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Background: African American men with chronic kidney disease (CKD) progress to end-stage renal disease more rapidly than African American women or whites. Uncontrolled hypertension worsens CKD, and disparities in hypertension control may contribute to disparities in CKD progression.Study Design: Cross-sectional.Setting& Participants: 10,827 individuals with CKD and self-reported hypertension screened in the Kidney Early Evaluation Program.Predictors: African American race, sex.Outcomes: Hypertension control (blood pressure <130 mm Hg systolic and/or <80 mm Hg diastolic).Measurements: Self-report, physical examination (blood pressure), laboratory data (serum creatinine, microalbuminuria by urine dipstick). We calculated estimated glomerular filtration rates by using the 4-variable isotope dilution mass spectrometry Modification of Diet in Renal Disease Study equation. We classified CKD as early (stages 1 to 2) or late (stages 3 to 5) based on estimated glomerular filtration rate and microalbuminuria.Results: In individuals with early CKD, African American women (odds ratio [OR], 1.47; 95% confidence interval [CI], 1.14 to 1.88), white men (OR, 1.85; 95% CI, 1.39 to 2.46), and white women (OR, 1.69; 95% CI, 1.28 to 2.22) had greater odds of hypertension control (blood pressure <130/80 mm Hg) than African American men. In individuals with late CKD, white men (OR, 1.66; 95% CI, 1.10 to 2.52) and white women (OR, 1.67; 95% CI, 1.13 to 2.46) had greater odds of hypertension control than African American men. No differences were seen between African American men and women with late CKD.Limitations: No information for medication regimens.Conclusions: African American men with CKD have poorly controlled hypertension compared with African American women and whites, particularly in the early stages of disease. Efforts to aggressively treat hypertension in this population may help narrow the race and sex disparities in progression to end-stage renal disease. [ABSTRACT FROM AUTHOR]

Objective: To describe the prevalence and awareness of abnormal renal function and risk factors for kidney disease (KD) and cardiovascular diseases among family members of patients with end-stage renal disease (ESRD) in a population participating in a screening program. Methodology: A cross-sectional survey was conducted by way of a voluntary screening of relatives of patients with ESRD in 10 communities in one southeastern state. Age; race; sex: family and personal history of KD. hypertension, and diabetes; height: weight: and blood pressure were determined. Proteinuria and random blood glucose and serum creatinine were measured. Results: Among 769 screened adults, 29.2% with a family history of ESRD were included. CKD (CrCl <90 mL/min) was present in 49.3%. 13.9% had a CrCI <60 mL/min, and 9,9% had proteinuria of≥1. Among those with a CrCl <60 mL/min or proteinuria of ≥1 or both. only 13.0% were aware of their KD. Awareness of CKD was not associated with age, race, sex, education, control of diabetes and hypertension, or physician's visits. Among those who had seen a physician recently, only 7.9% were aware of their KD. Conclusion: Awareness of KD is less than expected among relatives of patients with ESRD, considering the high prevalence of CKD in this population. Screening these individuals might help identify people with early KD. [ABSTRACT FROM AUTHOR]

Examines the risk of in-hospital mortality following percutaneous coronary intervention in older patients. Overall mortality rates and mortality rates in elective cases and after acute myocardial infarction; Association of an increased mortality rate with a decreased left ventricular function.

Objective: The progression of long-term diabetes complications has led to a decreased quality of life. Our objective was to evaluate the adverse outcomes associated with diabetes based on a patient's clinical profile by utilizing a multistate modeling approach., Methods: This was a retrospective study of diabetes patients seen in primary care practices from 2013 to 2017. We implemented a five-state model to examine the progression of patients transitioning from one complication to having multiple complications. Our model incorporated high dimensional covariates from multisource data to investigate the possible effects of different types of factors that are associated with the progression of diabetes., Results: The cohort consisted of 10,596 patients diagnosed with diabetes and no previous complications associated with the disease. Most of the patients in our study were female, White, and had type 2 diabetes. During our study period, 5928 did not develop complications, 3323 developed microvascular complications, 1313 developed macrovascular complications, and 1129 developed both micro- and macrovascular complications. From our model, we determined that patients had a 0.1334 [0.1284, .1386] rate of developing a microvascular complication compared to 0.0508 [0.0479, .0540] rate of developing a macrovascular complication. The area deprivation index score we incorporated as a proxy for socioeconomic information indicated that patients who reside in more disadvantaged areas have a higher rate of developing a complication compared to those who reside in least disadvantaged areas., Conclusions: Our work demonstrates how a multistate modeling framework is a comprehensive approach to analyzing the progression of long-term complications associated with diabetes., Competing Interests: None., (© The Author(s) 2024.)

Introduction: Higher incidences of interpersonal violence were reported throughout the country during the coronavirus (COVID) time period. We aimed to compare health-care encounters and resource utilization related to interpersonal violence with mental health (MH) disorders before and during the pandemic within a year of the index visit for interpersonal violence., Methods: A retrospective analysis of the Delaware Healthcare Claims data of all patients aged ≥16 y who suffered interpersonal violence was performed. Patients were followed up for 1 y pre and post their index visit of interpersonal violence episode during the pre-COVID (March 2018 through December 2018) and the COVID (March 2020 through December 2020) period. Census tract information was used to assess social determinants of health., Results: There were 431 patients in the COVID period and 527 patients in the pre-COVID period with index violence claim encounters. African American patients were more likely to have a violence encounter during COVID (60.3% versus 47.2%, P < 0.001). Patients in the COVID period were more likely to live in a census tract with public assistance households (median 3.3% versus 2.2%, P = 0.005) and higher unemployment (7.5% versus 7.1%, P = 0.01). In the following year of index violence claim, the mean numbers of MH claim-days for COVID and pre-COVID patients were 19.5 (53.3) and 26.2 (66.2), (P = 0.51). The COVID group had fewer MH claim-days mostly in the second half of the year after the index encounter with an incidence rate ratio of 0.61, 95% CI (0.45-0.83)., Conclusions: Racial and socioeconomic disparities were amplified and MH resource utilization was lower during COVID. Further injury prevention efforts should be focused on MH in future pandemics or disasters., (Published by Elsevier Inc.)

Introduction: Lung cancer screening rates are very low despite a level B recommendation from the United States Preventive Services Task Force since 2013 and clear evidence that lung cancer screening reduces mortality. The Center for Medicare and Medicaid Services requires shared decision-making (SDM) for lung cancer screening reimbursement. The objective of this study was to determine the effect of an SDM intervention on lung cancer screening in primary care., Methods: The study design was a single-arm clinical trial design. The intervention included phone contact outside of a primary care visit and the use of the Decision Counseling Program ®, an online interactive decision aid focused on determining the factors which influence patients to screen or not screen, prioritizing those factors, and determining a decision preference score. The primary outcome was the completion of low-dose computed tomography scan (LDCT) 1 year after the SDM session compared in participants versus nonparticipants., Results: From six practices, there were 1359 potentially eligible patients in electronic medical record data, and 336 were reached to assess eligibility criteria. A total of 80 patients consented to be in the study, 64 completed a decision counseling session and 16 did not complete a session. Among the 64 people who agreed to have decision counseling, 45% had LDCT, higher than typically seen in routine clinical practice. Although not a comparable group, among the 16 people who declined decision counseling, none had LDCT., Conclusions: Decision counseling is a promising intervention that might support SDM in the context of improving uptake of lung cancer screening in primary care. However, further, larger studies are needed., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: COVID-19 has greatly impacted the U.S. health system. What is not as well-understood is how this has altered specific aspects of lung cancer care. While cancer incidence and screening have been affected, it is not known whether pre-existing racial and socioeconomic disparities worsened or if treatment standards changed. The purpose of this study is to provide a comprehensive analysis of the impact of COVID-19 on lung cancer in the state of Delaware., Methods: Health care claims were analyzed from the Delaware Healthcare Claims Database for the years 2019-2020. Patients with a new lung cancer diagnosis and those who had undergone lung cancer screening were identified. Demographic and socioeconomic variables including gender, age, race, and insurance were studied. Patients were analyzed for type of treatment by CPT code. The intervention of interest in this study was the institution of restrictions at the end of March 2020. An interrupted time series analysis (ITSA) was utilized to evaluate baseline levels and overall trend changes., Results: The incidence of lung cancer diagnoses and lung cancer screenings decreased in the nine-month time period after the initiation of COVID-19 lockdowns. Demographic and socioeconomic variables including gender, race, income, and education level were not affected; however, statistical differences were seen in the most elderly subgroup. Treatment modalities including number of surgeries, chemotherapy, and radiation therapy did not change significantly., Conclusions: COVID-19 has had a significant impact on lung cancer care within the state of Delaware. Lung cancer incidence, screenings, and elderly patients were affected the most., (2024 The journal and its content is copyrighted by the Delaware Academy of Medicine / Delaware Public Health Association (Academy/DPHA).)

Introduction: The rapid implementation of telemedicine during the COVID-19 pandemic may have exacerbated the existing health disparities. This study investigated the association between the area deprivation index (ADI), which serves as a measure of socioeconomic deprivation within a geographic area, and the utilization of telemedicine in primary care., Methods: The study data source was electronic health records. The study population consisted of patients with at least one primary care visit between March 2020 and December 2021. The primary outcome of interest was the visit modality (office, phone, and video). The exposure of interest was the ADI score grouped into quartiles (one to four, with one being the least deprived). The confounders included patient sociodemographic characteristics (e.g., age, gender, race, ethnicity, insurance coverage, marital status). We utilized generalized estimating equations to compare the utilization of telemedicine visits with office visits, as well as phone visits with video visits., Results: The study population included 41,583 patients with 127,165 office visits, 39,484 phone visits, and 20,268 video visits. Compared to patients in less disadvantaged neighborhoods (ADI quartile = one), patients in more disadvantaged neighborhoods (ADI = two, three, or four) had higher odds of using phone visits vs office visits, lower odds of using video visits vs office visits, and higher odds of using phone visits vs video visits., Conclusions: Patients who resided in socioeconomically disadvantaged neighborhoods mainly relied on phone consultations for telemedicine visits with their primary care provider. Patient-level interventions are essential for achieving equitable access to digital healthcare, particularly for low-income individuals., Competing Interests: The authors have no conflicts of interest to disclose., (© The Author(s) 2023.)

Objective: To measure trends for the emergence of opioid withdrawal (OW) and leaving against medical advice (AMA) among hospitalized patients., Method: Retrospective time-series of hospitalized patients with OW, defined by a Clinical Opioid Withdrawal score &gt;8, using electronic health record data at a tertiary health system and of patients with a discharge status of AMA from January 1, 2017 to December 31, 2020., Results: The average number of monthly hospitalizations with OW showed a year-to-year increment of 15% in 2018, 21% in 2019, and 34% from 2019 to 2020, whereas the total monthly hospitalizations remained stable. The segmented regression analysis showed that the upward trend in hospitalizations with OW became significant after January 2019 (slope: 1.14, 95% confidence interval [CI]: 0.70, 1.57). After August 2019, Fentanyl was added to the hospital urine drug testing panel and was identified in most OW patients. The monthly proportion of patients who left AMA was significantly higher among the OW patients than among all other admitted patients. There was a significant increase of 0.39 (95% CI: 0.29-0.49, P &lt; 0.001) per month in %AMA among patients with OW. The estimated difference in %AMA among OW patients versus all other patients was 7.25 (95% CI: 5.12-9.38) in January 2017, and 16.92 (95% CI: 14.60-19.24) in December 2020., Conclusions: The number of hospitalized patients either presenting with or developing OW increased between 2017 and 2020 with a significant rise occurring after January 2019. The percentage of patients who left AMA among those who developed OW steadily worsened during the entire study period., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Society of Addiction Medicine.)

Introduction: Much of the suffering and expense associated with treatment of persons with dementia (Major Neurocognitive Disorder) arises from associated noncognitive behavioral and psychological symptoms of dementia (BPSD). Although a consensus on the prevalence of BPSD is lacking, evidence suggests that most people with dementia will manifest one or more of these symptoms during the disorder's progression. BPSD raise the cost of care by leading to more frequent emergency room visits, more and longer hospitalizations, and earlier admission to long-term care facilities (LTCF). Treatment of BPSD presents a stressful challenge in LTCFs. We sought to investigate the care burden of BPSD in Delaware's LTCFs and to gather data that can inform management approaches., Methods: Using REDCap, we created an anonymous cross-sectional survey designed for completion by LTCF administrators. The Delaware Health Care Facilities Association (DHCFA) and Delaware's Division of Services for Aging and Adults with Physical Disabilities (DSAAPD) encouraged participation. A link to the survey was emailed to the administrators of 81 facilities in Delaware. The resulting data were evaluated using descriptive statistics., Results: Forty-four of the 81 facilities surveyed opened the survey link. Thirty-eight facilities answered at least some of the questions, and 19 surveys were fully completed. The reported average prevalence of BPSD among Delaware LTCF residents with dementia was 49.3% (SD 28.9). The five most frequently reported BPSD symptoms were anxiety, agitation, wandering, dysphoria/depression, and appetite/eating abnormalities. All facilities reported employing a spectrum of pharmacologic and non-pharmacologic management strategies. Twenty-two of 24 respondents (91.7%) reported that behavioral health consultation was available at their facilities and 18 of 20 respondents (90.0%) indicated that they provided training on how to manage residents with BPSD., Conclusion: BPSD are a pervasive concern among Delaware's LTCFs. LTCFs may benefit from the development of training programs and dissemination of treatment guidelines incorporating evidence-based interventions and their implementation in managing BPSD to improve care, decrease stress on residents and caregivers, and reduce some avoidable health care costs.

Since the beginning of the COVID-19 pandemic, the State of Delaware has implemented various strategies including a stay-at-home order, mask-wearing requirements in public places, and community-based testing to control the spread of the disease. Health systems across the U.S. have taken actions including symptom monitoring and screening for visitors and healthcare workers, providing personal protection equipment (PPE), and contact tracing of confirmed infected individuals to provide maximum possible protection for healthcare workers. Despite such efforts, there remains a significant risk of intra-hospital transmission of COVID-19. Healthcare workers who contact patients with COVID-19 or were exposed to the disease in the community may transmit the infection to coworkers in the inpatient setting. In addition to universal and case-based precautions to prevent exposure and disease transmission, contact tracing is essential to minimizing the impact of outbreaks among healthcare workers and the community. A rapid increase in cases can quickly diminish hospital infection control and prevention program capacity to perform high-quality contact tracing. This article will describe an approach using the application of social network analysis (SNA) and Electronic Medical Records (EMR) to enhance the current efforts in COVID-19 contact tracings.

The national rate of  lung cancer screening, approximately 3-5%, is too low and strategies which include shared decision-making and increase screening are needed. A feasibility study in one large primary care practice of telephone-based delivery of decision support via an online tool, the Decision Counseling Program© (DCP) was administered to patients eligible for lung cancer screening according to USPSTF screening guidelines. We collected data on demographics, decisional conflict, and conducted chart audits to ascertain screening. From electronic medical record data, we identified 829 age-eligible current or former smokers. Of the 297 individuals reached, 54 were eligible and 28 were recruited to the study and 20 underwent the DCP© intervention. Participants in the intervention were more likely to complete low-dose CT scans at 90 days. Current smokers were less likely to complete the DCP. Women were less likely to complete LDCT. This non-persuasive, high-quality shared decision-making intervention significantly increased lung cancer screening and was feasible in real-world clinical care. This intervention offers a promising model whereby patients can be supported in a decision, based on their values and beliefs while also supporting gains in lung cancer screening.

Objectives: The aims of this study were, first, to compare the predicted (calculated) energy requirements based on standard equations with target energy requirement based on indirect calorimetry (IC) in critically ill, obese mechanically ventilated patients; and second, to compare actual energy intake to target energy requirements., Methods: We conducted a prospective cohort study of mechanically ventilated critically ill patients with body mass index ≥30.0 kg/m 2 for whom enteral feeding was planned. Clinical and demographic data were prospectively collected. Resting energy expenditure was measured by open-circuit IC. American Society of Parenteral and Enteral Nutrition (APSPEN)/Society of Critical Care Medicine (SCCM) 2016 equations were used to determine predicted (calculated) energy requirements. Target energy requirements were set at 65% to 70% of measured resting energy expenditure as recommended by ASPEN/SCCM. Nitrogen balance was determined via simultaneous measurement of 24-h urinary nitrogen concentration and protein intake., Results: Twenty-five patients (mean age: 64.5 ± 11.8 y, mean body mass index: 35.2 ± 3.6 kg/m 2 ) underwent IC. The mean predicted energy requirement was 1227 kcal/d compared with mean measured target energy requirement of 1691 kcal/d. Predicted (calculated) energy requirements derived from ASPEN/SCCM equations were less than the target energy requirements in most cases. Actual energy intake from enteral nutrition met 57% of target energy requirements. Protein intake met 25% of target protein requirement and the mean nitrogen balance was -2.3 ± 5.1 g/d., Conclusions: Predictive equations underestimated target energy needs in this population. Further, we found that feeding to goal was often delayed resulting in failure to meet both protein and energy intake goals., (Copyright © 2019 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Chronic Kidney Disease (CKD) is one of several conditions that affect a growing percentage of the US population; the disease is accompanied by multiple co-morbidities, and is hard to diagnose in-and-of itself. In its advanced forms it carries severe outcomes and can lead to death. It is thus important to detect the disease as early as possible, which can help devise effective intervention and treatment plan. Here we investigate ways to utilize information available in electronic health records (EHRs) from regular office visits of more than 13,000 patients, in order to distinguish among several stages of the disease. While clinical data stored in EHRs provide valuable information for risk-stratification, one of the major challenges in using them arises from data imbalance. That is, records associated with a more severe condition are typically under-represented compared to those associated with a milder manifestation of the disease. To address imbalance, we propose and develop a sampling-based ensemble approach, hierarchical meta-classification, aiming to stratify CKD patients into severity stages, using simple quantitative non-text features gathered from standard office visit records., Methods: The proposed hierarchical meta-classification method frames the multiclass classification task as a hierarchy of two subtasks. The first is binary classification, separating records associated with the majority class from those associated with all minority classes combined, using meta-classification. The second subtask separates the records assigned to the combined minority classes into the individual constituent classes., Results: The proposed method identifies a significant proportion of patients suffering from the more advanced stages of the condition, while also correctly identifying most of the less severe cases, maintaining high sensitivity, specificity and F-measure (≥ 93%). Our results show that the high level of performance attained by our method is preserved even when the size of the training set is significantly reduced, demonstrating the stability and generalizability of our approach., Conclusion: We present a new approach to perform classification while addressing data imbalance, which is inherent in the biomedical domain. Our model effectively identifies severity stages of CKD patients, using information readily available in office visit records within the realistic context of high data imbalance.

Background: The diagnosis of malnutrition remains controversial. Furthermore, it is unknown if physician diagnosis of malnutrition impacts outcomes. We sought to compare outcomes of patients with physician diagnosed malnutrition to patients recognized as malnourished by registered dietitians (RDs), but not physicians, and to describe the impact of each of 6 criteria on the diagnosis of malnutrition., Methods: We conducted a retrospective cohort study of adult patients identified as meeting criteria for malnutrition. Pediatric, psychiatric, maternity, and rehabilitation patients were excluded. Patient demographics, clinical data, malnutrition type and criteria, nutrition interventions, and outcomes were abstracted from the electronic medical record., Results: RDs identified malnutrition for 291 admissions during our study period. This represents 4.1% of hospital discharges. Physicians only diagnosed malnutrition on 93 (32%) of these cases. Physicians diagnosed malnutrition in 43% of patients with a body mass index <18.5 but only 26% of patients with body mass index higher than 18.5. Patients with a physician diagnosis had a longer length of stay (mean 14.9 days vs 7.1 days) and were more likely to receive parenteral nutrition (PN) (20.4% vs 4.6%). Of the patients, 62% had malnutrition due to chronic illness. Of the 6 criteria used to identify malnourished patients, weight loss and reduced energy intake were the most common., Conclusions: Malnutrition is underrecognized by physicians. However, further research is needed to determine if physician recognition and treatment of malnutrition can improve outcomes. The most important criteria for identifying malnourished patients in our cohort were weight loss and reduced energy intake., (© 2017 American Society for Parenteral and Enteral Nutrition.)

Patients associated with multiple co-occurring health conditions often face aggravated complications and less favorable outcomes. Co-occurring conditions are especially prevalent among individuals suffering from kidney disease, an increasingly widespread condition affecting 13% of the general population in the US. This study aims to identify and characterize patterns of co-occurring medical conditions in patients employing a probabilistic framework. Specifically, we apply topic modeling in a non-traditional way to find associations across SNOMED-CT codes assigned and recorded in the EHRs of >13,000 patients diagnosed with kidney disease. Unlike most prior work on topic modeling, we apply the method to codes rather than to natural language. Moreover, we quantitatively evaluate the topics, assessing their tightness and distinctiveness, and also assess the medical validity of our results. Our experiments show that each topic is succinctly characterized by a few highly probable and unique disease codes, indicating that the topics are tight. Furthermore, inter-topic distance between each pair of topics is typically high, illustrating distinctiveness. Last, most coded conditions grouped together within a topic, are indeed reported to co-occur in the medical literature. Notably, our results uncover a few indirect associations among conditions that have hitherto not been reported as correlated in the medical literature., (Copyright © 2018 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Clinical practice guidelines recommend enteral nutrition for most patients receiving mechanical ventilation. However, recently published evidence on the effect of enteral nutrition on mortality, particularly for patients who are well nourished, is conflicting., Objectives: To examine the association between enteral feeding and hospital mortality in critically ill patients receiving mechanical ventilation and to determine if body mass index mediates this relationship., Methods: A retrospective cohort study of patients receiving mechanical ventilation admitted to a medical intensive care unit in 2013. Demographic and clinical variables were collected. Cox proportional hazards regression was used to examine the relationship between an enteral feeding order and hospital mortality and to determine if the relationship was mediated by body mass index., Results: Of 777 patients who had 811 hospitalizations requiring mechanical ventilation, 182 (23.4%) died in the hospital. A total of 478 patients (61.5%) received an order for enteral tube feeding, which was associated with a lower risk of death (hazard ratio, 0.41; 95% CI, 0.29-0.59). Body mass index did not mediate the relationship between mortality and receipt of an order for enteral feeding. Median stay in the unit was 3.6 days. Most deaths (72.0%) occurred more than 48 hours after admission., Conclusion: The finding of a positive association between an order for enteral feeding and survival supports enteral feeding of patients in medical intensive care units. Furthermore, the beneficial effect of enteral feeding appears to apply to patients regardless of body mass index., (©2018 American Association of Critical-Care Nurses.)

Cardiovascular implantable electronic devices (CIEDs) are frequently utilized in hemodialysis patients. CIED leads are typically implanted via the subclavian vein resulting in stenosis and venous hypertension. We studied 1235 chronic hemodialysis patients under the care of our nephrology practice. For each, we determined the presence of a CIED, indication for implantable cardioverter-defibrillator (ICD), and type of hemodialysis access. Records were reviewed to identify all interventions performed on the access circuit and the central veins specifically. A CIED was present in 129 patients (10.5%), including ICDs in 75 (6.1%) and pacemakers in 54 (4.4%). The access circuit intervention rate was 1.48/access year (AY) and was similar when a CIED was ipsilateral (1.53/AY) or contralateral (1.44/AY) to arteriovenous access (p = 0.477). The rate of central venous interventions was greater in the ipsilateral (0.59/AY) versus contralateral group (0.28/AY), (p < 0.001). Fifty-four of 59 patients with ipsilateral access and CIED required <2 interventions per AY, but six failed angioplasty and required access ligation. None had superior vena cava stenosis requiring intervention. We conclude that there is a high prevalence of CIEDs in our HD patients. Ipsilateral CIED and arteriovenous access results in higher central venous intervention rates compared with contralateral cases; overall access circuit intervention rates are similar., (© 2014 Wiley Periodicals, Inc.)

Background: Because of concerns for propagating clots into pulmonary emboli by the placement of pneumatic compression boots (PCBs), the standard of care at our institution was to perform a duplex Doppler ultrasound with compression (DUSC) before applying PCBs. We sought to determine the rate of asymptomatic preexisting deep vein thrombosis (DVT) in hospitalized patients who underwent DUSC before PCB., Methods: We evaluated consecutive patients who underwent lower extremity DUSC within 48 hours of admission. All patients were assessed for DVT risk factors using the American College of Chest Physicians' criteria (American College of Chest Physicians Conference on Antithrombotic/Thrombolytic Therapy: Evidence-Based Guidelines, 9th Edition). A t test, Wilcoxon rank sum test, and χ(2) or Fisher exact test were used to compare patients characteristics according to DVT status. Logistic regression was used to determine the importance of each risk factor on the risk of DVT., Results: DUSC was performed during 1136 hospitalizations; 1071 patients were included in the dataset. Of those, 19 patients (1.8%) had asymptomatic DVT and had at least 1 risk factor; 16 (84.2%) had more than 1 risk factor. The only risk factors that were statistically significant were ambulatory dysfunction and thromboembolic disease history., Conclusion: Few patients have asymptomatic DVT upon admission; all of these patients have at least 1 predisposing risk factor. There appears to be no need for DUSC prior to initiation of PCBs. DUSC evaluation for DVT may be of value if there is a history of previous DVT, ambulatory dysfunction, or more than 3 risk factors, as the information may change therapeutic approaches., (© 2013 Society of Hospital Medicine.)

Background: Both anemia and secondary hyperparathyroidism are reflections of hormonal failure in chronic kidney disease (CKD). While the association of elevated levels of parathyroid hormone (PTH) and anemia has been studied among those with advanced CKD, less is known about this association in mild-to-moderate CKD., Methods: In a cross-sectional analysis, the relationship between PTH and hemoglobin levels was investigated in 10,750 participants in the National Kidney Foundation's Kidney Early Evaluation Program with an estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m 2 ., Results: In the unadjusted analysis, higher PTH levels were associated with lower hemoglobin levels. However, after multivariable adjustment for age, race, gender, smoking status, education, cardiovascular disease, diabetes, hypertension, cancer, albuminuria, BMI, baseline eGFR, calcium, and phosphorus, the direction of association changed. As compared to the first PTH quintile, hemoglobin levels were 0.09 g/dl (95% CI: 0.01-0.18), 0.15 g/dl (95% CI: 0.07-0.24), 0.18 g/dl (95% CI: 0.09-0.26), and 0.13 g/dl (95% CI: 0.07-0.25) higher for the second, third, fourth, and fifth quintiles, respectively. Similarly, each standard deviation increase in natural log transformed PTH was associated with a 0.06 g/dl (95% CI: 0.03-0.09, p = 0.0003) increase in hemoglobin. However, a significant effect modification was seen for diabetes (p = 0.0003). Each standard deviation increase in natural log transformed PTH was associated with a 0.10 g/dl (95% CI: 0.054-0.138, p < 0.0001) increase in hemoglobin, while no association was seen among those without diabetes mellitus., Conclusion: After multivariable adjustment, there was a small positive association between PTH and hemoglobin among diabetics but not among nondiabetics.

Background: Our goal was to define the prevalence of radiation-induced valvular heart (RIVD) disease among patients undergoing cardiac valve surgery in a community-based, regional academic medical center. Mediastinal radiation is a treatment modality for various hematologic and solid malignancies; however, long-term cardiac complications, including radiation-induced valvular heart disease, can occur years after the radiation treatments., Hypothesis: Mediastinal radiation exposure is an independent risk factor for valvular heart disease often necessitating valve replacement in patients without other risk factors for valve disease., Methods: Between January 1, 1998 and September 1, 2007, we retrospectively analyzed our institution's cardiac surgical database over a 10 year period and identified 189 consecutive patients ≤ 50 years of age who underwent valve surgery. Using case-control matching, we assessed the prevalence of mediastinal radiation among these young patients with valve disease necessitating surgery and to their matched controls from all patients admitted to the hospital., Results: Nine individuals (4.8%) were identified as having received previous mediastinal radiation, significantly increased from controls (p<0.0001), and 8 of whom had surgical or pathologic findings consistent with radiation damage. Compared with a matched case-control population, individuals who had severe valve disease and underwent valve replacement had a markedly increased prevalence of prior mediastinal radiation therapy., Conclusions: In conclusion, cardiologists must remain aware of the potential long term valvular complications in patients treated with mediastinal radiation. Increased surveillance for RIVD may be considered in the decades following radiation therapy., (© 2013 Wiley Periodicals, Inc.)

An acronym, a button, a script card, and a lot of fun are all an educator needs to turn dreaded education into a great learning experience for nurses as well as the patients. A multidisciplinary team pilot tested a new learning approach on a cardiac step-down unit. The goal was to educate both nurses and patients about the American Heart Association's Get-With-the-Guidelines Program for Coronary Artery Disease. The educational strategies were successful, and data revealed an increase in nursing knowledge of core measures. After a two-phase study, the program was eventually rolled out hospital-wide. The study results show that nurses' compliance with and knowledge of the AHA core measures increased as a direct result of the program.

Little is known about excessive daytime sleepiness (EDS) in heart failure (HF). The aim of this cross-sectional descriptive study was to describe the prevalence of EDS and factors associated with it in HF. A secondary purpose was to explore the correlates of fatigue. We enrolled a consecutive sample of 280 adults with a confirmed diagnosis of chronic HF from three outpatient settings in the northeastern United States. Patients with major depressive illness were excluded. Clinical, sociodemographic, behavioral, and perceptual factors were explored as possible correlates of EDS. Using an Epworth Sleepiness Scale score > 10, the prevalence of EDS was 23.6%. Significant determinants of EDS were worse sleep quality (p = .048), worse functional class (p = .004), not taking a diuretic (p = .005), and lack of physical activity (p = .04). Only sleep quality was associated with fatigue (p < .001). Sleep-disordered breathing was not significantly associated with EDS or with fatigue. These factors may be amenable to intervention.

Background: Pregnancy-induced hypertension (PIH) plays a major role in the perinatal outcome for mother and neonate. With the rising prevalence of obesity, the role of prepregnancy body mass index (BMI) as an independent risk factor for PIH and a target for preconception care is important to explore., Methods: We completed a retrospective cohort study of 16,582 women who received obstetrical care at a regional medical center and delivered a singleton pregnancy between 2003 and 2006. Clinical data were derived from the electronic medical record. Logistic regression was used to explore the association of demographic characteristics and medical risk factors with the outcome of PIH., Results: Diagnoses of chronic hypertension, prepregnancy diabetes, and gestational diabetes were more likely in women with increasing prepregnancy maternal BMI (p < 0.0001). The odds of PIH also increased with BMI, ranging from an odds ratio (OR) of 1.99 (95% confidence interval [CI] 1.73-2.31) for overweight women through OR 4.26 (95% CI 3.37-5.38) for those with a BMI of ≥40 kg/m(2). Other risk factors for PIH included chronic hypertension (OR 6.57, 95% CI 5.43-7.95), nulliparity (OR 1.89, 95% CI 1.69-2.12), prepregnancy diabetes (OR 2.05, 95% CI 1.33-3.17), and gestational diabetes (OR 1.28, 95% CI 1.04-1.58). The presence of chronic hypertension modified the association between obesity and PIH; for women with chronic hypertension, obesity was not associated with PIH (adjusted OR [aOR] 1.39, 95% CI 0.77-2.50 for BMI 30-34.9; aOR 0.98, 95% CI 0.52-1.87 for BMI 35-39.9; and aOR 1.33, 95% CI 0.73-2.43 for BMI ≥40 kg/m(2)) compared with women with a BMI in the normal range., Conclusions: The risk of PIH rises with maternal prepregnancy BMI independent of other obesity-associated comorbidity. Women with chronic hypertension carry the greatest risk of PIH but incur no obesity-associated increase in risk.