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Practicing health equity in kidney care by establishing improved access to timely disease management and kidney replacement therapy options: from providers to patients
No full textPurpose of review: The aim of this article is to review the current understanding of disparities in healthcare experienced by people living with kidney disease and emerging approaches to address root causes. Health equity for any disease state is an aspirational goal commonly sought out by the medical community, but all too often lacking the understanding and support required to improve the outcomes of people with complex conditions such as chronic kidney disease (CKD).
Recent findings: The main themes of the literature covered in this article include a review of the structural drivers of healthcare outcomes, a description of research in the fields of health literacy and patient activation for patients with CKD, and an analysis of the examples of healthcare disparities in CKD patients that include involuntary discharges from dialysis facilities as well as the toll taken from dialysis populations during natural disasters. The National Forum of the ESRD Networks is a coalition of 18 congressionally mandated ESRD network organizations committed to equitable access to home and in-center dialysis modalities and preemptive kidney transplantation. We conclude with the patient-centered story of a patient living with end-stage kidney disease for over 40 years and how her journey has helped shape her view on what she believes should encompass a \u27call to action\u27 to provide more equitable healthcare to people living with kidney disease.
Summary: The overarching implications of this article focus on improving the understanding of present-day healthcare inequality within the community of people living with kidney disease and providing a roadmap of resources and ideas that will help achieve more equitable outcomes. The National Forum of the ESRD Networks is committed to the effective implementation of \u27Practicing Health Equity in Kidney Care\u27 and improving access to dialysis modalities including home dialysis as well as kidney transplantation including preemptive transplant options
Racial/Ethnic and Sex Disparities in the Outcomes and Treatment of In-Hospital Cardiac Arrest: A Nationwide Analysis From the United States
No full textBackground: In-hospital cardiac arrest (IHCA) is associated with significant morbidity and mortality. The relationships of race/ethnicity and sex to outcomes and treatment patterns among patients with IHCA remain poorly understood.
Methods and results: We conducted a retrospective study using the National Inpatient Sample (NIS) database from 2016 to 2020 to identify adult patients with IHCA and examine associations between in-hospital outcomes and race/ethnicity (White, Black, Hispanic) and sex. The primary outcome was in-hospital mortality. Secondary outcomes included rates of in-hospital procedures. Multivariable logistic regression analysis was used to adjust for potential confounders. Among 207,770 patients with IHCA, 26.6% had ventricular tachycardia/fibrillation (VT/VF) and 73.4% had pulseless electrical activity (PEA)/asystole. For VT/VF arrest, Black males (aOR 1.42, 95% CI 1.21-1.66), Black females (aOR 1.25, 95% CI 1.05-1.50), and Hispanic females (aOR 1.30, 95% CI 1.01-1.66) had higher odds of mortality compared to White males (corresponding adjusted risk ratios (aRRs): 1.10 (CIs 1.06-1.14), 1.06 (1.02-1.11), and 1.08 (1.01-1.14), respectively). In the PEA/asystole arrest subgroup, Black males (aOR 1.25, 95% CI 1.11-1.39) and Hispanic males (aOR 1.22, 95% CI 1.07-1.40) had higher odds of mortality (corresponding aRRs 1.04 (1.02-1.06) and 1,04 (1.01-1.06), respectively). Black patients with IHCA were less likely to receive percutaneous coronary intervention, coronary artery bypass grafting, and mechanical circulatory support compared to White males.
Conclusions: Significant racial/ethnic and sex disparities exist in outcomes and treatment patterns among patients with IHCA. Targeted efforts and further studies are needed to better understand and address these disparities and improve outcomes.
Keywords: Cardiac Arrest; Disparities; Race/Ethnic; Sex
Assessment and mitigation of bias in influenza and COVID-19 vaccine effectiveness analyses - IVY Network, September 1, 2022-March 30, 2023
No full textBackground: In test-negative studies of vaccine effectiveness (VE), including patients with co-circulating, vaccine-preventable, respiratory pathogens in the control group for the pathogen of interest can introduce a downward bias on VE estimates.
Methods: A multicenter sentinel surveillance network in the US prospectively enrolled adults hospitalized with acute respiratory illness from September 1, 2022-March 31, 2023. We evaluated bias in estimates of VE against influenza-associated and COVID-19-associated hospitalization based on: inclusion vs exclusion of patients with a co-circulating virus among VE controls; observance of VE against the co-circulating virus (rather than the virus of interest), unadjusted and adjusted for vaccination against the virus of interest; and observance of influenza or COVID-19 against a sham outcome of respiratory syncytial virus (RSV).
Results: Overall VE against influenza-associated hospitalizations was 6 percentage points lower when patients with COVID-19 were included in the control group, and overall VE against COVID-19-associated hospitalizations was 2 percentage points lower when patients with influenza were included in the control group. Analyses of VE against the co-circulating virus and against the sham outcome of RSV showed that downward bias was largely attributable the correlation of vaccination status across pathogens, but also potentially attributable to other sources of residual confounding in VE models.
Conclusion: Excluding cases of confounding respiratory pathogens from the control group in VE analysis for a pathogen of interest can reduce downward bias. This real-world analysis demonstrates that such exclusion is a helpful bias mitigation strategy, especially for measuring influenza VE, which included a high proportion of COVID-19 cases among controls.
Keywords: Bias; COVID-19; Estimation; Influenza; RSV; Vaccine effectiveness
Disentangling sex differences in PTSD risk factors
No full textDespite extensive research on sex/gender differences in posttraumatic stress disorder (PTSD), underlying mechanisms are still not fully understood. Here we present a systematic overview of three sex/gender-related risk pathways. We assessed 16 risk factors as well as 3-month PTSD severity in a prospective cohort study (n=2924) of acutely traumatized individuals and investigated potential mediators in the pathway between sex assigned at birth and PTSD severity using multiple mediation analysis with regularization. Six risk factors were more prevalent/severe in women, and none were more pronounced in men. Analyses showed that acute stress disorder, neuroticism, lifetime sexual assault exposure, anxiety sensitivity, and pre-trauma anxiety symptoms fully mediated and uniquely contributed to the relationship between sex assigned at birth and PTSD severity. Our results demonstrate different risk mechanisms for women and men. Such knowledge can inform targeted interventions. Our systematic approach to differential risk pathways can be transferred to other mental disorders to guide sex- and gender-sensitive mental health research
Outcomes of ST-Segment Elevation Myocardial Infarction in Patients With Adrenal Insufficiency
No full textContext: Patients with adrenal insufficiency (AI) have both increased risk of cardiovascular disease and adverse outcomes with many medical emergencies. However, limited data exist specifically regarding ST-segment elevation myocardial infarction (STEMI) in the context of AI.
Objective: To evaluate associations between AI and in-hospital outcomes of patients with STEMI.
Methods: Admissions for STEMI were identified in the 2016-2019 National Inpatient Sample. In-hospital outcomes were compared between patients with and without AI. The primary outcome was in-hospital mortality. Secondary outcomes included percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG), intervention, acute kidney injury (AKI), vasopressor use, mechanical circulatory support (MCS), mechanical ventilation, ventricular tachycardia (VT), hospital length of stay (LOS), and total charges. Multivariable regression models were used to adjust for potential confounders.
Results: Among 690 430 STEMI hospitalizations, 1382 (0.2%) had a diagnosis of AI. AI was associated with higher odds of in-hospital mortality (adjusted OR [aOR] 1.51, 95% CI 1.03-2.2), lower odds of PCI (aOR 0.73, 95% CI 0.55-0.98), higher odds of CABG (aOR 2.8, 95% CI 1.89-4.2) and, AKI (aOR 2.38, 95% CI 1.72-3.3), VT (aOR 1.55, 95% CI 1.1-2.2), need for vasopressors (aOR 2.34, 95% CI 1.33-4.1), mechanical ventilation (aOR 2.11, 95% CI 1.54-2.89), and MCS (aOR 2.18, 95% CI 1.57-3.03). Patients with AI also had a longer LOS (10 days vs 4.2 days, P \u3c .001) and higher charges (115 505, P \u3c .001).
Conclusion: Patients with AI admitted for STEMI had higher in-hospital mortality, nonfatal adverse outcomes, and resource utilization than patients without AI.
Keywords: STEMI; adrenal insufficiency; hypoadrenalism; myocardial infarction
Acute Lung Injury
No full textAcute lung injury (ALI) is acute pulmonary inflammation with underlying pathology of disruption of the pulmonary vasculature endothelial and alveolar epithelial barriers. ALI is not an uncommon diagnosis and has a myriad of causes including pulmonary infection, (including sepsis), drugs, connective tissue disease, and polytrauma. Patients present clinically with hypoxemia with imaging supportive of bilateral pulmonary findings without pulmonary edema. The imaging findings in ALI mirror pathologic changes, with a transition from an early ( exudative ) phase to a later fibroblast-rich ( organizing or proliferative ) phase to, in some cases, a fibrotic phase. The diagnosis of ALI is separate from, but can clinically overlap in presentation with, acute respiratory distress syndrome and is characterized by diffuse alveolar damage and organizing pneumonia patterns on pathology. Clinical management is most often supportive and can include corticosteroids, mechanical ventilation, and careful fluid management, with the goal of preserving and recovering lung function
The Role of Cardiac Surgeons in Transcatheter Structural Heart Disease Interventions
No full textBackground: With the rapid growth and evolution of transcatheter valve therapies, surgeons are foreseeing a crucial change in their practice. Their role is rapidly evolving and the concept of a structured heart valve team is becoming central in every established SHD program. The knowledge and expertise of surgeons is adapting to a novel and revolutionized field of transcatheter valve therapies, where a multidisciplinary approach is crucial for optimal outcomes and patient satisfaction. This manuscript aims to discuss the evolving role of surgeons in structural heart interventions METHODS: We depict the importance of the heart valve team and outline the challenges surgeons are facing to establish themselves as structural heart operators.
Results: The switch in clinical practice surgeons are experiencing is extremely important for the future of cardiac surgery. The results of a globally conducted real-world survey shows that despite 97% of surgeons are active members of the heart team, 80% take part to TAVR procedures, and the percentage drops significantly in mitral and tricuspid interventions.
Conclusions: Surgeons need to evolve, adapt and embrace this new patient-centered paradigm and broaden their skills and competences maintaining a primary role in the treatment of valvular heat pathologies.
Keywords: TAVR; TEER; catheter; heart team; hybrid; valves
Effectiveness of Original Monovalent and Bivalent COVID-19 Vaccines Against COVID-19-Associated Hospitalization and Severe In-Hospital Outcomes Among Adults in the United States, September 2022-August 2023
No full textBackground: Assessments of COVID-19 vaccine effectiveness are needed to monitor the protection provided by updated vaccines against severe COVID-19. We evaluated the effectiveness of original monovalent and bivalent (ancestral strain and Omicron BA.4/5) COVID-19 vaccination against COVID-19-associated hospitalization and severe in-hospital outcomes.
Methods: During September 8, 2022 to August 31, 2023, adults aged ≥ 18 years hospitalized with COVID-19-like illness were enrolled at 26 hospitals in 20 US states. Using a test-negative case-control design, we estimated vaccine effectiveness (VE) with multivariable logistic regression adjusted for age, sex, race/ethnicity, admission date, and geographic region.
Results: Among 7028 patients, 2924 (41.6%) were COVID-19 case patients, and 4104 (58.4%) were control patients. Compared to unvaccinated patients, absolute VE against COVID-19-associated hospitalization was 6% (-7%-17%) for original monovalent doses only (median time since last dose [IQR] = 421 days [304-571]), 52% (39%-61%) for a bivalent dose received 7-89 days earlier, and 13% (-10%-31%) for a bivalent dose received 90-179 days earlier. Absolute VE against COVID-19-associated invasive mechanical ventilation or death was 51% (34%-63%) for original monovalent doses only, 61% (35%-77%) for a bivalent dose received 7-89 days earlier, and 50% (11%-71%) for a bivalent dose received 90-179 days earlier.
Conclusion: Bivalent vaccination provided protection against COVID-19-associated hospitalization and severe in-hospital outcomes within 3 months of receipt, followed by a decline in protection to a level similar to that remaining from previous original monovalent vaccination by 3-6 months. These results underscore the benefit of remaining up to date with recommended COVID-19 vaccines.
Keywords: COVID‐19; COVID‐19 vaccines; United States; adult; hospitalization
Stop The Falls! A framework for injury prevention outreach for older adults presented by the American Association for the Surgery of Trauma Geriatric Trauma and Injury Prevention Committees
No full textWith the increasing age of the population in the USA, fall prevention events to target older patients are imperative. The American Association for the Surgery of Trauma hosted a fall prevention event at the host city of the 2023 Annual Meeting. We review the planning and implementation of this Stop the Falls event, in hopes that other institutions may benefit and sustainably effectuate fall prevention events for an increasingly geriatric population.
Keywords: Accident Prevention; Multiple Trauma; epidemiology; geriatrics
