Acute Kidney Injury (AKI) after percutaneous coronary intervention (PCI) is an independent predictor of poor clinical outcomes, including mortality. Given the concern that SGLT2i may exacerbate post-PCI AKI vis-a-vis afferent arteriolar constriction which may amplify the risk of tubular ischemia, most clinical guidelines recommend withholding SGLT2i during the peri-PCI period. In contrast, post-hoc pooled analyses of randomized trials with SGLT2i show a significant reduction in AKI risk over time. This analysis examines kidney outcomes in patients undergoing PCI for acute coronary syndrome (ACS) with concurrent use of SGLT2i. We searched the TriNetX database to identify patients > 18 years old, with either ST-Elevation Myocardial Infarction (STEMI) or Non-STEMI, who underwent PCI from January 2019 to January 2023. Exclusion criteria include dialysis dependence, cardiogenic shock or the need for mechanical circulatory support. Patients were stratified into the SGLT2i cohort (on SGLT2i for at least 3 months before PCI) and no SGLT2i group (not taking SGLT2i before or up to 30 days after PCI). 1:1 nearest-neighbor propensity score matching was used to balance inter-group covariates. The primary outcome of interest was a clinical kidney composite (incidence of acute kidney injury (AKI) and new dialysis initiation) within 30 days post-PCI. There were 5507 (1786 had NSTEMI, 3721 had STEMI) patients in each cohort. Both groups were balanced in demographics, baseline comorbidities, and medication use (apart from more patients on insulin in non-SGLT2i and renin-angiotensin blockers in the SGLT2i group. In the SGLT2i group compared to the no SGLT2i group, the clinical kidney composite was significantly lower in those with baseline eGFR <15 cc/min (OR 0.54, 95% CI: 0.33 - 0.89, p=0.014) and those with eGFR 30 – 59 cc/min (OR 0.83, 95% CI: 0.73 - 0.95), with no difference in those with baseline eGFR 60 – 90 cc/min (OR 1.15, 95% CI: 0.97 - 1.36, p=0.102). SGLT2i exhibits a renoprotective effect peri-procedurally during PCI for ACS, with higher benefits in lower eGFR strata. Further research is necessary to identify appropriate use in patients at high risk for post PCI AKI with SGLT2i in addition to standard of care.
Physician burnout and emotional distress are associated with work dissatisfaction and provision of suboptimal patient care. Little is known about burnout among nephrology fellows.Validated items on burnout, depressive symptoms, and well being were included in the American Society of Nephrology annual survey emailed to US nephrology fellows in May to June 2018. Burnout was defined as an affirmative response to two single-item questions of experiencing emotional exhaustion or depersonalization.Responses from 347 of 808 eligible first- and second-year adult nephrology fellows were examined (response rate=42.9%). Most fellows were aged 30-34 years (56.8%), male (62.0%), married or partnered (72.6%), international medical graduates (62.5%), and pursuing a clinical nephrology fellowship (87.0%). Emotional exhaustion and depersonalization were reported by 28.0% and 14.4% of the fellows, respectively, with an overall burnout prevalence of 30.0%. Most fellows indicated having strong program leadership (75.2%), positive work-life balance (69.2%), presence of social support (89.3%), and career satisfaction (73.2%); 44.7% reported a disruptive work environment and 35.4% reported depressive symptoms. Multivariable logistic regression revealed a statistically significant association between female gender (odds ratio [OR], 1.90; 95% confidence interval [95% CI], 1.09 to 3.32), poor work-life balance (OR, 3.97; 95% CI, 2.22 to 7.07), or a disruptive work environment (OR, 2.63; 95% CI, 1.48 to 4.66) and burnout.About one third of US nephrology fellows surveyed reported experiencing burnout and depressive symptoms. Further exploration of burnout-especially that reported by female physicians, as well as burnout associated with poor work-life balance or a disruptive work environment-is warranted to develop targeted efforts that may enhance the educational experience and emotional well being of nephrology fellows.
The end of the 20th century saw the introduction of the internet. Approximately two decades later, the internet has been strongly adopted by every segment of public society. In 2013, 74.4% of all United States households reported internet use, with 73.4% reporting a dedicated high–speed internet connection (1). Specifically, the general public has gravitated toward the internet through their smartphones. Smartphones are powerful devices that combine the conventional functions of a mobile phone with advanced computing capabilities. These devices allow users to access software applications (apps) (2–4). From instant messaging to mobile banking, photography to gaming, apps allow users to perform various functions quickly and easily. Also, these users are growing: as of October of 2015, 68% of Americans use smartphones (up from 35% in 2011) (5). It should come as little surprise that, among the many functions that users perform with the smartphone, managing their health would be on the top of the list. As of 2014, 62% of smartphone owners had used their phones to look up information about a health condition (6). Clinicians have correctly identified smartphone apps as the next arena in which they should have a presence. Adult users who own a smartphone used that device for a monthly average of 37 hours and 28 minutes in 2014, increased from 23 hours and 2 minutes per month 2 years ago. Although most of these adults use apps focused on leisure, social networking, and/or entertainment, a growing body of literature suggests that a robust number of adults use medical-related apps (7–9). Data from Price Waterhouse Coopers indicate that one in three adult smartphone users have downloaded and used a health-related app (8). That translates into approximately 46 million smartphone owners who use apps to monitor their health (e.g., exercise, diet, or weight). That number grew by 18% from a year earlier (10). Many medical practitioners and other health care workers are also using apps as part of their professional practice (11). We are now experiencing a sea change in the patient-doctor relationship as patients take more control over their own bodies (taking blood sugar or BP measurements, etc.) and more teleconsultations with a physician do not result in a clinic visit. Mobile technologies enable the monitoring of more organ systems, and it is perhaps just a question of time before we can control the entire body in this way (12). In this issue of the Clinical Journal of the American Society of Nephrology, Ong et al. (13) make a strong case for the usefulness of a smartphone app to help patients manage complex medical conditions. The smartphone app targeted four behavioral elements in patients with CKD stage 4 or 5, it targeted BP, medication management, symptom assessment, and tracking laboratory results. Prebuilt, customizable algorithms provided real–time personalized patient feedback and alerts to providers when predefined treatment thresholds were crossed or critical changes occurred. User adherence was high (>80% performed at least 80% of recommended assessments) and sustained. The mean reductions in home BP readings between baseline and exit were statistically significant (systolic BP, −3.4 mmHg; 95% confidence interval [95% CI], −5.0 to −1.8 and diastolic BP, −2.1 mmHg; 95% CI, −2.9 to −1.2). Notably, 27% with normal clinic BP readings had newly identified masked hypertension. Also, 127 medication discrepancies were identified, and 59% (75) represented a medication error that required an intervention to prevent harm. In exit interviews, patients felt more confident and in control of their condition; clinicians perceived patients to be better informed and more engaged (13). These results provide a strong rationale for a randomized, controlled trial. More than one half of the digitally naïve patients found their natively programmed app beneficial in managing their BP and medications and helpful in recognizing symptoms and understanding abnormal test results (13). Although their investigation is a proof of principle study, their results highlight broader considerations when integrating smartphone technology with health care (13). The Tobacco, Exercise and Diet Messages Trial was a parallel group, single–blind, randomized clinical trial that recruited 710 patients with proven coronary heart disease between September of 2011 and November of 2013 from a large tertiary hospital in Sydney, Australia. Patients in the intervention group (n=352) received four text messages per week for 6 months in addition to usual care. Text messages provided advice, motivational reminders, and support to change lifestyle behaviors. Patients in the control group (n=358) received usual care. Messages for each participant were selected from a bank of messages according to baseline characteristics (e.g., smoking) and delivered via an automated computerized message management system. The program was not interactive. LDL cholesterol level, systolic BP, and body mass index at 6-month follow-up were all significantly lower in the intervention group compared with in the control group (difference in LDL cholesterol level, −5 mg/dl; 95% CI, −9 to 0; difference in systolic BP, −7.6 mmHg; 95% CI, −9.8 to −5.4; difference in body mass index, −1.3; 95% CI, −1.6 to −0.9). The duration of these effects and hence, whether they result in improved clinical outcomes remain to be determined (14). Multidisciplinary teams (MDTs) are now gaining preference over single-provider care in delivering health care to patients, especially those with complex medical conditions (15). Although MDTs include patients, they (patients) have been the weakest link within the team. Without easy access to their personal medical information and with limited scientific expertise, the most important members of the MDT are often observers. Apps, like the smartphone app by Ong et al. (13), have the real potential of transforming patients from mere observers into active participants and collaborators and potentially, drivers for their health care. Armed with their medical information, simple statistical analyses, and predefined algorithms that serve the purpose of increasing their scientific understanding of their condition, patients can actively participate as a fully informed participant in their MDT meetings. The app does not convert the patient into a full–fledged medical professional. Still, the study by Ong et al. (13) suggests that they are better informed and that the quality of their face to face interactions with other members of the MDT improves when using the app. The new health care paradigm encourages patients to access their medical data wherever they are, discuss such data with their physicians, decide their treatment plans with their physicians, and learn about their discharge plans. Health Information Technology can support these requirements, but accessibility and mobility issues must be solved. Today, hospitalized patients look for health information regarding their conditions with smartphones and tablets, and some hospitals even provide the hardware and the connectivity for the same. Smartphones or tablets can be used effectively for all of the above purposes (16). Perhaps inadvertently, this investigation introduces us to the next generation clinician extender (13). In our continued search to find more cost–effective ways to deliver improved health care, smartphone apps are poised to make a meaningful entry into this new model of health care. The app by Ong et al. (13) and particularly, the preprogrammed customizable feedback alerts have the capacity to function as one’s personal clinician extender or advisor. Available year-round, 24 hours a day, and 7 days a week, these alerts offer real-time information that not only educates the patient but can help them take the next steps toward better management of their disease. Although preliminary, today’s medical apps may become the forefathers of on–demand clinician extenders. With innovative digital technologies, cloud computing, and machine learning, the medicalized smartphone is going to change many aspects of medical care. The new health care paradigm encourages patients to access their medical data wherever they are and discuss such data with their health care team. Patients are actively encouraged to formulate treatment, discharge, and/or follow-up medical plans with their provider(s). Apps can support these expectations. Apps can help patients individualize and take more control over the health care that they receive. Taking it a step farther, on the basis of the concept of internet of things, smartphones have the ability to personalize one’s own health big data, with the user being alerted proactively (e.g., an alert advising the user that the manner in which the user is running led to injury in 30 other people with a relatively similar profile) on the basis of their fitness and historical medical or genetics history along with a server–based knowledge repository to create this level of near-real–time decision support. Eventually, similar to other people–finding apps, users could create their own virtual support group on the basis of certain settings that they may choose (17). Perhaps it is only a matter of time before app–driven patient empowerment becomes the standard of one’s care (12,16). Although investigators, such as Ong et al. (13), continue to work through the technical and programmatic challenges of app development, providers may have to shoulder the burden of app distribution (or lack thereof) and ensure that privacy requirements for health care data are met. The old axiom “if you build it, they will come” (or in the case of app development, “if you code it, they will download”) may not always be true. Socioeconomic disparities in CKD are fairly strong, irrespective of how socioeconomic status is measured, with low socioeconomic status associated with low eGFR (odds ratio [OR], 1.41; 95% CI, 1.21 to 1.62), high albuminuria (OR, 1.52; 95% CI, 1.22 to 1.82), low eGFR/high albuminuria (OR, 1.38; 95% CI, 1.03 to 1.74), and renal failure (OR, 1.55; 95% CI, 1.40 to 1.71) (18). This may become an issue with more generalized usage of apps given that smartphone ownership is lower (at 50%) with lower income (<$30,000 per year) compared with 84% in adults with higher income (≥$75,000 per year). Similar distribution exists across educational status, with smartphone ownership at 52% among adults with high school education or less compared with 78% among adults with college or higher education. However, smartphones may allow for greater digital equity given that internet accessibility is more available only via smartphones among adults with high school education or less and those with lower incomes (19). In the National Cancer Institute’s Health Information National Trends Survey, mHealth use was proportional to the socioeconomic status and overall health of the patient and inversely proportional to patient age (20). Kidney health providers are rightfully concerned about these relationships, because their patients are generally of lower socioeconomic status and suffer from more medically complex comorbidities than their contemporaries. As our patients live longer with kidney disease, their adoption of mHealth tools drops; in one study, the drop was 4% for every 1 year that a patient ages (21). These trends indicate that any programmatic solution must be accompanied by a distribution strategy to increase patient acceptance and use of health care–related apps. Ironically, to fully harness the power of smartphones and apps in health care, we must simultaneously look forward while firmly planting our footing into the honored tradition of caring for our patients. We must not forget or worse, ignore the cherished value of the in–person provider-patient visit or importantly, the provider-patient relationship. It rests on the shoulders of clinicians to integrate new technology with the time–tested traditional doctor-patient interaction. This interaction was, is, and should continue to be an honor for those of us who have the privilege of caring for patients. Many of us will rely on those who are on the leading edge of creating and using technology to shepherd such technology into health care as a supplement of and not a replacement to this privilege. Disclosures T.D. is owner, Nephrology On-Demand Analytics; member, International Society of Nephrology Education Committee; and leader, ISN Social Media Task Force. J.Y. and S.S. report no conflicts of interest or relevant disclosures. No financial support was received by any of the authors.
ABSTRACT The mainstay of laboratory diagnosis for Lyme disease is two-tiered serological testing, in which a reactive first-tier enzyme-linked immunosorbent assay (ELISA) or an immunofluorescence assay is supplemented by separate IgM and IgG immunoblots. Recent data suggest that the C6 ELISA can be substituted for immunoblots without a reduction in either sensitivity or specificity. In this study, the costs of 4 different two-tiered testing strategies for Lyme disease were compared using the median charges for these tests at 6 commercial diagnostic laboratories in 2012. The study found that a whole-cell sonicate ELISA followed by the C6 ELISA was the most cost-effective two-tiered testing strategy for Lyme disease with acute-phase serum samples. We conclude that the C6 ELISA can substitute for immunoblots in the two-tiered testing protocol for Lyme disease without a loss of sensitivity or specificity and is less expensive.
Introduction: Upper gastrointestinal bleeding (UGIB) risk stratification using validated prognostic scales can be used to provide appropriate management and give the clinician an indication of morbidity and mortality. The Glasgow-Blatchford Risk Score (GBRS) was developed to predict medical intervention needed, which included transfusion, endoscopy, or surgery. A higher GBS score also correlated with a higher likelihood of needing intervention. The AIMS65 Score has been validated to predict inpatient mortality in patients with UGIB. This particular study draws on these two prognostic tools and assesses their ability to risk stratify patients with UGIB on dual anti-platelet therapy (APA) or anti-platelet therapy (APA) with coumadin. Methods: This study was a retrospective study of 114 patients admitted to a tertiary care center with a primary diagnosis of UGIB from November 2013 to September 2015. Selected patients were on 2 APAs or APA and Coumadin at time of admission. The AIMS65 score was compared to the GBRS in predicting upper GI bleeding outcomes as it relates to 30 day readmission rates, mortality, re-bleeding, and intensive care unit (ICU) transfer amongst those on dual APAs or APA(s) with coumadin. The scores were compared using the area under the receiver operator curve (AUROC) with Statistical Analysis System soft ware. Results: The GBRS correlated with a higher likelihood of ICU admission than the AIMS65 score. The two scores did not differ statistically between 30 day readmission rates, mortality, or re-bleeding. Conclusion: Patients presenting with UGIB, currently on dual APA regimen or APA with coumadin should be risk stratified with the GBRS in order to assess their need for ICU admission. Application of these findings may improve utilization of resources and facilitate clinical decision making in this subset of high risk patients.
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