol of a Multisite Randomized Trial.

J Assoc Nurses AIDS Care 2021 Jan 20. Epub 2021 Jan 20.

Krisann K. Oursler, MD, ScM, is Director, Geriatric Research and Education, Salem Veterans Affairs Medical Center, and is an Associate Professor, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA. Vincent C. Marconi, MD, is Director, Infectious Diseases Research Program, Atlanta Veterans Affairs Medical Center, and is a Professor, Emory University School of Medicine and Emory University Rollins School of Public Health, Atlanta, Georgia, USA. Brandon C. Briggs, MS, is an Exercise Physiologist, Salem Veterans Affairs Medical Center, and a PhD Student, Concordia University Chicago, Chicago, Illinois, USA. John D. Sorkin, MD, PhD, is Chief, Biostatistics and Informatics, Veterans Affairs Maryland Health Care System, Baltimore Veterans Affairs Medical Center Geriatric Research, Education, and Clinical Center, and is a Professor, University of Maryland School of Medicine, Baltimore, Maryland, USA. Alice S. Ryan, PhD, is Senior Research Career Scientist, Rehabilitation Research & Development, Veterans Affairs Maryland Health Care System, Baltimore Veterans Affairs Medical Center Geriatric Research, Education, and Clinical Center, and is a Professor, University of Maryland School of Medicine, Baltimore, Maryland, USA. The FIT VET Project Team is listed in Acknowledgments.

Abstract: People with HIV (PWH) have reduced cardiorespiratory fitness, but a high intensity, easily disseminated exercise program has not yet been successfully developed in older PWH. The purpose of this article is to describe a synchronous telehealth exercise intervention in older PWH, delivered from one medical center to two other centers. Eighty older PWH (≥50 years) on antiretroviral therapy will be randomized to exercise or delayed entry control groups. Functional circuit exercise training, which does not entail stationary equipment, will be provided by real-time videoconferencing, 3 times weekly for 12 weeks, to small groups. Continuous remote telemonitoring of heart rate will ensure high exercise intensity. We hypothesize that telehealth exercise will be feasible and increase cardiorespiratory fitness and reduce sarcopenia and frailty. Findings will provide new insight to target successful aging in older PWH and can also be widely disseminated to PWH of any age or other patient populations.
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http://dx.doi.org/10.1097/JNC.0000000000000235DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8289938PMC
January 2021

Periprocedural complications in patients with SARS-CoV-2 infection compared to those without infection: A nationwide propensity-matched analysis.

Am J Surg 2021 Aug 28;222(2):431-437. Epub 2020 Dec 28.

Geriatrics Research, Education, and Clinical Center, Veterans Affairs Medical Center, Baltimore, MD, USA; Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA.

Background: Reports on emergency surgery performed soon after a COVID-19 infection that are not controlled for premorbid risk-factors show increased 30-day mortality and pulmonary complications. This contributed to a virtual cessation of elective surgery during the pandemic surge. To inform evidence-based guidance on the decisions for surgery during the recovery phase of the pandemic, we compare 30-day outcomes in patients testing positive for COVID-19 before their operation, to contemporary propensity-matched COVID-19 negative patients undergoing the same procedures.

Methods: This prospective multicentre study included all patients undergoing surgery at 170 Veterans Health Administration (VA) hospitals across the United States. COVID-19 positive patients were propensity matched to COVID-19 negative patients on demographic and procedural factors. We compared 30-day outcomes between COVID-19 positive and negative patients, and the effect of time from testing positive to the date of procedure (≤10 days, 11-30 days and >30 days) on outcomes.

Results: Between March 1 and August 15, 2020, 449 COVID-19 positive and 51,238 negative patients met inclusion criteria. Propensity matching yielded 432 COVID-19 positive and 1256 negative patients among whom half underwent elective surgery. Infected patients had longer hospital stays (median seven days), higher rates of pneumonia (20.6%), ventilator requirement (7.6%), acute respiratory distress syndrome (ARDS, 17.1%), septic shock (13.7%), and ischemic stroke (5.8%), while mortality, reoperations and readmissions were not significantly different. Higher odds for ventilation and stroke persisted even when surgery was delayed 11-30 days, and for pneumonia, ARDS, and septic shock >30 days after a positive test.

Discussion: 30-day pulmonary, septic, and ischaemic complications are increased in COVID-19 positive, compared to propensity score matched negative patients. Odds for several complications persist despite a delay beyond ten days after testing positive. Individualized risk-stratification by pulmonary and atherosclerotic comorbidities should be considered when making decisions for delaying surgery in infected patients.
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http://dx.doi.org/10.1016/j.amjsurg.2020.12.024DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7836786PMC
August 2021

Asymptomatic carotid artery stenosis is associated with cerebral hypoperfusion.

J Vasc Surg 2021 May 7;73(5):1611-1621.e2. Epub 2020 Nov 7.

Department of Vascular Surgery, University of Maryland School of Medicine, Baltimore, Md; Vascular Service, Veterans Affairs Medical Center, Baltimore, Md. Electronic address:

Objective: We have shown that almost 50% of patients with asymptomatic carotid stenosis (ACS) will demonstrate cognitive impairment. Recent evidence has suggested that cerebral hypoperfusion is an important cause of cognitive impairment. Carotid stenosis can restrict blood flow to the brain, with consequent cerebral hypoperfusion. In contrast, cross-hemispheric collateral compensation through the Circle of Willis, and cerebrovascular vasodilation can also mitigate the effects of flow restriction. It is, therefore, critical to develop a clinically relevant measure of net brain perfusion in patients with ACS that could help in risk stratification and in determining the appropriate treatment. To determine whether ACS results in cerebral hypoperfusion, we developed a novel approach to quantify interhemispheric cerebral perfusion differences, measured as the time to peak (TTP) and mean transit time (MTT) delays using perfusion-weighted magnetic resonance imaging (PWI) of the whole brain. To evaluate the utility of using clinical duplex ultrasonography (DUS) to infer brain perfusion, we also assessed the relationship between the PWI findings and ultrasound-based peak systolic velocity (PSV).

Methods: Structural and PWI of the brain and magnetic resonance angiography of the carotid arteries were performed in 20 patients with ≥70% ACS. DUS provided the PSV, and magnetic resonance angiography provided plaque geometric measures at the stenosis. Volumetric perfusion maps of the entire brain from PWI were analyzed to obtain the mean interhemispheric differences for the TTP and MTT delays. In addition, the proportion of brain volume that demonstrated a delay in TTP and MTT was also measured. These proportions were measured for increasing severity of perfusion delays (0.5, 1.0, and 2.0 seconds). Finally, perfusion asymmetries on PWI were correlated with the PSV and stenosis features on DUS using Pearson's correlation coefficients.

Results: Of the 20 patients, 18 had unilateral stenosis (8 right and 10 left) and 2 had bilateral stenoses. The interhemispheric (left-right) TTP delays measured for the whole brain volume identified impaired perfusion in the hemisphere ipsilateral to the stenosis in 16 of the 18 patients. More than 45% of the patients had had ischemia in at least one half of their brain volume, with a TTP delay >0.5 second. The TTP and MTT delays showed strong correlations with PSV. In contrast, the correlations with the percentage of stenosis were weaker. The correlations for the PSV were strongest with the perfusion deficits (TTP and MTT delays) measured for the whole brain using our proposed algorithm (r = 0.80 and r = 0.74, respectively) rather than when measured on a single magnetic resonance angiography slice as performed in current clinical protocols (r = 0.31 and r = 0.58, respectively).

Conclusions: Interhemispheric TTP and MTT delay measured for the whole brain using PWI has provided a new tool for assessing cerebral perfusion deficits in patients with ACS. Carotid stenosis was associated with a detectable reduction in ipsilateral brain perfusion compared with the opposite hemisphere in >80% of patients. The PSV measured at the carotid stenosis using ultrasonography correlated with TTP and MTT delays and might serve as a clinically useful surrogate to brain hypoperfusion in these patients.
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http://dx.doi.org/10.1016/j.jvs.2020.10.063DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8209736PMC
May 2021

Association between Physical Activity and Mortality in Patients with Claudication.

Med Sci Sports Exerc 2021 04;53(4):732-739

Department of Physical Medicine and Rehabilitation, Penn State College of Medicine, Hershey, PA.

Purpose: This study aimed to determine the association between light-intensity physical activity and the incidence of all-cause and cardiovascular mortality in patients with peripheral artery disease (PAD) limited by claudication followed for up to 18.7 yr.

Methods: A total of 528 patients with PAD and claudication were screened in Baltimore between 1994 and 2002, and 386 were deemed eligible for the study. At baseline, patients were classified into three physical activity groups: 1) physically sedentary, 2) light intensity, and 3) moderate to vigorous intensity based on a questionnaire. All-cause and cardiovascular mortality of patients through December 2014 was determined using the National Death Index and the U.S. Department of Veterans Affairs and the U.S. Department of Defense Suicide Data Repository.

Results: Median survival time was 9.9 yr (interquartile range, 4.9-15.7 yr; range, 0.38-18.7 yr). During follow-up, 257 patients (66.6%) died, consisting of 40/48 (83.3%) from the sedentary group, 135/210 (64.3%) from the light-intensity group, and 82/128 (64.0%) from the moderate- to vigorous-intensity group. For all-cause mortality, light-intensity activity status (hazard ratio [HR] = 0.523, P = 0.0007) and moderate- to vigorous-intensity status (HR = 0.425, P < 0.0001) were significant predictors. During follow-up, 125 patients died because of cardiovascular causes (32.4%), in which light-intensity activity status (HR = 0.511, P = 0.0113) and moderate- to vigorous-intensity activity status (HR = 0.341, P = 0.0003) were significant predictors.

Conclusions: Light-intensity physical activity is associated with nearly 50% lower risk of all-cause and cardiovascular mortality in high-risk patients with PAD and claudication. Furthermore, moderate- to vigorous-intensity physical activity performed regularly is associated with 58% and 66% lower risk of all-cause and cardiovascular mortality, respectively. The survival benefits associated with light-intensity physical activity make it a compelling behavioral intervention that extends beyond improving ambulation.
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http://dx.doi.org/10.1249/MSS.0000000000002526DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7969371PMC
April 2021

Feasibility and effects of high-intensity interval training in older adults living with HIV.

J Sports Sci 2021 Feb 23;39(3):304-311. Epub 2020 Sep 23.

Geriatrics and Extended Care, Salem Veterans Affairs Medical Center , Salem, VA, USA.

Adults with HIV on therapy can live a normal lifespan but exhibit advanced ageing which includes reduced cardiorespiratory fitness. Our objective was to determine the feasibility and effects of high-intensity interval training (HIIT) combined with resistance training (RT) in older adults with HIV. We conducted a cross-over pilot study within a randomized exercise trial in sedentary adults with HIV ≥50 years of age. First, participants were randomized to 4 months of continuous high-intensity aerobic exercise (AEX) and RT 3x/week or standard of care control. Then, the control group completed 4 months of HIIT + RT (3x/week). Among the 32 individuals enrolled, 26 eligible participants were randomized. Most participants were African American (63%) and male (95%) with a mean (SD) age of 61.5 (6.7) years and VOpeak of 24.5 (4.9) ml/kg/min. Attendance and adherence to both exercise training interventions were high. The clinically significant increases in VOpeak (ml/kg/min) after HIIT (3.09 ±1.04, p=0.02) and AEX (2.09 ±0.72, p=0.01) represented improvements of 17.1% and 7.7%, respectively. Both groups had improvements in exercise endurance (time on the treadmill) and strength (all p< 0.01). This pilot study supports HIIT as an efficient means to deliver high-intensity AEX to improve cardiorespiratory fitness toward the goal of attenuating the accelerated ageing process in adults with HIV.
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http://dx.doi.org/10.1080/02640414.2020.1818949DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8212165PMC
February 2021

Age-Related Differences in Arm and Trunk Responses to First and Repeated Exposure to Laterally Induced Imbalances.

Brain Sci 2020 Aug 20;10(9). Epub 2020 Aug 20.

Department of Physical Therapy and Rehabilitation Science, University of Maryland School of Medicine, Baltimore, MD 21201, USA.

The objective of this study was to examine age-related differences in arm and trunk responses during first and repeated step induced balance perturbations. Young and older adults received 10 trials of unpredictable lateral platform translations. Outcomes included maximum arm and trunk displacement within 1 s of perturbation and at first foot lift off (FFLO), arm and neck muscle activity as recorded using electromyography (EMG), initial step type, balance confidence, and percentage of harness-assisted trials. Compared to young adults, older adults demonstrated greater arm and trunk angular displacements during the first trial, which were present at FFLO and negatively associated with balance confidence. Unlike young adults, recovery steps in older adults were directed towards the fall with a narrowed base of support. Over repeated trials, rapid habituation of first-trial responses of bilateral arm and trunk displacement and EMG amplitude was demonstrated in young adults, but was absent or limited in older adults. Older adults also relied more on harness assistance during balance recovery. Exaggerated arm and trunk responses to sudden lateral balance perturbations in older adults appear to influence step type and balance recovery. Associations of these persistently amplified movements with an increased reliance on harness assistance suggest that training to reduce these deficits could have positive effects in older adults with and without neurological disorders.
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http://dx.doi.org/10.3390/brainsci10090574DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7564542PMC
August 2020

Burden of perianal colonization in nursing home residents increases transmission to healthcare worker gowns and gloves.

Infect Control Hosp Epidemiol 2020 12 7;41(12):1396-1401. Epub 2020 Aug 7.

Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland.

Objective: To evaluate the effect of the burden of Staphylococcus aureus colonization of nursing home residents on the risk of S. aureus transmission to healthcare worker (HCW) gowns and gloves.

Design: Multicenter prospective cohort study.

Setting And Participants: Residents and HCWs from 13 community-based nursing homes in Maryland and Michigan.

Methods: Residents were cultured for S. aureus at the anterior nares and perianal skin. The S. aureus burden was estimated by quantitative polymerase chain reaction detecting the nuc gene. HCWs wore gowns and gloves during usual care activities; gowns and gloves were swabbed and then cultured for the presence of S. aureus.

Results: In total, 403 residents were enrolled; 169 were colonized with methicillin-resistant S. aureus (MRSA) or methicillin-sensitive S. aureus (MSSA) and comprised the study population; 232 were not colonized and thus were excluded from this analysis; and 2 were withdrawn prior to being swabbed. After multivariable analysis, perianal colonization with S. aureus conferred the greatest odds for transmission to HCW gowns and gloves, and the odds increased with increasing burden of colonization: adjusted odds ratio (aOR), 2.1 (95% CI, 1.3-3.5) for low-level colonization and aOR 5.2 (95% CI, 3.1-8.7) for high level colonization.

Conclusions: Among nursing home patients colonized with S. aureus, the risk of transmission to HCW gowns and gloves was greater from those colonized with greater quantities of S. aureus on the perianal skin. Our findings inform future infection control practices for both MRSA and MSSA in nursing homes.
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http://dx.doi.org/10.1017/ice.2020.336DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8221075PMC
December 2020

Reducing Inpatient Hypoglycemia in the General Wards Using Real-time Continuous Glucose Monitoring: The Glucose Telemetry System, a Randomized Clinical Trial.

Diabetes Care 2020 11 5;43(11):2736-2743. Epub 2020 Aug 5.

Division of Endocrinology, Baltimore Veterans Affairs Medical Center, Baltimore, MD

Objective: Use of real-time continuous glucose monitoring (RT-CGM) systems in the inpatient setting is considered investigational. The objective of this study was to evaluate whether RT-CGM, using the glucose telemetry system (GTS), can prevent hypoglycemia in the general wards.

Research Design And Methods: In a randomized clinical trial, insulin-treated patients with type 2 diabetes at high risk for hypoglycemia were recruited. Participants were randomized to RT-CGM/GTS or point-of-care (POC) blood glucose testing. The primary outcome was difference in inpatient hypoglycemia.

Results: Seventy-two participants were included in this interim analysis, 36 in the RT-CGM/GTS group and 36 in the POC group. The RT-CGM/GTS group experienced fewer hypoglycemic events (<70 mg/dL) per patient (0.67 [95% CI 0.34-1.30] vs. 1.69 [1.11-2.58], = 0.024), fewer clinically significant hypoglycemic events (<54 mg/dL) per patient (0.08 [0.03-0.26] vs. 0.75 [0.51-1.09], = 0.003), and a lower percentage of time spent below range <70 mg/dL (0.40% [0.18-0.92%] vs. 1.88% [1.26-2.81%], = 0.002) and <54 mg/dL (0.05% [0.01-0.43%] vs. 0.82% [0.47-1.43%], = 0.017) compared with the POC group. No differences in nocturnal hypoglycemia, time in range 70-180 mg/dL, and time above range >180-250 mg/dL and >250 mg/dL were found between the groups. The RT-CGM/GTS group had no prolonged hypoglycemia compared with 0.20 episodes <54 mg/dL and 0.40 episodes <70 mg/dL per patient in the POC group.

Conclusions: RT-CGM/GTS can decrease hypoglycemia among hospitalized high-risk insulin-treated patients with type 2 diabetes.
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http://dx.doi.org/10.2337/dc20-0840DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7576426PMC
November 2020

Safety of exercise therapy after acute pulmonary embolism.

Phlebology 2020 Dec 27;35(10):824-832. Epub 2020 Jul 27.

Division of Vascular Surgery, Department of Surgery, University of Maryland, Baltimore, MD, USA.

Objective: The role of exercise therapy after acute pulmonary embolism (PE) is unknown. Exercise therapy is safely used after myocardial infarction and chronic obstructive pulmonary disease. The aim of this study was to investigate the safety of exercise therapy after acute PE.

Methods: We implemented a 3-month exercise program after acute PE. Outcomes were death, bleeding, readmissions, recurrent events, changes in peak VO2 and quality of life (QoL).

Results: A total of 23 patients were enrolled and received anticoagulation; no adverse events were reported during the exercise period. One death, 1 DVT and 5 readmissions were reported due to non-exercise related reasons. Functional capacity improved as evidenced by an increased peak VO2 at 3 months (+3.9 ± 5.6 mL/kg/min; p = 0.05). Improvement in QoL was observed at 6-months on the functional (+17.0 ± 22.6, p = 0.03) and physical health factor scales (+0.9 ± 4.6, p = 0.03).

Conclusion: Exercise therapy is feasible and safe in appropriately anticoagulated patients after PE.
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http://dx.doi.org/10.1177/0268355520946625DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8209689PMC
December 2020

A Propensity Score Matched Study of the Positive Impact of Infectious Diseases Consultation on Antimicrobial Appropriateness in Hospitalized Patients with Antimicrobial Stewardship Oversight.

Antimicrob Agents Chemother 2020 07 22;64(8). Epub 2020 Jul 22.

University of Maryland School of Medicine, Division of Infectious Diseases, Baltimore, Maryland, USA.

Hospital-based antibiotic stewardship (AS) programs provide oversight and guidance for appropriate antimicrobial use in acute care settings. Infectious disease expertise is beneficial in the care of hospitalized patients with infections. The impact of infectious diseases consultation (IDC) on antimicrobial appropriateness in a large tertiary hospital with an established AS program was investigated. This was a cross-sectional study from October 2017 to March 2019 at a large academic hospital with an AS-directed prospective audit and feedback process and multiple IDC services. Antimicrobial appropriateness was adjudicated by an AS team member after antimicrobial start. Antimicrobial appropriateness was compared among antimicrobial orders with and without IDC using propensity score matching and multivariable logistic regression. Analyses were stratified by primary services caring for the patients. There were 10,508 antimicrobial orders from 6,165 unique patient encounters. Overall appropriateness was 92%, with higher appropriateness among patients with IDC versus without IDC (94% versus 84%;  < 0.0001). After propensity score matching and adjustment for certain antibiotics, organisms, syndromes, and locations, IDC was associated with a greater antimicrobial appropriateness odds ratio (OR) of 2.4 (95% confidence interval [CI], 1.9 to 3.0). Stratification by primary service showed an OR of 2.9 (95% CI, 2.1 to 3.8) for surgical specialties and an OR of 1.6 (95% CI, 1.1 to 2.2) for medical specialties. Even with a high overall antimicrobial appropriateness, patients with IDC had greater odds of antimicrobial appropriateness than those without IDC, and this impact was greater in surgical specialties. Infectious diseases consultation can be synergistic with antimicrobial stewardship programs.
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http://dx.doi.org/10.1128/AAC.00307-20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7526803PMC
July 2020

Association of glucose variability at the last day of hospitalization with 30-day readmission in adults with diabetes.

BMJ Open Diabetes Res Care 2020 05;8(1)

Division of Endocrinology, Metabolism, and Lipids, Emory University School of Medicine, Atlanta, Georgia, USA.

Objective: To evaluate whether increased glucose variability (GV) during the last day of inpatient stay is associated with increased risk of 30-day readmission in patients with diabetes.

Research Design And Methods: A comprehensive list of clinical, pharmacy and utilization files were obtained from the Veterans Affairs (VA) Central Data Warehouse to create a nationwide cohort including 1 042 150 admissions of patients with diabetes over a 14-year study observation period. Point-of-care glucose values during the last 24 hours of hospitalization were extracted to calculate GV (measured as SD and coefficient of variation (CV)). Admissions were divided into 10 categories defined by progressively increasing SD and CV. The primary outcome was 30-day readmission rate, adjusted for multiple covariates including demographics, comorbidities and hypoglycemia.

Results: As GV increased, there was an overall increase in the 30-day readmission rate ratio. In the fully adjusted model, admissions with CV in the 5th-10th CV categories and admissions with SD in the 4th-10th categories had a statistically significant progressive increase in 30-day readmission rates, compared with admissions in the 1st (lowest) CV and SD categories. Admissions with the greatest CV and SD values (10th category) had the highest risk for readmission (rate ratio (RR): 1.08 (95% CI 1.05 to 1.10), p<0.0001 and RR: 1.11 (95% CI 1.09 to 1.14), p<0.0001 for CV and SD, respectively).

Conclusions: Patients with diabetes who exhibited higher degrees of GV on the final day of hospitalization had higher rates of 30-day readmission.

Trial Registration Number: NCT03508934, NCT03877068.
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http://dx.doi.org/10.1136/bmjdrc-2019-000990DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7222883PMC
May 2020

Incidence of Postoperative Opioid Overdose and New Diagnosis of Opioid Use Disorder Among US Veterans.

Am J Addict 2020 07 22;29(4):295-304. Epub 2020 Mar 22.

VA Maryland Health Care System, Baltimore, Maryland.

Background And Objectives: Perioperative exposure to opioids is associated with adverse outcomes. We aim to determine the associations between surgery and subsequent opioid overdose, an acute event, and a new diagnosis of opioid use disorder (OUD), a chronic relapsing disease, in parallel.

Methods: This retrospective cohort study of US veterans used surgery as exposure and the two outcomes were (1) occurrence of overdose and (2) new diagnosis of OUD in the first postoperative year. Surgical group was matched to the reference controls based on the propensity score of having surgery, and matched logistic regression was used to calculate the odds ratio (OR).

Results: A total of 261 208 surgical patients were matched to 479 531 controls. Overdose occurred in 1893 (0.7%) of the surgical patients and in 518 (0.1%) of the matched controls in the first postoperative year (OR, 6.71; 95% confidence interval [CI], 5.80-7.75; P < .001). Among patients with no history of OUD, surgery was also associated with a new diagnosis of OUD in the first postoperative year (OR, 1.13; 95% CI, 1.02-1.24; P = .015).

Discussion And Conclusions: The postoperative period is strongly associated with opioid overdose, but only weakly associated with new diagnosis of OUD. This is likely due to the difficulty of diagnosing OUD in the postoperative period.

Scientific Significance: This is the first study that has examined opioid overdose and new-onset OUD in the postoperative period in parallel. Our analysis suggests different risk factors for each, as well as different strengths of association with surgery. More sensitive diagnostic criteria for postoperative OUD are needed to promptly diagnose and treat this condition. (Am J Addict 2020;00:00-00).
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http://dx.doi.org/10.1111/ajad.13022DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7416726PMC
July 2020

High prevalence of chronic venous disease among health care workers in the United States.

J Vasc Surg Venous Lymphat Disord 2020 03;8(2):224-230

Division of Vascular Surgery, Department of Surgery, University of Maryland, Baltimore, Md; Vascular Service, Veterans Affairs Medical Center, Baltimore, Md; Baltimore VA Geriatric Research, Education, and Clinical Center, Veterans Affairs Medical Center, Baltimore, Md. Electronic address:

Background: Health care workers spend extended times standing and walking short distances and are at risk for development of chronic venous insufficiency (CVI). We conducted a hospital-wide venous screening program designed to measure the prevalence of and risk factors for clinical manifestations of CVI and ultrasound evidence of venous reflux or obstruction in health care workers. We also determined their risk for deep venous thrombosis (DVT).

Methods: Free venous screening and education were offered to all hospital employees; the program started in April 2016, and results are presented from the first year. Demographics, medical history, and use of compression stockings were recorded. A physical examination determined the clinical class of the Clinical, Etiology, Anatomy, and Pathophysiology (CEAP) classification for clinical disease, and an ultrasound test evaluated for reflux or obstruction in the common femoral vein, popliteal vein, and saphenofemoral junction. The Caprini score was recorded to evaluate risk of DVT. Descriptive statistics were reported, and logistic regression was used for multivariate analysis of risk factors.

Results: We enrolled 636 participants (1272 legs); 93.0% were women. The median age was 42 years (interquartile range, 31-52 years), mean body mass index was 29.2 ± 6.6 kg/m, and most participants were white (49.1%) or African American (39.5%); 18% reported having hypertension, 7.1% had diabetes, and 6.1% were current smokers. The majority reported occasional leg pain (72.7%) and evening leg swelling (42.3%). Only 2.7% used daily compression stockings. Clinical evidence of CVI was present in at least one leg in 69.1% (C1, 49.0%; C2, 17.7%; C3, 1.9%; C4, 0.2%; C5, 0.2%). Venous reflux was present in at least one leg in 82.1%; obstruction was rare (0.2%). Reflux in either the superficial (saphenofemoral junction) or the deep (femoral or popliteal) venous system was present in the majority (71.0%) of patients with CVI (clinical class ≥C1). Reflux and white race were risk factors for clinical disease; clinical disease, age, female sex, and white race were risk factors for reflux. On the basis of the Caprini score, 14.1% of participants were in the highest risk category for DVT when experiencing a high-risk situation (including 2.2% with history of DVT).

Conclusions: Prevalence of clinical CVI and venous reflux is high among health care workers despite a low frequency of cardiovascular comorbidities. Increased awareness about CVI and DVT and preventive strategies for venous disease must be instituted in this high-risk cohort.
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http://dx.doi.org/10.1016/j.jvsv.2019.10.017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7375188PMC
March 2020

The relationship between sleep-disordered breathing, blood pressure, and urinary cortisol and catecholamines in children.

J Clin Sleep Med 2020 06;16(6):907-916

Division of Pulmonary Medicine and Sleep Center, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.

Study Objectives: Hypertension is a complication of obstructive sleep apnea (OSA) syndrome in adults. A correlation between OSA syndrome and elevated blood pressure (BP) is suggested in children, but its pathogenesis remains unclear. Our aim was to study the effects of sleep and sleep apnea on BP and sympathetic nervous system activation as measured by serum cortisol and urinary catecholamines. We hypothesized that children with OSA syndrome would have higher BP, urinary catecholamines, and cortisol compared with controls.

Methods: We measured BP during polysomnography in 78 children with suspected sleep-disordered breathing and 18 nonsnoring controls. BP was measured during wakefulness and every 30-60 minutes throughout the night. All participants had 24-hour urinary catecholamine and free cortisol collections 48 hours before polysomnography.

Results: BP varied with sleep stage; it was highest during wakefulness and N1 and lowest during non-rapid eye movement stage 3. Children classified as high apnea-hypopnea index (AHI) snorers (AHI >5 events/h) had a greater prevalence of systolic hypertension (57%) than low-AHI snorers (22%) and nonsnoring controls (22%; P = .04). The high-AHI snorers also had higher diastolic BP (P < .02) as well as blunted nocturnal diastolic BP changes during sleep (P = .02) compared with low-AHI snorers (AHI <5 events/h). Twenty-hour urinary free cortisol and 24-hour urinary catecholamines were not associated with BP.

Conclusions: BP in children varies with sleep stage. OSA is associated with systolic hypertension, higher BP during rapid eye movement sleep, as well as elevation of diastolic BP and blunted BP changes with sleep.
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http://dx.doi.org/10.5664/jcsm.8360DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7849664PMC
June 2020

Quality Assurance for Carotid Stenting in the CREST-2 Registry.

J Am Coll Cardiol 2019 12;74(25):3071-3079

Department of Neurology, Mayo Clinic, Jacksonville, Florida.

Background: The CREST-2 Registry (C2R) was approved by National Institute of Neurological Disorders and Stroke-National Institutes of Health in September 2014 with Centers for Medicare & Medicaid Services, U.S. Food and Drug Administration, and industry collaboration to enroll patients undergoing CAS. The registry credentials interventionists and promotes optimal patient selection, procedural-technique, and outcomes.

Objectives: This study reports periprocedural outcomes in a cohort of carotid artery stenting (CAS) performed for asymptomatic and symptomatic carotid stenosis.

Methods: Asymptomatic patients with ≥70% and symptomatic patients with ≥50% carotid stenosis, ≤80 years of age, and at standard or high risk for carotid endarterectomy are eligible for enrollment. Interventionists are credentialed by a multispecialty committee that reviews experience, lesion selection, technique, and outcomes. The primary endpoint was a composite of stroke and death (S/D) in the 30-day periprocedural period. Myocardial infarction and access-site complications were assessed as secondary outcomes.

Results: As of December 2018, 187 interventionists from 98 sites in the United States performed 2,219 CAS procedures in 2,141 patients with primary atherosclerosis (78 were bilateral). The mean age of the cohort was 68 years, 65% were male, and 92% were white; 1,180 (55%) were for asymptomatic disease, and 961 (45%) were for symptomatic disease. All U.S. Food and Drug Administration-approved stents and embolic protection devices were represented. The 30-day rate of S/D was 1.4% for asymptomatic, 2.8% for symptomatic, and 2.0% for all patients.

Conclusions: C2R is the first national registry for CAS cosponsored by federal and industry partners. CAS was performed by experienced operators using appropriate patient selection and optimal technique. In that setting, a broad group of interventionists achieved very low periprocedural S/D rates for asymptomatic and symptomatic patients.
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http://dx.doi.org/10.1016/j.jacc.2019.10.032DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7012370PMC
December 2019

Association of Diastolic Dysfunction with Reduced Cardiorespiratory Fitness in Adults Living with HIV.

AIDS Patient Care STDS 2019 12;33(12):493-499

Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland.

Despite the high prevalence of diastolic dysfunction in adults living with HIV, the impact on cardiorespiratory fitness (CRF) is understudied. The objective of this cross-sectional study was to investigate the relationship between cardiac function and CRF in adults with HIV. Adults receiving antiretroviral therapy with no history of coronary artery disease (CAD) or heart failure were eligible to participate. Cardiac function was assessed by resting Doppler echocardiography. CRF was measured by oxygen utilization at peak exercise (VOpeak). The majority of participants were African American (86%) and male (97%) with a mean [standard deviation (SD)] age of 56.6 (7.1) years and median CD4 lymphocyte count of 492 cells/mL. The mean (SD) VOpeak was 26.1 (5.5) mL/(kg·min). Age, diabetes, hypertension, and hemoglobin were associated with VOpeak. Overall, diastolic dysfunction was present in 38% and was associated with lower VOpeak ( < 0.05). VOpeak was lower among those with impaired myocardial relaxation (e' <8 cm/s) compared with normal relaxation [mean ± SE mL/(kg·min), 25.2 ± 0.6 vs. 27.7 ± 0.9,  < 0.05]. Adjusted for age and clinical factors, each unit increase in left ventricular relaxation (E/A) was associated with an average 4.4 mL/(kg·min) higher VOpeak, representing more than one metabolic equivalent. We conclude that diastolic dysfunction is independently associated with clinically significant low CRF in adults with HIV and no history of CAD or heart failure. These results highlight the importance of recognizing diastolic dysfunction in individuals living with HIV regardless of their cardiovascular disease history.
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http://dx.doi.org/10.1089/apc.2019.0149DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6918848PMC
December 2019

Short Communication: Low Muscle Mass Is Associated with Osteoporosis in Older Adults Living with HIV.

AIDS Res Hum Retroviruses 2020 04 23;36(4):300-302. Epub 2019 Dec 23.

Baltimore Veterans Affairs Medical Center Geriatric Research, Education, and Clinical Center at the VA Maryland Health Care System, Baltimore, Maryland.

Sarcopenia, age-related low muscle mass and function, is a well-established independent risk factor for bone fracture in the geriatric population but is understudied in older people living with HIV (PLWH). The objective of this cross-sectional study was to investigate in older PLWH the relationship between muscle mass and bone mineral density (BMD). Sedentary PLWH who were ≥50 years of age, receiving antiretroviral therapy, and enrolled in an exercise intervention trial were included. Established definitions for sarcopenia and osteopenia/osteoporosis were applied to muscle mass data and BMD collected by dual-energy X-ray absorptiometry before exercise training. Participants were 93% male and 33% Caucasian race with median age 61 years, and median CD4 lymphocytes 707 cells/μL. The majority (64%) were overweight and obese by body mass index. Appendicular skeletal muscle index (ASMI) correlated with BMD at the femoral neck ( = 0.49,  < .01), total hip ( = 0.54,  < .01), and lumbar spine ( = 0.48,  < .05). Low BMD at the femoral neck was present in 39% (26% osteopenia, 13% osteoporosis). ASMI was lower among those with low BMD compared with normal BMD ( = .02). Low muscle mass measured by ASMI is associated with low BMD in clinically stable older PLWH. Detailed body composition assessment may help guide lifestyle recommendations to prevent bone fractures in older PLWH.
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http://dx.doi.org/10.1089/AID.2019.0207DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7185343PMC
April 2020

Genetic changes associated with the temporal shift in invasive non-typhoidal Salmonella serovars in Bamako Mali.

PLoS Negl Trop Dis 2019 06 6;13(6):e0007297. Epub 2019 Jun 6.

Institute for Genome Sciences, Department of Microbiology and Immunology, University of Maryland School of Medicine, Baltimore, MD, United States of America.

Background: Invasive non-typhoidal Salmonella (iNTS) serovars S. Typhimurium and S. Enteritidis are major etiologic agents of invasive bacterial disease among infants and young children in sub-Saharan Africa, including in Mali. Early studies of iNTS serovars in several countries indicated that S. Typhimurium was more prevalent than S. Enteritidis, including in Mali before 2008. We investigated genomic and associated phenotypic changes associated with an increase in the relative proportion of iNTS caused by S. Enteritidis versus S. Typhimurium in Bamako, Mali, during the period 2002-2012.

Methodology/principal Findings: Comparative genomics studies identified homologs of tetracycline resistance and arsenic utilization genes that were associated with the temporal shift of serovars causing iNTS shift, along with several hypothetical proteins. These findings, validated through PCR screening and phenotypic assays, provide initial steps towards characterizing the genomic changes consequent to unknown evolutionary pressures associated with the shift in serovar prevalence.

Conclusions/significance: This work identified a shift to S. Enteritidis from the more classic S. Typhimurium, associated with iNTS in Bamako, Mali, during the period 2002-2012. This type of shift in underlying iNTS pathogens are of great importance to pediatric public health in endemic regions of sub-Saharan Africa. Additionally, this work demonstrates the utility of combining epidemiologic data, whole genome sequencing, and functional characterization in the laboratory to identify and characterize genomic changes in the isolates that may be involved with the observed shift in circulating iNTS agents.
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http://dx.doi.org/10.1371/journal.pntd.0007297DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6592554PMC
June 2019

Association of Glucose Concentrations at Hospital Discharge With Readmissions and Mortality: A Nationwide Cohort Study.

J Clin Endocrinol Metab 2019 09;104(9):3679-3691

Baltimore Veterans Affairs Medical Center Geriatric Research, Education, and Clinical Center, Baltimore, Maryland.

Context: Low blood glucose concentrations during the discharge day may affect 30-day readmission and posthospital discharge mortality rates.

Objective: To investigate whether patients with diabetes and low glucose values during the last day of hospitalization are at increased risk of readmission or mortality.

Design And Outcomes: Minimum point of care glucose values were collected during the last 24 hours of hospitalization. We used adjusted rates of 30-day readmission rate, 30-, 90-, and 180-day mortality rates, and combined 30-day readmission/mortality rate to identify minimum glucose thresholds above which patients can be safely discharged.

Patients And Setting: Nationwide cohort study including 843,978 admissions of patients with diabetes at the Veteran Affairs hospitals 14 years.

Results: The rate ratios (RRs) increased progressively for all five outcomes as the minimum glucose concentrations progressively decreased below the 90 to 99 mg/dL category, compared with the 100 to 109 mg/dL category: 30-day readmission RR, 1.01 to 1.45; 30-day readmission/mortality RR, 1.01 to 1.71; 30-day mortality RR, 0.99 to 5.82; 90-day mortality RR, 1.01 to 2.40; 180-day mortality RR, 1.03 to 1.91. Patients with diabetes experienced greater 30-day readmission rates, 30-, 90- and 180-day postdischarge mortality rates, and higher combined 30-day readmission/mortality rates, with glucose levels <92.9 mg/dL, <45.2 mg/dL, 65.8 mg/dL, 67.3 mg/dL, and <87.2 mg/dL, respectively.

Conclusion: Patients with diabetes who had hypoglycemia or near-normal glucose values during the last day of hospitalization had higher rates of 30-day readmission and postdischarge mortality.
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http://dx.doi.org/10.1210/jc.2018-02575DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6642668PMC
September 2019
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