Publications by authors named "Seungyoung Hwang"

33 Publications

Association of perioperative hypotension with subsequent greater healthcare resource utilization.

J Clin Anesth 2021 Sep 15;75:110516. Epub 2021 Sep 15.

Mayo Clinic, Department of Anesthesiology & Critical Care Medicine, 200 1st Street SW, Rochester, MN 55905, USA.

Study Objective: Determine if perioperative hypotension, a modifiable risk factor, is associated with increased postoperative healthcare resource utilization (HRU).

Design: Retrospective cohort study.

Setting: Multicenter using the Optum® electronic health record database.

Patients: Patients discharged to the ward after non-cardiac, non-obstetric surgeries between January 1, 2008 and December 31, 2017 with six months of data, before and after the surgical visit.

Interventions/exposure: Perioperative hypotension, a binary variable (presence/absence) at an absolute MAP of ≤65-mmHg, measured during surgery and within 48-h after, to dichotomize patients with greater versus lesser hypotensive exposures.

Measurements: Short-term HRU defined by postoperative length-of-stay (LOS), discharge to a care facility, and 30-day readmission following surgery discharge. Mid-term HRU (within 6 months post-discharge) quantified via number of outpatient and emergency department (ED) visits, and readmission LOS.

Main Results: 42,800 distinct patients met study criteria and 37.5% experienced perioperative hypotension. After adjusting for study covariates including patient demographics and comorbidities, patients with perioperative hypotension had: longer LOS (4.01 vs. 3.83 days; LOS ratio, 1.05; 95% CI, 1.04-1.06), higher odds of discharge to a care facility (OR, 1.18; 95% CI, 1.12-1.24; observed rate 22.1% vs. 18.1%) and of 30-day readmission (OR, 1.22; 95% CI, 1.11-1.33; observed rate 6.2% vs. 5.0%) as compared to the non-hypotensive population (all outcomes, p < 0.001). During 6-month follow-up, patients with perioperative hypotension showed significantly greater HRU regarding number of ED visits (0.34 vs. 0.31 visits; visit ratio, 1.10; 95% CI, 1.05-1.15) and readmission LOS (1.06 vs. 0.92 days; LOS ratio, 1.15; 95% CI, 1.07-1.24) but not outpatient visits (10.47 vs. 10.82; visit ratio, 0.97; 95% CI, 0.95-0.99) compared to those without hypotension. There was no difference in HRU during the 6-month period before qualifying surgery.

Conclusions: We report a significant association of perioperative hypotension with an increase in HRU, including additional LOS and readmissions, both important contributors to overall medical costs.
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http://dx.doi.org/10.1016/j.jclinane.2021.110516DOI Listing
September 2021

An Ecological Study of a Universal Employee Depression Awareness and Stigma Reduction Intervention: "Right Direction".

Front Psychiatry 2021 20;12:581876. Epub 2021 Aug 20.

American Psychiatric Association, Washington, DC, United States.

Right Direction (RD) was a component of a universal employee wellness program implemented in 2014 at Kent State University (KSU) to increase employees' awareness of depression, reduce mental health stigma, and encourage help-seeking behaviors to promote mental health. We explored changes in mental health care utilization before and after implementation of RD. KSU Human Resources census and service use data were used to identify the study cohort and examine the study objectives. A pre-post design was used to explore changes in mental health utilization among KSU employees before and after RD. Three post-intervention periods were examined. A generalized linear mixed model approach was used for logistic regression analysis between each outcome of interest and intervention period, adjusted by age and sex. Logit differences were calculated for post-intervention periods compared to the pre-intervention period. Compared to the pre-intervention period, the predicted proportion of employees seeking treatment for depression and anxiety increased in the first post-intervention period (OR = 2.14, 95% Confidence Interval [CI] = 1.37-3.34), then declined. Outpatient psychiatric treatment utilization increased significantly in the first two post-intervention periods (OR =1.89, 95% CI = 1.23-2.89; OR = 1.75, 95% CI = 1.11-2.76). No difference was noted in inpatient psychiatric treatment utilization across post-intervention periods. Unlike prescription for anxiolytic prescriptions, receipt of antidepressant prescriptions increased in the second (OR = 2.25, 95% CI = 1.56-3.27) and third (OR = 2.16, 95% CI = 1.46-3.20) post-intervention periods. Effects of RD may be realized over the long-term with follow-up enhancements such as workshops/informational sessions on mindfulness, stress management, resiliency training, and self-acceptance.
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http://dx.doi.org/10.3389/fpsyt.2021.581876DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8417939PMC
August 2021

Point-of-Care Ultrasound for Evaluation of Systolic Heart Function in Outpatient Hemodialysis Units.

Kidney Med 2021 Mar-Apr;3(2):317-319. Epub 2021 Feb 10.

Department of Medicine, Division of Nephrology, University of Mississippi Medical Center, Jackson, MS.

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http://dx.doi.org/10.1016/j.xkme.2020.11.018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8039423PMC
February 2021

Psychiatrist Burnout: Response to Schonfeld and Bianchi.

Am J Psychiatry 2021 02;178(2):204-205

Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia (Summers); American Psychiatric Association, Washington, D.C. (Gorrindo, Hwang); Department of Psychiatry, Rutgers New Jersey Medical School, Newark (Aggarwal); Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston (Guille).

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http://dx.doi.org/10.1176/appi.ajp.2020.20071110rDOI Listing
February 2021

Association between perioperative fluid management and patient outcomes: a multicentre retrospective study.

Br J Anaesth 2021 Mar 13;126(3):720-729. Epub 2020 Dec 13.

Department of Critical Care Medicine, Orlando Regional Medical Center, Orlando, FL, USA. Electronic address:

Background: Postoperative complications increase hospital length of stay and patient mortality. Optimal perioperative fluid management should decrease patient complications. This study examined associations between fluid volume and noncardiac surgery patient outcomes within a large multicentre US surgical cohort.

Methods: Adults undergoing noncardiac procedures from January 1, 2012 to December 31, 2017, with a postoperative length of stay ≥24 h, were extracted from a large US electronic health record database. Patients were segmented into quintiles based on recorded perioperative fluid volumes with Quintile 3 (Q3) serving as the reference. The primary outcome was defined as a composite of any complications during the surgical admission and a postoperative length of stay ≥7 days. Secondary outcomes included in-hospital mortality, respiratory complications, and acute kidney injury.

Results: A total of 35 736 patients met the study criteria. There was a U-shaped pattern with highest (Q5) and lowest (Q1) quintiles of fluid volumes having increased odds of complications and a postoperative length of stay ≥7 days (Q5: odds ratio [OR] 1.51 [95% confidence interval {CI}: 1.30-1.74], P<0.001; Q1: OR 1.20 [95% CI: 1.04-1.38], P=0.011) compared with Q3. Patients in Q5 had greater odds of more severe acute kidney injury compared with Q3 (OR 1.52 [95% CI: 1.22-1.90]; P<0.001) and respiratory complications (OR 1.44 [95% CI: 1.17-1.77]; P<0.001).

Conclusions: Both very high and very low perioperative fluid volumes were associated with an increase in complications after noncardiac surgery.
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http://dx.doi.org/10.1016/j.bja.2020.10.031DOI Listing
March 2021

Well-Being, Burnout, and Depression Among North American Psychiatrists: The State of Our Profession.

Am J Psychiatry 2020 10 14;177(10):955-964. Epub 2020 Jul 14.

Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia (Summers); American Psychiatric Association, Washington, D.C. (Gorrindo, Hwang); Department of Psychiatry, Rutgers New Jersey Medical School, Newark (Aggarwal); Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston (Guille).

Objective: The authors examined the prevalence of burnout and depressive symptoms among North American psychiatrists, determined demographic and practice characteristics that increase the risk for these symptoms, and assessed the correlation between burnout and depression.

Methods: A total of 2,084 North American psychiatrists participated in an online survey, completed the Oldenburg Burnout Inventory (OLBI) and the Patient Health Questionnaire-9 (PHQ-9), and provided demographic data and practice information. Linear regression analysis was used to determine factors associated with higher burnout and depression scores.

Results: Participants' mean OLBI score was 40.4 (SD=7.9) and mean PHQ-9 score was 5.1 (SD=4.9). A total of 78% (N=1,625) of participants had an OLBI score ≥35, suggestive of high levels of burnout, and 16.1% (N=336) of participants had PHQ-9 scores ≥10, suggesting a diagnosis of major depression. Presence of depressive symptoms, female gender, inability to control one's schedule, and work setting were significantly associated with higher OLBI scores. Burnout, female gender, resident or early-career stage, and nonacademic setting practice were significantly associated with higher PHQ-9 scores. A total of 98% of psychiatrists who had PHQ-9 scores ≥10 also had OLBI scores >35. Suicidal ideation was not significantly associated with burnout in a partially adjusted linear regression model.

Conclusions: Psychiatrists experience burnout and depression at a substantial rate. This study advances the understanding of factors that increase the risk for burnout and depression among psychiatrists and has implications for the development of targeted interventions to reduce the high rates of burnout and depression among psychiatrists. These findings have significance for future work aimed at workforce retention and improving quality of care for psychiatric patients.
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http://dx.doi.org/10.1176/appi.ajp.2020.19090901DOI Listing
October 2020

Prevalence and Persistence of Uremic Symptoms in Incident Dialysis Patients.

Kidney360 2020 Feb;1(2):86-92

Division of Nephrology, University of Mississippi Medical Center, Jackson, Mississippi.

Background: Uremic symptoms are major contributors to the poor quality of life among patients on dialysis, but whether their prevalence or intensity has changed over time is unknown.

Methods: We examined responses to validated questionnaires in two incident dialysis cohort studies, the Choices for Health Outcomes in Caring for ESRD (CHOICE) study (=926, 1995-1998) and the Longitudinal United States/Canada Incident Dialysis (LUCID) study (=428, 2011-2017). We determined the prevalence and severity of uremic symptoms-anorexia, nausea/vomiting, pruritus, sleepiness, difficulty concentrating, fatigue, and pain-in both cohorts.

Results: In CHOICE and LUCID, respectively, mean age of the participants was 58 and 60 years, 53% and 60% were male, and 28% and 32% were black. In both cohorts, 54% of the participants had diabetes. Median time from dialysis initiation to the symptoms questionnaires was 45 days for CHOICE and 77 days for LUCID. Uremic symptom prevalence in CHOICE did not change from baseline to 1-year follow-up and was similar across CHOICE and LUCID. Baseline symptom prevalence in CHOICE and LUCID was as follows: anorexia (44%, 44%, respectively), nausea/vomiting (36%, 43%), pruritus (72%, 63%), sleepiness (86%, 68%), difficulty concentrating (55%, 57%), fatigue (89%, 77%), and pain (82%, 79%). In both cohorts, >80% of patients had three or more symptoms and >50% had five or more symptoms. The correlation between individual symptoms was low (<0.5 for all comparisons). In CHOICE, no clinical or laboratory parameter was strongly associated with multiple symptoms.

Conclusions: The burden of uremic symptoms among patients on dialysis is substantial and has not changed in the past 15 years. Improving quality of life will require identification of the factors that underlie the pathogenesis of uremic symptoms and better ways of removing the toxins that are responsible.
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http://dx.doi.org/10.34067/kid.0000072019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7289028PMC
February 2020

Prevalence and Persistence of Uremic Symptoms in Incident Dialysis Patients.

Kidney360 2020 Feb;1(2):86-92

Division of Nephrology, University of Mississippi Medical Center, Jackson, Mississippi.

Background: Uremic symptoms are major contributors to the poor quality of life among patients on dialysis, but whether their prevalence or intensity has changed over time is unknown.

Methods: We examined responses to validated questionnaires in two incident dialysis cohort studies, the Choices for Health Outcomes in Caring for ESRD (CHOICE) study (=926, 1995-1998) and the Longitudinal United States/Canada Incident Dialysis (LUCID) study (=428, 2011-2017). We determined the prevalence and severity of uremic symptoms-anorexia, nausea/vomiting, pruritus, sleepiness, difficulty concentrating, fatigue, and pain-in both cohorts.

Results: In CHOICE and LUCID, respectively, mean age of the participants was 58 and 60 years, 53% and 60% were male, and 28% and 32% were black. In both cohorts, 54% of the participants had diabetes. Median time from dialysis initiation to the symptoms questionnaires was 45 days for CHOICE and 77 days for LUCID. Uremic symptom prevalence in CHOICE did not change from baseline to 1-year follow-up and was similar across CHOICE and LUCID. Baseline symptom prevalence in CHOICE and LUCID was as follows: anorexia (44%, 44%, respectively), nausea/vomiting (36%, 43%), pruritus (72%, 63%), sleepiness (86%, 68%), difficulty concentrating (55%, 57%), fatigue (89%, 77%), and pain (82%, 79%). In both cohorts, >80% of patients had three or more symptoms and >50% had five or more symptoms. The correlation between individual symptoms was low (<0.5 for all comparisons). In CHOICE, no clinical or laboratory parameter was strongly associated with multiple symptoms.

Conclusions: The burden of uremic symptoms among patients on dialysis is substantial and has not changed in the past 15 years. Improving quality of life will require identification of the factors that underlie the pathogenesis of uremic symptoms and better ways of removing the toxins that are responsible.
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http://dx.doi.org/10.34067/kid.0000072019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7289028PMC
February 2020

Abnormal shock index exposure and clinical outcomes among critically ill patients: A retrospective cohort analysis.

J Crit Care 2020 06 21;57:5-12. Epub 2020 Jan 21.

Department of Critical Care Medicine, Orlando Regional Medical Center, 86 W Underwood Suite 101, Orlando, FL 32806, USA.

Purpose: To assess the predictive value of a single abnormal shock index reading (SI ≥0.9; heart rate/systolic blood pressure [SBP]) for mortality, and association between cumulative abnormal SI exposure and mortality/morbidity.

Materials And Methods: Cohort comprised of adult patients with an intensive care unit (ICU) stay ≥24-h (years 2010-2018). SI ≥0.9 exposure was evaluated via cumulative minutes or time-weighted average; SBP ≤100-mmHg was analyzed. Outcomes were in-hospital mortality, acute kidney injury (AKI), and myocardial injury.

Results: 18,197 patients from 82 hospitals were analyzed. Any single SI ≥0.9 within the ICU predicted mortality with 90.8% sensitivity and 36.8% specificity. Every 0.1-unit increase in maximum-SI during the first 24-h increased the odds of mortality by 4.8% [95%CI; 2.6-7.0%; p < .001]. Every 4-h exposure to SI ≥0.9 increased the odds of death by 5.8% [95%CI; 4.6-7.0%; p < .001], AKI by 4.3% [95%CI; 3.7-4.9%; p < .001] and myocardial injury by 2.1% [95%CI; 1.2-3.1%; p < .001]. ≥2-h exposure to SBP ≤100-mmHg was significantly associated with mortality.

Conclusions: A single SI reading ≥0.9 is a poor predictor of mortality; cumulative SI exposure is associated with greater risk of mortality/morbidity. The associations with in-hospital mortality were comparable for SI ≥0.9 or SBP ≤100-mmHg exposure. Dynamic interactions between hemodynamic variables need further evaluation among critically ill patients.
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http://dx.doi.org/10.1016/j.jcrc.2020.01.024DOI Listing
June 2020

Serum Metabolites and Cardiac Death in Patients on Hemodialysis.

Clin J Am Soc Nephrol 2019 05 8;14(5):747-749. Epub 2019 Apr 8.

Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University School of Medicine, Baltimore, Maryland;

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http://dx.doi.org/10.2215/CJN.12691018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6500939PMC
May 2019

Contribution of 'clinically negligible' residual kidney function to clearance of uremic solutes.

Nephrol Dial Transplant 2020 05;35(5):846-853

Department of Medicine, Division of Nephrology, Johns Hopkins School of Medicine, Baltimore, MD, USA.

Background: Residual kidney function (RKF) is thought to exert beneficial effects through clearance of uremic toxins. However, the level of native kidney function where clearance becomes negligible is not known.

Methods: We aimed to assess whether levels of nonurea solutes differed among patients with 'clinically negligible' RKF compared with those with no RKF. The hemodialysis study excluded patients with urinary urea clearance >1.5 mL/min, below which RKF was considered to be 'clinically negligible'. We measured eight nonurea solutes from 1280 patients participating in this study and calculated the relative difference in solute levels among patients with and without RKF based on measured urinary urea clearance.

Results: The mean age of the participants was 57 years and 57% were female. At baseline, 34% of the included participants had clinically negligible RKF (mean 0.7 ± 0.4 mL/min) and 66% had no RKF. Seven of the eight nonurea solute levels measured were significantly lower in patients with RKF than in those without RKF, ranging from -24% [95% confidence interval (CI) -31 to -16] for hippurate, -7% (-14 to -1) for trimethylamine-N-oxide and -4% (-6 to -1) for asymmetric dimethylarginine. The effect of RKF on plasma levels was comparable or more pronounced than that achieved with a 31% higher dialysis dose (spKt/Vurea 1.7 versus 1.3). Preserved RKF at 1-year follow-up was associated with a lower risk of cardiac death and first cardiovascular event.

Conclusions: Even at very low levels, RKF is not 'negligible', as it continues to provide nonurea solute clearance. Management of patients with RKF should consider these differences.
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http://dx.doi.org/10.1093/ndt/gfz042DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7203561PMC
May 2020

Advance Directives, Medical Conditions, and Preferences for End-of-Life Care Among Physicians: 12-year Follow-Up of the Johns Hopkins Precursors Study.

J Pain Symptom Manage 2019 03 19;57(3):556-565. Epub 2018 Dec 19.

Johns Hopkins University School of Nursing, Baltimore, Maryland, USA.

Context: Stability of preferences for life-sustaining treatment may vary depending on personal characteristics.

Objective: We estimated the stability of preferences for end-of-life treatment over 12 years and whether advance directives and medical conditions were associated with change in preferences for end-of-life treatment.

Design: Mailed survey of older physicians.

Methods: Longitudinal cohort study of medical students in the graduating classes from 1948 to 1964 at Johns Hopkins University. Eight hundred ninety eight physicians who completed the life-sustaining treatment questionnaire anytime in 1999, 2002, 2005, and 2011 (mean age 68.2 years at baseline). Preferences for life-sustaining treatment were assessed using a checklist questionnaire in response to a standard "brain injury" scenario and considered as a package using the latent class transition model.

Results: End-of-life preferences grouped into three classes: most aggressive (wanting most interventions; 14% of physicians), least aggressive (declining most interventions; 61%), and an intermediate class (declining most interventions except intravenous fluids and antibiotics; 25%). Physicians without an advance directive were more likely to desire more treatment and were less likely to transition out the most aggressive class. Transition probabilities from class to class did not vary over time. Persons with cancer expressed preference for the least aggressive treatment, whereas persons with cardiovascular disease and depression had preferences for more aggressive treatment.

Conclusion: Transitions in end-of-life preferences and the factors influencing change and stability suggest that periodic reassessment for planning end-of-life care is needed.
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http://dx.doi.org/10.1016/j.jpainsymman.2018.12.328DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6382559PMC
March 2019

The effect of community socioeconomic status on sepsis-attributable mortality.

J Crit Care 2018 08 12;46:129-133. Epub 2018 Jan 12.

Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States.

Purpose: Community factors may play a role in determining individual risk for sepsis, as well as sepsis-related morbidity and mortality. We sought to define the relationship between community socioeconomic status and mortality due to sepsis in an urban locale.

Methods: Using community statistical areas of Baltimore City, we dichotomized neighborhoods at median household income, and compared distribution of outcomes of interest within the two income categories. We performed multivariable regression analyses to determine the relationship between socioeconomic variables and sepsis-attributable mortality.

Results: The collective median household income was $38,660 (IQR $32,530, 54,480), family poverty rate was 28.4% (IQR 13.5, 38.8%), and rate of death from sepsis was 3.1 per 10,000 persons (IQR 2.60, 4.10). Lower household income communities demonstrated higher rates of death from sepsis (3.65 (IQR 2.78, 4.40)) than higher household income communities (2.80 (IQR 2.05, 3.55)) (p = .02). In regression models, household income (β = -8.42, p = .006) and percentage of poverty in communities (β = 2.71, p = .01) demonstrated associations with sepsis-attributable mortality.

Discussion: Our findings suggest that socioeconomic variables play significant role in sepsis-attributable mortality. Such confirmation of regional disparities in mortality due to sepsis warrants further consideration, as well as integration, for future national sepsis policies.
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http://dx.doi.org/10.1016/j.jcrc.2018.01.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6014883PMC
August 2018

Impact of Alcohol Tax Increase on Maryland College Students' Alcohol-Related Outcomes.

Subst Use Misuse 2018 05 1;53(6):1015-1020. Epub 2017 Dec 1.

a Department of Epidemiology and Biostatistics , Michigan State University College of Human Medicine , Flint , Michigan , USA.

Objective: This study A) assessed whether levels of alcohol-related disciplinary actions on college campuses changed among MD college students after the 2011 Maryland (MD) state alcohol tax increase from 6% to 9%, and B) determined which school-level factors impacted the magnitude of changes detected.

Method: A quasi-experimental interrupted time series (ITS) analysis of panel data containing alcohol-related disciplinary actions on 33 MD college campuses in years 2006-2013. Negative binomial regression models were used to examine whether there was a statistically significant difference in counts of alcohol-related disciplinary actions comparing time before and after the tax increase.

Results: The ITS anaysis showed an insignificant relationship between alcohol-related disciplinary actions and tax implementation (β = -.27; p =.257) but indicated that alcohol-related disciplinary actions decreased significantly over the time under study (β = -.05; p =.022).

Discussion: Alcohol related disciplinary actions did decrease over time in the years of study, and this relationship was correlated with several school-level characteristics, including school price, school funding type, types of degrees awarded, and specialty. School price may serve as a proxy mediator or confounder of the effect of time on disciplinary actions.
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http://dx.doi.org/10.1080/10826084.2017.1392978DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6440696PMC
May 2018

The impact of peer mentor communication with older adults on depressive symptoms and working alliance: A pilot study.

Patient Educ Couns 2018 04 20;101(4):665-671. Epub 2017 Oct 20.

Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 North Broadway, Baltimore, MD 21205, USA. Electronic address:

Objective: The objective of this pilot study was to describe peer communication in meetings with depressed elders, associate their relationship with working alliance and depression and assess congruence of communication with training.

Methods: Three peers with a history of depression, in recovery, received 20h of training in peer mentoring for depression as part of an 8-week pilot program for 23 depressed older adults. Each peer-client meeting was recorded; a sample of 69 recorded meetings were chosen across the program period and coded with the Roter Interaction Analysis System, a validated medical interaction analysis system. Generalized linear mixed models were used to examine peer talk during meetings in relation to working alliance and client depression.

Results: Peers used a variety of skills congruent with their training including client-centered talk, positive rapport building and emotional responsiveness that remained consistent or increased over time. Client-centered communication and positive rapport were associated with increased working alliance and decreased depressive symptoms (all p<0.001).

Conclusion: Trained peer mentors can use communication behaviors useful to older adults with depression. Specifically, client-centered talk may be important to include in peer training.

Practice Implications: Peer mentors can be a valuable resource in providing depression counseling to older adults.
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http://dx.doi.org/10.1016/j.pec.2017.10.012DOI Listing
April 2018

Impact of Physical Activity on Reporting of Childhood Asthma Symptoms.

Lung 2017 12 15;195(6):693-698. Epub 2017 Sep 15.

Johns Hopkins University School of Medicine, Baltimore, MD, USA.

This study aims to determine the impact of physical activity on asthma symptom reporting among children living in an inner city. Among 147 children aged 5-12 years with physician-diagnosed asthma, we assessed asthma symptoms using twice-daily diaries and physical activity using the physical activity questionnaire for children during three 8-day periods (baseline, 3 and 6 months). Linear, logistic, and quasi-poisson regression models were used to determine the association between physical activity and asthma symptoms; adjusting for age, sex, race, BMI, caregiver's education, asthma severity, medication use, and season. A 1-unit increase in PAQ score was significantly associated with reporting more nocturnal symptoms [risk ratio (RR): 1.03; 95% CI 1.00-1.06], daytime symptoms (RR: 1.04; 95% CI 1.00-1.09), being bothered by asthma (RR: 1.05; 95% CI 1.00-1.09), and trouble breathing (RR: 1.05; 95% CI 1.00-1.10). Level of physical activity should be taken into account in clinical management of asthma and epidemiological studies of asthma symptom burden.
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http://dx.doi.org/10.1007/s00408-017-0049-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5674113PMC
December 2017

Physician Preferences for Aggressive Treatment at the End of Life and Area-Level Health Care Spending: The Johns Hopkins Precursors Study.

Gerontol Geriatr Med 2017 Jan-Dec;3:2333721417722328. Epub 2017 Jul 24.

University of Pennsylvania, Philadelphia, USA.

To determine whether physician preferences for end-of-life care were associated with variation in health care spending. We studied 737 physicians who completed the life-sustaining treatment questionnaire in 1999 and were linked to end-of-life care data for the years 1999 to 2009 from Medicare-eligible beneficiaries from the Dartmouth Atlas of Health Care (in hospital-related regions [HRRs]). Using latent class analysis to group physician preferences for end-of-life treatment into most, intermediate, and least aggressive categories, we examined how physician preferences were associated with health care spending over a 7-year period. When all HRRs in the nation were arrayed in quartiles by spending, the prevalence of study physicians who preferred aggressive end-of-life care was greater in the highest spending HRRs. The mean area-level intensive care unit charges per patient were estimated to be US$1,595 higher in the last 6 months of life and US$657 higher during the hospitalization in which death occurred for physicians who preferred the most aggressive treatment at the end of life, when compared with average spending. Physician preference for aggressive end-of-life care was correlated with area-level spending in the last 6 months of life. Policy measures intended to minimize geographic variation in health care spending should incorporate physician preferences and style.
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http://dx.doi.org/10.1177/2333721417722328DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5528938PMC
July 2017

Results of the HEMO Study suggest that p-cresol sulfate and indoxyl sulfate are not associated with cardiovascular outcomes.

Kidney Int 2017 12 21;92(6):1484-1492. Epub 2017 Jul 21.

Department of Medicine, University of California, San Francisco, California, USA.

Cardiovascular disease, the leading cause of mortality in hemodialysis patients, is not fully explained by traditional risk factors. To help define non-traditional risk factors, we determined the association of predialysis total p-cresol sulfate, indoxyl sulfate, phenylacetylglutamine, and hippurate with cardiac death, sudden cardiac death, and first cardiovascular event in the 1,273 participants of the HEMO Study. The results were adjusted for potential demographic, clinical, and laboratory confounders. The mean age of the patients was 58 years, 63% were Black and 42% were male. Overall, there was no association between the solutes and outcomes. However, in sub-group analyses, among patients with lower serum albumin (under 3.6 g/dl), a twofold higher p-cresol sulfate was significantly associated with a 12% higher risk of cardiac death (hazard ratio 1.12; 95% confidence interval, 0.98-1.27) and 22% higher risk of sudden cardiac death (1.22, 1.06-1.41). Similar trends were also noted with indoxyl sulfate. Trial interventions did not modify the association between these solutes and outcomes. Routine clinical and lab data explained less than 22% of the variability in solute levels. Thus, in prevalent hemodialysis patients participating in a large U.S. hemodialysis trial, uremic solutes p-cresol sulfate, indoxyl sulfate, hippurate, and phenylacetylglutamine were not associated with cardiovascular outcomes. However, there were trends of toxicity among patients with lower serum albumin.
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http://dx.doi.org/10.1016/j.kint.2017.05.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5696072PMC
December 2017

Incremental short daily home hemodialysis: a case series.

BMC Nephrol 2017 Jul 5;18(1):216. Epub 2017 Jul 5.

Division of Nephrology, Johns Hopkins University School of Medicine, 301 Mason Lord Drive, Suite 2500, Baltimore, MD, 21224, USA.

Background: Patients starting dialysis often have substantial residual kidney function. Incremental hemodialysis provides a hemodialysis prescription that supplements patients' residual kidney function while maintaining total (residual + dialysis) urea clearance (standard Kt/Vurea) targets. We describe our experience with incremental hemodialysis in patients using NxStage System One for home hemodialysis.

Case Presentation: From 2011 to 2015, we initiated 5 incident hemodialysis patients on an incremental home hemodialysis regimen. The biochemical parameters of all patients remained stable on the incremental hemodialysis regimen and they consistently achieved standard Kt/Vurea targets. Of the two patients with follow-up >6 months, residual kidney function was preserved for ≥2 years. Importantly, the patients were able to transition to home hemodialysis without automatically requiring 5 sessions per week at the outset and gradually increased the number of treatments and/or dialysate volume as the residual kidney function declined.

Conclusions: An incremental home hemodialysis regimen can be safely prescribed and may improve acceptability of home hemodialysis. Reducing hemodialysis frequency by even one treatment per week can reduce the number of fistula or graft cannulations or catheter connections by >100 per year, an important consideration for patient well-being, access longevity, and access-related infections. The incremental hemodialysis approach, supported by national guidelines, can be considered for all home hemodialysis patients with residual kidney function.
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http://dx.doi.org/10.1186/s12882-017-0651-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5498869PMC
July 2017

Residual Kidney Function: Implications in the Era of Personalized Medicine.

Semin Dial 2017 05 6;30(3):241-245. Epub 2017 Mar 6.

Division of Nephrology, Department of Medicine, Academic Medical Center, Amsterdam, The Netherlands.

The association of residual kidney function (RKF) with improved outcomes in peritoneal dialysis and hemodialysis patients is now widely recognized. RKF provides substantial volume and solute clearance even after dialysis initiation. In particular, RKF provides clearance of nonurea solutes, many of which are potential uremic toxins and not effectively removed by conventional hemodialysis. The presence of RKF provides a distinct advantage to incident dialysis patients and is an opportunity for nephrologists to individualize dialysis treatments tailored to their patients' unique solute, volume, and quality of life needs. The benefits of RKF present the opportunity to personalize the management of uremia.
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http://dx.doi.org/10.1111/sdi.12587DOI Listing
May 2017

Costs of substance use disorders from claims data for Medicare recipients from a population-based sample.

J Subst Abuse Treat 2017 06 24;77:174-177. Epub 2017 Feb 24.

Department of Mental Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA.

Medicare spending is projected to increase over the next decade, including for substance use disorders (SUD). Our objective was to determine whether SUDs are associated with higher six-year Medicare costs (1999-2004) among participants in the Baltimore Epidemiologic Catchment Area (ECA) Study. Medicare claims data for the years 1999-2004 from the Centers for Medicare and Medicaid Services were linked to four waves of data from the Baltimore ECA cohort collected between 1981 and 2005 (n=566). A generalized linear model with a log link and gamma distribution was used to examine direct Medicare costs associated with SUD status. Medicare recipients with no history of SUD had mean six-year costs of $42,576. Those with a history of SUD based on both Baltimore ECA and Medicare data, or based on Medicare claims data alone, had significantly higher costs ($98,754 and $64,876, respectively). A history of SUD based solely on Baltimore ECA data alone had lower average costs ($25,491). Findings indicate that Medicare costs differ by source of SUD diagnosis when comparing treatment versus survey data. This may have future implications for projecting Medicare costs among SUD individuals as healthcare coverage expands under the Affordable Care Act.
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http://dx.doi.org/10.1016/j.jsat.2017.02.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5420335PMC
June 2017

Serum Asymmetric and Symmetric Dimethylarginine and Morbidity and Mortality in Hemodialysis Patients.

Am J Kidney Dis 2017 Jul 12;70(1):48-58. Epub 2017 Jan 12.

Department of Medicine, University of California, San Francisco, CA.

Background: Asymmetric (ADMA) and symmetric dimethylarginine (SDMA) are putative uremic toxins that may exert toxicity by a number of mechanisms, including impaired nitric oxide synthesis and generation of reactive oxygen species. The study goal was to determine the association between these metabolites and cardiovascular outcomes in hemodialysis patients.

Study Design: Post hoc analysis of the Hemodialysis (HEMO) Study.

Setting & Participants: 1,276 prevalent hemodialysis patients with available samples 3 to 6 months after randomization.

Predictor: ADMA and SDMA measured in stored specimens.

Outcomes: Cardiac death, sudden cardiac death, first cardiovascular event, and any-cause death. Association with predictors analyzed using Cox regression adjusted for potential confounders (including demographics, clinical characteristics, comorbid conditions, albumin level, and residual kidney function).

Results: Mean age of patients was 57±14 (SD) years, 63% were black, and 57% were women. Mean ADMA (0.9±0.2μmol/L) and SDMA levels (4.3±1.4μmol/L) were moderately correlated (r=0.418). Higher dialysis dose or longer session length were not associated with lower predialysis ADMA or SDMA concentrations. In fully adjusted models, each doubling of ADMA level was associated with higher risk (HR per 2-fold higher concentration; 95% CI) of cardiac death (1.83; 1.29-2.58), sudden cardiac death (1.79; 1.19-2.69), first cardiovascular event (1.50; 1.20-1.87), and any-cause death (1.44; 1.13-1.83). Compared to the lowest ADMA quintile (<0.745 μmol/L), the highest ADMA quintile (≥1.07μmol/L) was associated with higher risk (HR; 95% CI) of cardiac death (2.10; 1.44-3.05), sudden cardiac death (2.06; 1.46-2.90), first cardiovascular event (1.75; 1.35-2.27), and any-cause death (1.56; 1.21-2.00). SDMA level was associated with higher risk for cardiac death (HR, 1.40; 95% CI, 1.03-1.92), but this was no longer statistically significant after adjusting for ADMA level (HR, 1.20; 95% CI, 0.86-1.68).

Limitations: Single time-point measurement of ADMA and SDMA.

Conclusions: ADMA and, to a lesser extent, SDMA levels are associated with cardiovascular outcomes in hemodialysis patients.
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http://dx.doi.org/10.1053/j.ajkd.2016.10.033DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5483385PMC
July 2017

Kt/Vurea and Nonurea Small Solute Levels in the Hemodialysis Study.

J Am Soc Nephrol 2016 Nov 29;27(11):3469-3478. Epub 2016 Mar 29.

Department of Medicine, Case Western Reserve University, Cleveland, Ohio.

The Hemodialysis (HEMO) Study showed that high-dose hemodialysis providing a single-pool Kt/V of 1.71 provided no benefit over a standard treatment providing a single-pool Kt/V of 1.32. Here, we assessed whether the high-dose treatment used lowered plasma levels of small uremic solutes other than urea. Measurements made ≥3 months after randomization in 1281 patients in the HEMO Study showed a range in the effect of high-dose treatment compared with that of standard treatment: from no reduction in the level of p-cresol sulfate or asymmetric dimethylarginine to significant reductions in the levels of trimethylamine oxide (-9%; 95% confidence interval [95% CI], -2% to -15%), indoxyl sulfate (-11%; 95% CI, -6% to -15%), and methylguanidine (-22%; 95% CI, -18% to -27%). Levels of three other small solutes also decreased slightly; the level of urea decreased 9%. All-cause mortality did not significantly relate to the level of any of the solutes measured. Modeling indicated that the intermittency of treatment along with the presence of nondialytic clearance and/or increased solute production accounted for the limited reduction in solute levels with the higher Kt/V In conclusion, failure to achieve greater reductions in solute levels may explain the failure of high Kt/V treatment to improve outcomes in the HEMO Study. Furthermore, levels of the nonurea solutes varied widely among patients in the HEMO Study, and achieved Kt/V accounted for very little of this variation. These results further suggest that an index only on the basis of urea does not provide a sufficient measure of dialysis adequacy.
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http://dx.doi.org/10.1681/ASN.2015091035DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5084890PMC
November 2016

COSTS OF DEPRESSION FROM CLAIMS DATA FOR MEDICARE RECIPIENTS IN A POPULATION-BASED SAMPLE.

J Health Hum Serv Adm 2016 ;39(1):72-94

Background: Many persons with depressive disorder are not treated and associated costs are not recorded.

Aims Of The Study: To determine whether major depressive disorder (MDD) is associated with higher medical cost among Medicare recipients.

Methods: Four waves of the Baltimore-Epidemiologic Catchment Area (Baltimore ECA) Study conducted between 1981 and 2004 were linked to Medicare claims data for the years 1999 to 2004 from the Centers for Medicare and Medicaid Services (CMS). Generalized linear models specified with a gamma distribution and log link function were used to examine direct medical care costs associated with MDD.

Results: Medicare recipients with no history of MDD in either the ECA or CMS data had mean six-year medical costs of US $40,670, compared to $87,445 for Medicare recipients with MDD as recorded in CMS data and $43,583 for those with MDD as recorded in Baltimore-ECA data. Multivariable regressions found that compared to Medicare recipients with no history of depression, those with depression identified in the CMS data had significantly higher medical costs; about 1.87 times (95% confidence interval (CI) 1.32 to 2.67) higher. Medicare recipients with a history of depression identified in the ECA data were no more likely to have higher costs than were Medicare recipients with no history of depression (relative ratio 1.33, 95% CI 0.87 to 2.02).

Discussion: Medicare recipients with a history of depression identified in claims data had significantly higher medical costs than recipients with no history of depression. However, no significant differences were found between Medicare recipients with depression in the community-based Baltimore ECA data and those with no history of depression. The results show that the source of diagnosis, in treatment versus survey data, produces differences in results as regards costs.

Limitations: This study involved only Medicare recipients with claims data over the six years 1999 to 2004. Many of the ECA respondents were too young to qualify for Medicare.

Implications For Health Policy: Depressive disorder involves substantial medical care costs. The findings provide information on the economic burden of depression, an important but often omitted dimension and perspective of the burden of mental illnesses.
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August 2016

Trimethylamine N-Oxide and Cardiovascular Events in Hemodialysis Patients.

J Am Soc Nephrol 2017 Jan 19;28(1):321-331. Epub 2016 Jul 19.

Department of Medicine, Case Western University School of Medicine, Cleveland, Ohio.

Cardiovascular disease causes over 50% of the deaths in dialysis patients, and the risk of death is higher in white than in black patients. The underlying mechanisms for these findings are unknown. We determined the association of the proatherogenic metabolite trimethylamine N-oxide (TMAO) with cardiovascular outcomes in hemodialysis patients and assessed whether this association differs by race. We measured TMAO in stored serum samples obtained 3-6 months after randomization from a total of 1232 white and black patients of the Hemodialysis Study, and analyzed the association of TMAO with cardiovascular outcomes using Cox models adjusted for potential confounders (demographics, clinical characteristics, comorbidities, albumin, and residual kidney function). Mean age of the patients was 58 years; 35% of patients were white. TMAO concentration did not differ between whites and blacks. In whites, 2-fold higher TMAO associated with higher risk (hazard ratio [95% confidence interval]) of cardiac death (1.45 [1.24 to 1.69]), sudden cardiac death [1.70 (1.34 to 2.15)], first cardiovascular event (1.15 [1.01 to 1.32]), and any-cause death (1.22 [1.09 to 1.36]). In blacks, the association was nonlinear and significant only for cardiac death among patients with TMAO concentrations below the median (1.58 [1.03 to 2.44]). Compared with blacks in the same quintile, whites in the highest quintile for TMAO (≥135 μM) had a 4-fold higher risk of cardiac or sudden cardiac death and a 2-fold higher risk of any-cause death. We conclude that TMAO concentration associates with cardiovascular events in hemodialysis patients but the effects differ by race.
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http://dx.doi.org/10.1681/ASN.2016030374DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5198291PMC
January 2017

Analysis of the Association of Clubhouse Membership with Overall Costs of Care for Mental Health Treatment.

Community Ment Health J 2017 01 5;53(1):102-106. Epub 2016 Jul 5.

Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, 624 North Broadway, Baltimore, MD, 21205, USA.

We examined whether frequency of attendance at the B'More Clubhouse was associated with lower mental health care costs in the Medicaid database, and whether members in the B'More Clubhouse (n = 30) would have lower mental health care costs compared with a set of matched controls from the same claims database (n = 150). Participants who attended the Clubhouse 3 days or more per week had mean 1-year mental health care costs of US $5697, compared to $14,765 for those who attended less often. B'More Clubhouse members had significantly lower annual total mental health care costs than the matched comparison group ($10,391 vs. $15,511; p < 0.0001). Membership in the B'More Clubhouse is associated with a substantial beneficial influence on health care costs.
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http://dx.doi.org/10.1007/s10597-016-0041-3DOI Listing
January 2017

Analysis of the Association of Clubhouse Membership with Overall Costs of Care for Mental Health Treatment.

Community Ment Health J 2017 01 5;53(1):102-106. Epub 2016 Jul 5.

Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, 624 North Broadway, Baltimore, MD, 21205, USA.

We examined whether frequency of attendance at the B'More Clubhouse was associated with lower mental health care costs in the Medicaid database, and whether members in the B'More Clubhouse (n = 30) would have lower mental health care costs compared with a set of matched controls from the same claims database (n = 150). Participants who attended the Clubhouse 3 days or more per week had mean 1-year mental health care costs of US $5697, compared to $14,765 for those who attended less often. B'More Clubhouse members had significantly lower annual total mental health care costs than the matched comparison group ($10,391 vs. $15,511; p < 0.0001). Membership in the B'More Clubhouse is associated with a substantial beneficial influence on health care costs.
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http://dx.doi.org/10.1007/s10597-016-0041-3DOI Listing
January 2017

An Innovative Model of Depression Care Delivery: Peer Mentors in Collaboration with a Mental Health Professional to Relieve Depression in Older Adults.

Am J Geriatr Psychiatry 2016 05 10;24(5):407-16. Epub 2016 Feb 10.

Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD.

Objectives: Traditional mental health services are not used by a majority of older adults with depression, suggesting a need for new methods of health service delivery. We conducted a pilot study using peer mentors to deliver depression care to older adults in collaboration with a mental health professional. We evaluated the acceptability of peer mentors to older adults and examined patient experiences of the intervention.

Methods: Six peer mentors met 30 patients for 1 hour weekly for 8 weeks. A mental health professional provided an initial clinical evaluation as well as supervision and guidance to peer mentors concurrent with patient meetings. We measured depressive symptoms at baseline and after study completion, and depressive symptoms and working alliance at weekly peer-patient meetings. We also interviewed participants and peer mentors to assess their experiences of the intervention.

Results: Ninety-six percent of patients attended all eight meetings with the peer mentor and PHQ-9 scores decreased for 85% of patients. Patients formed strong, trusting relationships with peer mentors. Patients emphasized the importance of trust, of developing a strong relationship, and of the credibility and communication skills of the peer mentor. Participants described benefits such as feeling hopeful, and reported changes in attitude, behavior, and insight.

Conclusions: Use of peer mentors working in collaboration with a mental health professional is promising as a model of depression care delivery for older adults. Testing of effectiveness is needed and processes of recruitment, role definition, and supervision should be further developed.
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http://dx.doi.org/10.1016/j.jagp.2016.02.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5116434PMC
May 2016

Association of NTproBNP and cTnI with outpatient sudden cardiac death in hemodialysis patients: the Choices for Healthy Outcomes in Caring for ESRD (CHOICE) study.

BMC Nephrol 2016 Feb 20;17:18. Epub 2016 Feb 20.

Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD, USA.

Background: Sudden cardiac death (SCD) is the most common etiology of death in hemodialysis patients but not much is known about its risk factors. The goal of our study was to determine the association and risk prediction of SCD by serum N-terminal prohormone of brain natriuretic peptide (NTproBNP) troponin I (cTnI) in hemodialysis patients.

Methods: We measured NTproBNP and cTnI in 503 hemodialysis patients of a national prospective cohort study. We determined their association with SCD using Cox regression, adjusting for demographics, co-morbidities, and clinical factors and risk prediction using C-statistic and Net Reclassification Improvement (NRI).

Results: Patients' mean age was 58 years and 54 % were male. During follow-up (median 3.5 years), there were 75 outpatient SCD events. In unadjusted and fully-adjusted models, NTproBNP had a significant association with the risk of SCD. Analyzed as a continuous variable, the risk of SCD increased 27 % with each 2-fold increase in NTproBNP (HR, 1.27 per doubling; 95 % CI, 1.13-1.43; p < 0.001). In categorical models, the risk of SCD was 3-fold higher in the highest tertile of NTproBNP (>7,350 pg/mL) compared with the lowest tertile (<1,710 pg/mL; HR for the highest tertile, 3.03; 95 % CI, 1.56-5.89; p = 0.001). Higher cTnI showed a trend towards increased risk of SCD in fully adjusted models, but was not statistically significant (HR, 1.17 per doubling; 95 % CI, 0.98-1.40; p = 0.08). Sensitivity analyses using competing risk models showed similar results. Improvement in risk prediction by adding cardiac biomarkers to conventional risk factors was greater with NTproBNP (C-statistic for 3-year risk: 0.810; 95 % CI, 0.757 to 0.864; and continuous NRI: 0.270; 95 % CI, 0.046 to 0.495) than with cTnI.

Conclusions: NTproBNP is associated with the risk of SCD in hemodialysis patients. Further research is needed to determine if biomarkers measurement can guide SCD risk prevention strategies in dialysis patients.
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http://dx.doi.org/10.1186/s12882-016-0230-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4761195PMC
February 2016

Association of NTproBNP and cTnI with outpatient sudden cardiac death in hemodialysis patients: the Choices for Healthy Outcomes in Caring for ESRD (CHOICE) study.

BMC Nephrol 2016 Feb 20;17:18. Epub 2016 Feb 20.

Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD, USA.

Background: Sudden cardiac death (SCD) is the most common etiology of death in hemodialysis patients but not much is known about its risk factors. The goal of our study was to determine the association and risk prediction of SCD by serum N-terminal prohormone of brain natriuretic peptide (NTproBNP) troponin I (cTnI) in hemodialysis patients.

Methods: We measured NTproBNP and cTnI in 503 hemodialysis patients of a national prospective cohort study. We determined their association with SCD using Cox regression, adjusting for demographics, co-morbidities, and clinical factors and risk prediction using C-statistic and Net Reclassification Improvement (NRI).

Results: Patients' mean age was 58 years and 54 % were male. During follow-up (median 3.5 years), there were 75 outpatient SCD events. In unadjusted and fully-adjusted models, NTproBNP had a significant association with the risk of SCD. Analyzed as a continuous variable, the risk of SCD increased 27 % with each 2-fold increase in NTproBNP (HR, 1.27 per doubling; 95 % CI, 1.13-1.43; p < 0.001). In categorical models, the risk of SCD was 3-fold higher in the highest tertile of NTproBNP (>7,350 pg/mL) compared with the lowest tertile (<1,710 pg/mL; HR for the highest tertile, 3.03; 95 % CI, 1.56-5.89; p = 0.001). Higher cTnI showed a trend towards increased risk of SCD in fully adjusted models, but was not statistically significant (HR, 1.17 per doubling; 95 % CI, 0.98-1.40; p = 0.08). Sensitivity analyses using competing risk models showed similar results. Improvement in risk prediction by adding cardiac biomarkers to conventional risk factors was greater with NTproBNP (C-statistic for 3-year risk: 0.810; 95 % CI, 0.757 to 0.864; and continuous NRI: 0.270; 95 % CI, 0.046 to 0.495) than with cTnI.

Conclusions: NTproBNP is associated with the risk of SCD in hemodialysis patients. Further research is needed to determine if biomarkers measurement can guide SCD risk prevention strategies in dialysis patients.
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http://dx.doi.org/10.1186/s12882-016-0230-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4761195PMC
February 2016
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