Impact of arteriovenous fistula on flow states in the evaluation of aortic stenosis among ESKD patients on dialysis.

INTRODUCTION: An arteriovenous fistula (AVF) in patients with end-stage kidney disease (ESKD) can influence flow states. We sought to evaluate if assessment of aortic stenosis (AS) by transthoracic echocardiographic (TTE) differs in the presence of AVF compared to other dialysis accesses in patients on dialysis. METHODS: We identified consecutive ESKD patients on dialysis and concomitant AS from a single center between January 2000 and March 2021. We analyzed TTE parameters of AS severity (velocities, gradients, aortic valve area [AVA]) and hemodynamics (cardiac output [CO], valvuloarterial impedance [Zva]) and compared AS parameters in patients with AVF versus other dialysis access. RESULTS: The cohort included 94 patients with co-prevalent ESKD and AS; mean age 66 years, 71% male; 43% Black, 24% severe AS. Dialysis access: 53% AVF, 47% others. In the overall cohort, no significant differences were noted between AVF versus non-AVF in AVA/CO/Zva, but with notable subgroup differences. In mild AS, CO was significantly higher in AVF versus non-AVF (6.3 vs. 5.2 L/min; p = .04). In severe AS, Zva was higher in the AVF versus non-AVF (4.6 vs. 3.6 mm Hg/mL/m2 ). With increasing AS severity in the AVF group, CO decreased, coupled with increase in Zva, likely counterbalancing the net hemodynamic impact of the AVF. CONCLUSION: Among ESKD patients with AS, TTE parameters of flow states and AS severity differed in those with AVF versus other dialysis accesses and varied with progression in severity of AS. Future longitudinal assessment of hemodynamic parameters in a larger cohort of co-prevalent ESRD and AS would be valuable.

Association of hypoxic ischemic brain injury on early CT after out of hospital cardiac arrest with neurologic outcome.

AIM: This study aimed to describe the prevalence of hypoxic-ischemic brain injury (HIBI) on head CT (HCT) obtained within two hours of return of spontaneous circulation (ROSC) care in the Emergency Department following out-of-hospital cardiac arrest (OHCA) and evaluate the association between early HIBI and neurologic outcome. METHODS: Retrospective single center observational study of post-OHCA patients between 2009 and 2017. Two cohorts were analyzed: those who underwent non-contrast HCT within two hours of ROSC and all others who survived to ICU admission. HIBI was defined as the presence of cerebral edema and/or abnormal gray-white matter differentiation in the HCT interpretation by a neuroradiologist. The primary outcomes were the prevalence of HIBI on early HCT and the magnitude of the association between HIBI and survival with good neurologic outcome using multivariable logistic regression. RESULTS: Following OHCA, 333 of 520 patients (64%) underwent HCT within two hours of ROSC and HIBI was present in 96 of 333 patients (29%). Of the early HCT cohort, those with HIBI had a significantly lower hospital survival (2%) and favorable neurologic outcome (1%). In those without HIBI on imaging, 88 of 237 patients (37%) had a favorable outcome. After adjustment for confounding variables, HIBI on early HCT was independently associated with a decreased likelihood of good neurologic outcome (aOR 0.015, 95% CI 0.002-0.12). CONCLUSION: HIBI was present on 29% of HCTs obtained within 2 h of ROSC in the patients selected for early imaging by emergency physicians and was strongly and inversely associated with survival with a good neurologic outcome.

Prevalence and Impact of Adverse Social and Behavioral Determinants of Health in Heart Failure: Analysis of a Safety-Net Population.

OBJECTIVE: To determine the impact of adverse social and behavioral determinants of health (SBDH) on health care use in a safety-net community hospital (SNCH) heart failure (HF) population. METHODS: We performed a retrospective analysis of HF patients at a single SNCH between 2018-2019 (N= 4594). RESULTS: At least one adverse SBDH was present in 21% of the study population. Patients with at least one adverse SBDH were younger (57 vs. 68 years), more likely to identify as Black (50% vs. 36%), be male (68% vs. 53%), and have Medicaid insurance (48% vs. 22%), p<.001. Presence of at least one adverse SBDH (homelessness, substance use, or incarceration) correlated with increased hospitalizations (2.3 vs 1.4/patient) and ED visits (5.1 vs 2.1/patient), p<.0001. Adverse SBDH were independent predictors of HF readmissions. Prescribing of guideline-directed medical therapy was similar among all patients. CONCLUSIONS: In a SNCH HF cohort, adverse SBDH predominantly afflict younger Black men on Medicaid and are associated with increased utilization.

Statin Utilization Among Individuals Infected With Hepatitis C Virus: A Retrospective Cohort Study.

Introduction and Objectives Statin use for primary prevention of coronary artery disease (CAD) has historically been limited in patients with chronic liver disease due to concerns for increased adverse events with statin use in this population. We aimed to quantify the underutilization of statins among individuals with a history of HCV infection in a community health system to understand the clinical implications of statin underutilization in a diverse, generalizable population of patients infected with HCV. Materials and Methods We performed a single-center retrospective study of individuals with a history of HCV infection aged 40-75 years from 2019-2021. Statin eligibility was determined using the 2019 American College of Cardiology/American Heart Association (ACC/AHA) guidelines with the 2013 Pooled Cohort Equation used to determine atherosclerotic cardiovascular disease (ASCVD) risk. Baseline characteristics and adverse events of statin and non-statin users were compared, and factors associated with statin use were determined using multivariable logistical regression. Results Based on 2019 ACC/AHA guidelines, 752/1,077 (69.8%) subjects had an indication for a statin, 280/752 (37.2%) of which were treated with a statin. Cirrhosis was independently associated with statin underutilization. Diabetes, anti-hypertensive use, and Black race were all independently associated with statin use in subjects with an indication for therapy. Statin use was not associated with adverse events. Conclusions Statins were underutilized and well tolerated in the cohort of individuals with a history of HCV infection. This high-risk population would benefit from increased CAD screening and utilization of statins for the primary prevention of CAD.

An Evidence-Based Roadmap for the Provision of More Equitable Telemedicine.

OBJECTIVE: During the coronavirus disease 2019 pandemic, as a safety-net organization with a substantial percentage of patients of color and with limited English proficiency (LEP), we were wary of furthering health disparities in our community. We analyzed gaps in telemedicine (telephone and video) delivery in our communities, quantified the effects of our tests of change, and began the process of accumulating evidence to create a road map for other organizations. METHODS: We leveraged Lean problem-solving strategies to identify modifiable gaps across multiple domains that could inhibit equity in telemedicine. We implemented tests of change across domains of community engagement, technology, education, and access. We observed the proportion of telemedicine encounters across races and languages between April and November, 2020. Regression analyses tested the impact of race and language on telemedicine controlling for age, gender, insurance, and time. RESULTS: Several rounds of changes and enhancements were associated with changes in telemedicine use of +5.5% (p < 0.0001) for Hispanic, +4.0% (p < 0.0001) for Spanish-speaking, -2.1% for Black (p < 0.05), and -4.4% for White patients (p < 0.001). African-American, Hispanic, and non-English-speaking patients had between 2.3 and 4.6 times the odds of preferring telephone to video encounters (p < 0.0001), with increases in preferences for video use over time (p < 0.05). CONCLUSION: Our roadmap to improve equitable delivery of telemedicine was associated with a significant improvement in telemedicine use among certain minority populations. Most populations of color used telephone more often than video. This preference changed over time and with equity-focused changes in telemedicine delivery.

Interobserver variability among experienced electrocardiogram readers to diagnose acute thrombotic coronary occlusion in patients with out of hospital cardiac arrest: Impact of metabolic milieu and angiographic culprit.

OBJECTIVES: We sought to evaluate interobserver concordance among experienced electrocardiogram (ECG) readers in predicting acute thrombotic coronary occlusion (ATCO) in the context of abnormal metabolic milieu (AMM) following resuscitated out of hospital cardiac arrest (OHCA). METHODS: OHCA patients with initial shockable rhythm who underwent invasive coronary angiography (ICA) were included. AMM was defined as one of: pH < 7.1, lactate > 2 mmol/L, serum potassium < 2.8 or >6.0 mEq/L. The initial ECG following ROSC but prior to ICA was adjudicated by 2 experienced readers using classic ST elevation myocardial infarction [STEMI] and expanded criteria and their combination to predict ATCO on ICA. RESULTS: 152 consecutive patients (mean age 58 years, 76% male) met inclusion criteria. AMM was present in 77%; and 42% had ATCO on ICA. Sensitivity, specificity, PPV, NPV using classic STEMI criteria were 50%, 98%, 94%, 72% (c-statistic 0.74); whereas for combined (STEMI + expanded) criteria they were 69%, 88%, 81%, 79% respectively (c-statistic 0.79). Inter-observer agreement (kappa) was 0.7 for classic STEMI criteria, and 0.66 for combined criteria. Agreement between readers was consistently higher when ATCO was absent and with NMM (kappa 0.78), but lower in AMM (kappa 0.6). CONCLUSIONS: Despite experienced ECG readers, there was only modest overall concordance in predicting ATCO in the context of resuscitated OHCA. Significant interobserver variations were noted dependent on metabolic milieu and angiographic ATCO. These observations fundamentally question the role of the 12-lead ECG as primary triaging tool for early angiography among patients with OHCA.

Targeting Causes of Burnout in Residency: An Innovative Approach Used at Hennepin Healthcare.

PROBLEM: Rates of burnout are high in physicians in the United States. While others have reported on the success of burnout-reduction strategies on practicing physicians and residents, few strategies have approached the problem longitudinally in residents. APPROACH: From 2014 to 2019, the authors used a previously developed survey to assess factors related to resident burnout, including sleep, personal time, professional fulfillment, effects on relationships, program recognition, and peer support. At Hennepin Healthcare, a safety-net hospital in Minneapolis, Minnesota, the authors created a reproducible process for collecting data from internal medicine residents annually, and for using evidence-based conceptual frameworks to develop a continuous improvement method to address worklife across training years. Interventions included jeopardy coverage for essential life events, a newsletter celebrating resident achievements, removal of after-hours consult pager call, an extra day off for senior residents on the wards, and care packages distributed to night teams. OUTCOMES: Annually from 2014 to 2019, 40/66 (60.6%) to 62/73 residents (84.9%) completed the survey (average response rate was 72.1% over 6 years). Survey results were shared with residents in multiple formats, and feedback was requested, demonstrating that burnout reduction is a priority for program leadership. High professional fulfillment scores were documented every year. Self-reported rates of burnout were between 25% and 35%. Significant improvements were seen in perception of empathy, sleep impairment, and peer support. NEXT STEPS: The authors developed a plan for minimizing burnout, which includes the following evidence-based domains: workload, control, balance in effort and reward, work-life balance, fairness, values, support, gender equity, moral distress, and moral injury. Additional interventions include protected time for didactics, trauma-informed care training, and addressing workplace racism. The authors aspire to achieve an integrated culture of well-being for residents and faculty; foster an efficient, effective, and fair learning environment; and reduce-and ultimately eliminate-burnout.

Promoting Hepatitis B Awareness: Evaluating an Educational Approach through Health Care Workers in Tanzania.

Background: Hepatitis B virus (HBV) infection disproportionally affects populations in sub-Saharan Africa. Lack of HBV awareness perpetuates disease burden in Africa. Objective: To promote HBV awareness in Tanzania using a systematic, measurable, and expandable approach to educating health care workers (HCW). Methods: We designed and implemented an HBV knowledge and teaching skills session in southern Tanzania to empower HCWs in leading education to promote disease awareness in their communities. Training was divided into two sessions: didactic and practical. A five-question anonymous survey was distributed in person immediately before and after the practical portion of the training to evaluate HBV knowledge as well as specific skills for teaching. Differences between responses before and after the sessions were evaluated by Chi-Square analysis. A sub-group of questions were further analyzed for differences based on HCW self-report of HBV serostatus awareness. Findings: 130 HCWs participated in the didactic lecture and 30 HCWs participated in both portions. A pre-post training five-question survey showed an increase in correct answers for all questions, with two showing statistical significance: HBV is silent (7% pre vs. 87% post; p < 0.0001), and repetition as key to promote awareness (63% pre vs. 100% post; p = 0.0002). Conclusions: Our low-cost intervention is applicable to increase HBV awareness in low resource settings across Africa.

Response to hepatitis B virus vaccination in individuals with chronic hepatitis C virus infection.

BACKGROUND: Previous reports show conflicting results regarding hepatitis B virus (HBV) vaccine efficacy in Hepatitis C virus (HCV)-infected individuals. AIMS: To evaluate HBV-vaccine response and identify possible factors that may contribute to lower vaccine efficacy in patients infected with HCV. METHODS: We retrospectively evaluated all patients with chronic HCV infection at Hennepin County Medical Center, in Minneapolis, Minnesota, between 2002 and 2018. We addressed laboratory, liver-related, virus-related as well as vaccine-related variables, and their association to HBV vaccine response. Differences were tested using either a Chi-squared test or a T test to compare means between the two populations. Multivariate regression was modeled as a logistic regression. RESULTS: 1506 patients were evaluated, of which 525 received appropriate HBV vaccination and were assessed for response. Among those, 79% were vaccine responders and 21% were non-responders. On multivariate analysis, cirrhosis was associated with lower response to the vaccine (OR 0.6, CI 0.44-0.94). We found no significant differences for vaccine response in relation to smoking (87% vs 86%), IV drug abuse (74% vs 72%), Diabetes Mellitus (26% vs 22%) being on hemodialysis (2% vs.5%), or virus related variables. CONCLUSION: HCV infection seems to impair HBV vaccine response, with cirrhosis being the only identifiable risk factor for hypo-responsiveness among studied clinical and virus-related variables.

Do not disregard the initial 12 lead ECG after out-of-hospital cardiac arrest: It predicts angiographic culprit despite metabolic abnormalities.

OBJECTIVES: The initial 12 lead electrocardiogram (ECG) following return of spontaneous circulation (ROSC) after out-of-hospital cardiac arrest (OHCA), is often disregarded by clinicians in ability to predict acute thrombotic coronary occlusion (ATCO) due to markedly abnormal metabolic milieu (AMM). We sought to evaluate the accuracy of initial vs. follow-up ECG prior to invasive coronary angiography (ICA) to predict ATCO following resuscitated OHCA. METHODS: We included OHCA patients with initial shockable rhythm who underwent invasive coronary angiography (ICA). AMM was defined as one of: pH ​< ​7.1, lactate >2 ​mmol/L, serum potassium <2.8 or >6.0 mEq/L. Two ECGs A (initial) and B (follow-up) following ROSC but prior to ICA were adjudicated by 2 experienced readers using expanded ECG criteria to predict angiographic ATCO on ICA. RESULTS: 152 consecutive patients (mean age 58 years, 75% male) met inclusion criteria, 77% had AMM. Among those with both ECGs (n ​= ​102), overall accuracy, sensitivity, specificity, positive predictive value, negative predictive value for correctly predicting angiographic ATCO for ECG A was 72%, 63%, 81%, 61%, 83% and for ECG B was 71%, 50%, 91%, 73%, 80% respectively. Predictive accuracy for angiographic ATCO was similar between ECG A [odds ratio (OR) 7.31, CI 2.87-18.62, p ​< ​0.0001) and ECG B [OR 10.67; CI 3.6-31.61, p ​< ​0.0001], and consistent in AMM. CONCLUSIONS: In OHCA, despite AMM, the initial post ROSC ECG retains a statistically significant, and similar accuracy as the follow-up ECG to predict angiographic ATCO using expanded criteria.

Hepatitis B Awareness and Vaccination Patterns among Healthcare Workers in Africa.

Hepatitis B virus (HBV) vaccination patterns and the understanding of its risks among healthcare workers (HCWs) is a critical step to decrease transmission. However, the depth of this understanding is understudied. We distributed surveys to HCWs in 12 countries in Africa. Surveys had nine multiple-choice questions that assessed HCWs' awareness and understanding of HBV. Participants included consultants, medical trainees, nurses, students, laboratory personnel, and other hospital workers. Surveys were completed anonymously. Fisher's exact test was used for analysis, with a P-value of < 0.05 considered significant; 1,044 surveys were collected from Kenya, Egypt, Sudan, Tanzania, Ethiopia, Uganda, Malawi, Madagascar, Nigeria, Cameroon, Ghana, and Sierra Leone. Hepatitis B virus serostatus awareness, vaccination rate, and vaccination of HCWs' children were 65%, 61%, and 48%, respectively. Medical trainees had higher serostatus awareness, vaccination rate, and vaccination of their children than HCWs in other occupations (79% versus 62%, P < 0.001; 74% versus 58%, P < 0.001; and 62% versus 45%, P = 0.006, respectively). Cost was cited as the most frequent reason for non-vaccination. West African countries were more aware of their serostatus but less often vaccinated than East African countries (79% versus 59%, P < 0.0001 and 52% versus 60%, P = 0.03, respectively). West African countries cited cost as the reason for non-vaccination more than East African countries (59% versus 40%, P = 0.0003). Our study shows low HBV serostatus awareness and vaccination rate among HCWs in Africa, and reveals gaps in the perception and understanding of HBV prevention that should be addressed to protect HCWs and improve their capacity to control HBV infection.

Measuring adequacy of coverage for the privately insured: new state estimates to monitor trends in health insurance coverage.

The privately insured are assuming a greater share of the costs of their health care, yet little is known about changes in out-of-pocket spending at the state level. The central problem is that national surveys with the relevant data are not designed to generate state-level estimates. The study addresses this shortcoming by using a two-sample modeling approach to estimate state-level measures of out-of-pocket spending relative to income for privately insured adults and children. National data from the Medical Expenditure Panel Survey-Household Component and state representative data from the Current Population Survey are used. Variation in out-of-pocket spending over time and across states is shown, highlighting concern about the adequacy of coverage for 2.9% of privately insured children and 7.8% of privately insured adults. Out-of-pocket spending relative to income is an important indicator of access to care and should be monitored at the state level.

Impact of immigration in presentation and outcomes of hepatocellular carcinoma in the USA.

BACKGROUND AND AIMS: Hepatocellular carcinoma's (HCC) epidemiology and prognosis differs among regions across the globe, largely because of environmental factors and underlying liver disease. Little is known about the changes led by immigration and the effect on HCC outcome. We aimed to understand the effect of immigration on HCC. PATIENTS AND METHODS: A retrospective cohort study of patients diagnosed with HCC was carried out in a tertiary center in the USA between 2005 and 2016. We characterized individuals as US born or having immigrated there after being born elsewhere. Variables related to clinical presentation, surveillance, therapy, and survival were evaluated. RESULTS: A total of 232 HCC cases were included, 169 US born (73%) and 63 immigrants (27%). Both groups were diagnosed with HCC at similar ages (60 vs. 62 years, P=0.13). Hepatitis C was the most common underlying liver disease in the US-born population compared with the immigrant population (83 vs. 52%, P<0.001), whereas hepatitis B was more common in the latter (4 vs. 29%, P<0.001). Interestingly, hepatitis B virus-related HCC was diagnosed at similar ages in US-born and immigrant individuals (59 and 57 years). At the time of diagnosis, both populations had similar tumor sizes, rates of metastasis, and diagnosis during surveillance. One-year survival was similar in both groups (65 vs. 63%). CONCLUSION: Immigrants that develop HCC have different underlying liver disease than those born in the USA, but similar HCC characteristics and outcomes, even when including hepatitis B virus-related HCCs. Our study, albeit small, suggests that changes in the environment by immigration leads to clinical adaptation of HCC.

Short article: Association between liver fibrosis and hepatitis E seroprevalence among HIV-positive individuals in Nepal.

OBJECTIVE: Hepatitis E virus (HEV) seropositivity may confer an increased risk of liver fibrosis in immunosuppressed individuals. We studied this effect in HIV-infected individuals in Nepal, a country hyperendemic for HEV. PARTICIPANTS AND METHODS: We prospectively evaluated 200 HIV-positive individuals. Serum samples were tested for components of fibrosis scores and cytokeratin-18. RESULTS: Of 200 patients, 43% were HEV-immunoglobulin G+. The mean fibrosis-4 score was 8.02 in the HEV-positive and 1.17 in the HEV-negative group (P<0.001). The mean nonalcoholic fatty liver disease score was 2.12 in the HEV-positive and -2.53 in the HEV-negative group (P=0.02). The mean aminotransferase-platelet ratio index score was 0.37 in the HEV-positive and 0.38 in the HEV-negative group (P=0.9). The mean cytokeratin-18 levels were 119.9 in the HEV-positive group and 158.6 in the HEV-negative group (P=0.08). CONCLUSION: We found higher fibrosis-4 and nonalcoholic fatty liver disease scores in HEV-HIV-positive individuals, suggesting an increased liver fibrosis profile in this group. Further studies using liver stiffness measurements should be carried out.

Are the Current Population Survey uninsurance estimates too high? An examination of the imputation process.

RESEARCH OBJECTIVE: To determine whether the imputation procedure used to replace missing data by the U.S. Census Bureau produces bias in the estimates of health insurance coverage in the Current Population Survey's (CPS) Annual Social and Economic Supplement (ASEC). DATA SOURCE: 2004 CPS-ASEC. STUDY DESIGN: Eleven percent of the respondents to the monthly CPS do not take the ASEC supplement and the entire supplement for these respondents is imputed by the Census Bureau. We compare the health insurance coverage of these "full-supplement imputations" with those respondents answering the ASEC supplement. We then compare demographic characteristics of the two groups and model the likelihood of having insurance coverage given the data are imputed controlling for demographic characteristics. Finally, in order to gauge the impact of imputation on the uninsurance rate we remove the full-supplement imputations and reweight the data, and we also use the multivariate regression model to simulate what the uninsurance rate would be under the counter-factual simulation that no cases had the full-supplement imputation. POPULATION STUDIED: The noninstitutionalized U.S. population under 65 years of age in 2004. DATA EXTRACTION METHODS: The CPS-ASEC survey was extracted from the U.S. Census Bureau's FTP web page in September of 2004 (http://www.bls.census.gov/ferretftp.htm). PRINCIPAL FINDINGS: In the 2004 CPS-ASEC, 59.3 percent of the full-supplement imputations under age 65 years had private health insurance coverage as compared with 69.1 percent of the nonfull-supplement imputations. Furthermore, full-supplement imputations have a 26.4 percent uninsurance rate while all others have an uninsurance rate of 16.6 percent. Having imputed data remains a significant predictor of health insurance coverage in multivariate models with demographic controls. Both our reweighting strategy and our counterfactual modeling show that the uninsured rate is approximately one percentage point higher than it should be for people under 65 (i.e., approximately 2.5 million more people are counted as uninsured due to this imputation bias). CONCLUSIONS: The imputed ASEC data are coding too many people to be uninsured. The situation is complicated by the current survey items in the ASEC instrument allowing all members of a household to be assigned coverage with the single press of a button. The Census Bureau should consider altering its imputation specifications and, more importantly, altering how it collects survey data from those who respond to the supplement. IMPLICATIONS FOR POLICY DELIVERY OR PRACTICE: The bias affects many different policy simulations, policy evaluations and federal funding allocations that rely on the CPS-ASEC data. PRIMARY FUNDING SOURCE: The Robert Wood Johnson Foundation.

The effect of income question design in health surveys on family income, poverty and eligibility estimates.

OBJECTIVE: To compare systematic differences between an "omnibus" income measure that asks for total family income amounts with a central survey item and an aggregated income measure that sums specific amounts of income obtained from multiple income sources from everyone within a family. DATA SOURCE: The 2001 Current Population Survey-Demographic Supplement (CPS-DS). Data were collected from 78,000 households from February through April 2001. STUDY DESIGN: First, we compare the omnibus family income to the aggregated family income amounts for each family. Second, we use the various aggregated family income sources to predict whether there is a mismatch between the omnibus and aggregated family income amounts. Finally, we assign a new aggregated amount of income that is restricted to be within the range of the omnibus amount to observe differences in poverty rates. DATA COLLECTION: Data were extracted from University of Michigan's ICPSR website. PRINCIPAL FINDINGS: There is a great deal of variation between the omnibus family income measure and the aggregated family income measure, with the omnibus amount generally being lower than the aggregated. As a result, the percent of people estimated to be in poverty is higher using the omnibus income item. CONCLUSIONS: Health surveys generally rely on an omnibus income measure and analysts should be aware that the income estimates derived from it are limited with respect to poverty determination, and the related concept of eligibility estimation. Analysts of health surveys should also consider matching respondents or multiple imputation to improve the usability of the data.