Citations

SAGE-Journals-Accessible-Video-Player 10.1089/vid.2014.0017.M1 sj-vid-1-vid-10.1089_vid.2014.0017

Background Assessing hospital quality in the performance of carotid endarterectomy ( CEA ) requires appropriate risk adjustment across hospitals with varying case mixes. The aim of this study was to develop and validate a prediction model to assess the risk of in‐hospital stroke or death after CEA that could aid in the assessment of hospital quality. Methods and Results Patients from National Cardiovascular Data Registry (NCDR)'s Carotid Artery Revascularization and Endarterectomy (CARE) Registry undergoing CEA without acute evolving stroke from 2005 to 2013 were included. In‐hospital stroke or death was modeled using hierarchical logistic regression with 20 candidate variables and accounting for hospital‐level clustering. Internal validation was achieved with bootstrapping; model discrimination and calibration were assessed. A total of 213 (1.7%) primary end point events occurred during 12 889 procedures. Independent predictors of stroke or death included age, prior peripheral artery disease, diabetes mellitus, prior coronary artery disease, having a symptomatic carotid lesion, having a contralateral carotid occlusion, or having New York Heart Association Class III or IV heart failure. The model was well calibrated and demonstrated moderate discriminative ability (c‐statistic 0.65). The NCDR CEA score was then developed to support simple, prospective risk quantification in the clinical setting. Conclusions The NCDR CEA score, comprising 7 clinical variables, predicts in‐hospital stroke or death after CEA . This model can be used to estimate hospital risk‐adjusted outcomes for CEA and to assist with the assessment of hospital quality.

AbstractBackgroundPregnancy after solid organ transplant is a significant priority for transplant recipients but how patients report being counseled is unknown.MethodsWe performed a single‐center retrospective cohort study and telephone survey of female patients ages 18–49 at the time of kidney, pancreas, or liver transplant from 2000 to 2012 (n = 532). Data on pregnancy counseling, fertility, and maternal, fetal‐ and transplant‐specific outcomes were collected. Multivariate Cox models assessed the impact of pregnancy on graft‐specific outcomes.ResultsThe survey response rate was 29% (n = 152). One‐third (n = 51) of women were actively counseled against pregnancy by one or more providers. A total of 17 pregnancies occurred among nine patients (5.9%), with 47% live births, 47% early embryonic demises, 5.9% stillbirths. Of live births, 50% were premature. Gestational complications, including diabetes, hypertension, and preeclampsia were present in 88% of mothers. Pregnancy after transplant was associated with higher rates of acute rejection than nulliparous transplant recipients (33% vs. 5.6%, p = 0.07) but did not significantly affect graft survival (HR = 1.00, 95% CI 0.99–1.01), after stratifying by organ and adjusting for clinical factors.ConclusionThis study suggests that transplant patients are being counseled against pregnancy despite acceptable risks of complications and no specific effects on long‐term graft function.

ABSTRACTObjectives:The lactulose:mannitol (L:M) diagnostic test is frequently used in field studies of environmental enteropathy (EE); however, heterogeneity in test administration and disaccharide measurement has limited the comparison of results between studies and populations. We aim to assess the agreement between L:M measurement between high‐performance liquid chromatography with pulsed amperometric detection (HPLC‐PAD) and liquid chromatography‐tandem mass spectrometry (LC‐MSMS) platforms.Methods:The L:M test was administered in a cohort of Peruvian infants considered at risk for EE. A total of 100 samples were tested for lactulose and mannitol at 3 independent laboratories: 1 running an HPLC‐PAD platform and 2 running LC‐MSMS platforms. Agreement between the platforms was estimated.Results:The Spearman correlation between the 2 LC‐MSMS platforms was high (ρ ≥ 0.89) for mannitol, lactulose, and the L:M ratio. The correlation between the HPLC‐PAD platform and LC‐MSMS platform was ρ = 0.95 for mannitol, ρ = 0.70 for lactulose, and ρ = 0.43 for the L:M ratio. In addition, the HPLC‐PAD platform overestimated the lowest disaccharide concentrations to the greatest degree.Conclusions:Given the large analyte concentration range, the improved accuracy of LC‐MSMS has important consequences for the assessment of lactulose and mannitol following oral administration in populations at risk for EE. We recommend that researchers wishing to implement a dual‐sugar test as part of a study of EE use an LC‐MSMS platform to optimize the accuracy of results and increase comparability between studies.

Abstract Background Innate lymphoid cells ( ILC s) play important roles in innate immunity and tissue remodeling via production of various cytokines and growth factors. Group 2 ILC s ( ILC 2s) were recently shown to mediate the immune pathology of asthma even without adaptive immunity. However, little is known about possible interactions between ILC 2s and other immune cells. We sought to investigate the capacity of ILC 2s to regulate effector functions of T cells. Methods We isolated ILC 2s from the lungs of naïve mice. We cultured CD 4 + T cells with ILC 2s in vitro and examined the functions of these cell types. The mechanisms were investigated using blocking antibodies and cells isolated from cytokine‐deficient mice. For the in vivo study, we adoptively transferred ILC 2s and CD 4 + T cells into Il7ra −/− mice and subsequently exposed the mice to ovalbumin and a cysteine protease. Results Lung ILC 2s enhanced CD 4 + T‐cell proliferation and promoted production of type 2 cytokines in vitro . The interaction between ILC 2s and CD 4 + T cells involved costimulatory molecule OX 40L and cytokine IL ‐4, which was mainly derived from ILC 2s. Adoptive transfer of both ILC 2 and CD 4 + T‐cell populations, but not each population alone, into Il7ra −/− mice resulted in induction of a robust antigen‐specific type 2 cytokine response and airway inflammation. Conclusion Lung ILC 2s function to promote adaptive immunity in addition to their established roles in innate immunity. This novel function of ILC 2s needs to be taken into account when considering the pathophysiology of asthma and other allergic airway diseases.

OBJECTIVES: ImproveCareNow (ICN) is the largest pediatric learning health system in the nation and started as a quality improvement collaborative. To test the feasibility and validity of using ICN data for clinical research, we evaluated the effectiveness of anti-tumor necrosis factor-α (anti-TNFα) agents in the management of pediatric Crohn disease (CD). METHODS: Data were collected in 35 pediatric gastroenterology practices (April 2007 to March 2012) and analyzed as a sequence of nonrandomized trials. Patients who had moderate to severe CD were classified as initiators or non-initiators of anti-TNFα therapy. Among 4130 patients who had pediatric CD, 603 were new users and 1211 were receiving anti-TNFα therapy on entry into ICN. RESULTS: During a 26-week follow-up period, rate ratios obtained from Cox proportional hazards models, adjusting for patient and disease characteristics and concurrent medications, were 1.53 (95% confidence interval [CI], 1.20–1.96) for clinical remission and 1.74 (95% CI, 1.33–2.29) for corticosteroid-free remission. The rate ratio for corticosteroid-free remission was comparable to the estimate produced by the adult SONIC study, which was a randomized controlled trial on the efficacy of anti-TNFα therapy. The number needed to treat was 5.2 (95% CI, 3.4–11.1) for clinical remission and 5.0 (95% CI, 3.4–10.0) for corticosteroid-free remission. CONCLUSIONS: In routine pediatric gastroenterology practice settings, anti-TNFα therapy was effective at achieving clinical and corticosteroid-free remission for patients who had Crohn disease. Using data from the ICN learning health system for the purpose of observational research is feasible and produces valuable new knowledge.