Serum α-Klotho with all-cause and cause-specific mortality.

AIMS: The relationship between α-Klotho (αK) and mortality is controversial and has not been examined in a large, diverse cohort. We investigated the association between serum αK protein levels with all-cause and cause-specific mortality in a cohort representative of the US population. METHODS: We used National Health and Nutrition Examination Survey (NHANES) data from 2007 to 2016. A nonlinear association between mortality and αK levels as a quadratic variable were examined using Cox proportional hazard models and competing risk models. Multivariable models were adjusted for age, gender, race, hypertension, diabetes, smoking, alcohol use, physical activity, body mass index (BMI), serum cholesterol, estimated glomerular filtration rate, highest educational status attained and family income to poverty threshold ratio. RESULTS: Of the 13 749 participants, 1569 (11%) died, 7092 (52%) were female, and 5918 (43%) were Caucasian. The mean (SD) of age was 58 (11) years, BMI 29.7 (6.7) kg/m2, and αK was 0.85 (0.31) ng/mL. In the adjusted Cox proportional hazards model with quadratic αK, we found a U-shaped relationship between all-cause mortality and αK levels (continuous αK hazard ratio [HR] = 0.56, 95% confidence interval [CI]: 0.37, 0.85; P = .007; squared-αK HR = 1.25, 95% CI: 1.11, 1.41; P < 0.001). A similar U-shaped relationship was noted between αK and cancer mortality in the adjusted Cox proportional hazards model (continuous αK HR = 0.45, 95% CI: 0.19, 1.06; P = 0.07; squared αK HR = 1.32, 95% CI: 1.07, 1.61; P = 0.009). No relationship was present with cardiovascular or other-cause mortality. CONCLUSIONS: In this large diverse cohort, we report a U-shaped relationship between αK with all-cause and cancer mortality. Further research to elucidate the underlying biological mechanism of these relationships is needed.

Medicaid expansion and 30-day hospital readmissions: A nationwide study.

In 2010, Congress enacted the Patient Protection and Affordable Care Act (ACA) to enhance health insurance affordability via subsidies and Medicaid expansion (ME). However, not all states adopted ME. We examined national hospital readmissions from 2005 to 2019 to investigate readmission reduction trends based on state ME status. The states were divided into those that expanded Medicaid in 2014 (ME-States) and those that did not until 2019 (non-ME States). Using a difference-in-difference framework and adjusting for hospital and population characteristics, we assessed the relationship between ME and 30-day readmissions following pneumonia, heart failure (HF), and acute myocardial infarction (AMI) hospitalizations. Both before and after the expansion, ME-States had higher mean readmission rates than non-ME-States. After ME, hospitals in ME-States exhibited larger reductions in readmission rates compared to non-ACA States: pneumonia (-0.12%; 95% confidence interval [CI] = -0.19%, -0.04%; p = .002), HF (-0.18%; 95% CI = -0.28%, -0.08%; p = .001), and AMI (-0.23%; 95% CI = -0.32%, -0.13%; p < .001).

Sunscreen compound benzophenone-3 and its relationship with white blood cell counts.

BACKGROUND: Evidence from animal models suggests a role for the organic ultraviolet filter benzophenone-3's (BP-3) on white blood cells (WBCs). However, BP-3's effect on WBCs in humans is unknown. MATERIALS AND METHODS: We used National Health and Nutrition Examination Survey data from 2003 to 2016. We included participants >6 years with data on urinary BP-3, urinary creatinine, and WBC count. Quintiles of urinary creatinine-normalized BP-3 (CnBP-3) levels were used in linear regression models adjusting for age, gender, race, body mass index (BMI), smoking status, education level, family income to poverty threshold ratio, survey cycle, and season. RESULTS: Of the 16 959 participants, 8564 (50.5%) were females, 6602 (38.9%) were White, and 3870 (22.8%) were Black. The mean (standard deviation) age was 37.6 (22.7) years, BMI was 26.8 (7.40) kg/m2, WBC count was 7.22 (2.53) × 109/L, neutrophil count was 4.15 (1.86) × 109/L, and lymphocyte count was 2.25 (1.33) × 109/L and median (interquartile range) of CnBP-3 was 12.1 (44.9) µg/gm. The highest quintile of CnBP-3 was associated with significantly lower WBC and neutrophil counts compared to the lowest quintile of CnBP-3 (Δ quintiles = -137 × 106/L, 95% CI: -249 to -24, p = 0.02 and = -177 × 106/L, 95% CI: -323 to -30, p = 0.02, respectively). In contrast, we did not observe a difference in lymphocyte count between the lowest and highest quintiles of CnBP-3 in unadjusted or adjusted analyses. CONCLUSION: We found an inverse relationship between BP-3 levels and WBC and neutrophil counts, and not with lymphocyte count. Further research is needed to confirm our findings.

Association of platelet distribution width with all-cause and cause-specific mortality in US adults.

BACKGROUND: Platelet distribution width (PDW) indicates heterogeneity in circulating platelet sizes. Studies reporting PDW association with mortality were limited by small sample sizes. Therefore, we examined the relationship between PDW and all-cause and cause-specific mortality in a large representative cohort. METHODS: The NHANES III data were linked to mortality files to examine the association between PDW and mortality. We excluded participants <18 years old and had a history of myocardial infarction. Since the hazards violated the proportionality assumption, we used piece-wise spline with 5-year time intervals in Cox models without and with adjustment for age, gender, race, smoking history, diabetes mellitus, hypertension, eGFR and total cholesterol. RESULTS: Of 15,688 participants, 53.2% were females, 36.2% had a history of hypertension, and 6368(40.6%) died during follow-up (range 0 to 31 years). The mean (SD) age of the participants was 47(20) years, platelet count was 275.0(71.7) 109/L, and PDW 16.5(0.5). In multivariable analyses, PDW was associated with all-cause mortality at 0-5 years (HR = 1.44; 95%CI = 1.21, 1.72; P < 0.001) and at 5-10 years (HR = 1.23; 95%CI =1.03, 1.46; P = 0.02). Similarly, PDW association was significant for the first 0-5 years in cardiovascular mortality (HR = 1.58, 95%CI = 1.10, 2.25; P = 0.013) and for cancer mortality (HR = 1.48 (1.15, 95%CI = 1.15, 1.91, P = 0.003). For other-cause mortality, PDW remained significantly associated for 0-5 years (HR = 1.35, 95%CI =1.05, 1.74; P = 0.02) and for 5-10 years (HR = 1.38, 95%CI = 1.05, 1.83; P = 0.023). CONCLUSIONS: PDW is an independent, but time-dependent, predictor of all-cause, cardiovascular, cancer and other-cause mortality up to 5 years. The mechanisms underlying this association need further study.

Increased donor inhibitory KIR are associated with reduced GVHD and improved survival following HLA-matched unrelated donor HCT in paediatric acute leukaemia.

Killer immunoglobulin-like receptor (KIR) and KIR-ligand (KIRL) interactions play an important role in natural killer cell-mediated effects after haematopoietic stem cell transplantation (HCT). Previous work has shown that accounting for known KIR-KIRL interactions may identify donors with optimal NK cell-mediated alloreactivity in the adult transplant setting. Paediatric acute leukaemia patients were retrospectively analysed, and KIR-KIRL combinations and maximal inhibitory KIR ligand (IM-KIR) scores were determined. Clinical outcomes were examined using a series of graphs depicting clinical events and endpoints. The graph methodology demonstrated that prognostic variables significant in the occurrence of specific clinical endpoints remained significant for relevant downstream events. KIR-KIRL combinations were significantly predictive for reduced grade 3-4 aGVHD likelihood, in patients transplanted with increased inhibitory KIR gene content and IM-KIR = 5 scores. Improvements were also observed in associated outcomes for both ALL and AML patients, including relapse-free survival, GRFS and overall survival. This study demonstrates that NK cell KIR HLA interactions may be relevant to the paediatric acute leukaemia transplant setting. Reduction in aGVHD suggests KIR effects may extend beyond NK cells. Moving forward clinical trials utilizing donors with a higher iKIR should be considered for URD HCT in paediatric recipients with acute leukaemia to optimize clinical outcomes.

Improving Interdisciplinary Communication on an Academic Hospitalist Service: A Quality Improvement Project.

ABSTRACT: Effective communication is essential for quality patient care, and paging remains among the most common forms of communication despite the introduction of secure texting platforms. The goal of this project was to use quantitative and qualitative analyses of paging to guide improvements in paging best practices. A retrospective analysis of pages sent over a 7-day period was completed, characterizing the volume, content, and effectiveness of pages both preintervention and 3-month postintervention. The content of each page was categorized into laboratories, medications, vital signs, diet, patient assessment/clinical change, pain, or miscellaneous/other. Effectiveness was based on the following five critical elements: (1) two patient identifiers, (2) the sender's name, (3) the sender's callback number, (4) priority or acuity of the page, and (5) patient-care concern. Pages were considered successful if they contained all the five essential elements. The preintervention results guided interventions. Of 3,483 included pages, 1,806 and 1,677 were sent during the preintervention and postintervention periods, respectively. Adherence to all essential paging elements increased from 15.2% to 40% ( p < .001). The largest deficiency was labeling the urgency of a page, which increased from 31.6% to 51.9% ( p < .001). Quantitative and qualitative analyses of pages effectively guided this project to increase the standardization of paging.

Competency-based assessment of procedural skills in resident training.

BACKGROUND: No standardized summative tools exist to assess competency in bedside procedures or provide residents and programs with summative feedback. OBJECTIVE: To provide competency-based procedure training and feedback to residents, we created a procedure competency committee (PCC). Here, we describe the PCC process, its impact on procedure training, and examine residents' attainment of competency in bedside procedures. DESIGN, SETTING, AND PARTICIPANTS: The PCC consisted of hospitalists and met twice annually to review resident procedure portfolios for three academic years 2019-2022 at a university-based internal medicine residency program. Residents were designated to one of the five competency levels; being able to participate, perform under supervision with assistance, perform under direct supervision (DS) without assistance, perform independently with indirect supervision (IS), and perform independently with IS and supervise others. We analyzed the probability of advancing competency levels with each additional procedure using multinomial logistic regression models. RESULTS: Of the 97 residents, 48 (49.5%) were women and 60 (62%) subsequently matched in procedure-oriented fields. More residents achieved IS level for paracentesis than for lumbar puncture (LP) or central venous catheterization (CVC) (62 vs. 25 and 37, respectively; p < .001). Each incremental procedure performed was associated with a higher chance of being advanced to IS group from the DS group; 1.31 times for paracentesis (95% confidence interval [CI] = 1.07, 1.60; p < .008), 1.83 times for LP (95% CI = 1.35, 2.47; p = .0001), and two times for CVC (95% CI = 1.32, 3.05; p = .001). CONCLUSION: The PCC provided competency-based assessment of a resident's procedural skills and may be used to assess the impact of curriculum changes.

The Long-Term Effect of Financial Penalties on 30-Day Hospital Readmission Rates.

BACKGROUND: Although the immediate effect of financial penalties imposed by the Hospital Readmissions Reduction Program (HRRP) was a decrease in 30-day hospital readmission rates, the long-term effects are unclear. The authors studied 30-day readmissions before and immediately after HRRP penalties and during the most recent period before the COVID-19 pandemic and examined whether readmission trends differed between penalized and non-penalized hospitals. METHODS: Centers for Medicare & Medicaid Services hospital archive data and US Census Bureau data were used to analyze hospital characteristics, including readmission penalty status, and hospital service area (HSA) demographic information, respectively. These two datasets were matched by HSA crosswalk files, available through the Dartmouth Atlas files. Using data from 2005-2008 as baseline, the authors examined hospital readmission trends before (2008-2011) and after penalties (during three periods: 2011-2014, 2014-2017, 2017-2019). Mixed linear models were used to examine readmission trends through periods, and differences by hospital penalty status without and with adjustment for hospital characteristics and HSA demographic information. RESULTS: For all hospitals combined, rates for 2008-2011 vs. 2011-2014 were as follows: pneumonia, 18.6% vs. 17.0%; heart failure (HF), 24.8% vs. 22.0%; acute myocardial infarction (AMI), 19.7% vs. 17.0% (p < 0.001 for all three conditions). Rates for 2014-2017 vs. 2017-2019 were as follows: pneumonia, 16.8% vs. 16.8% (p = 0.87), HF, 21.7% vs. 21.9% (p < 0.001); AMI, 16.0% vs. 15.8% (p < 0.001). Compared to penalized hospitals, using difference-in-differences, non-penalized hospitals had a significantly greater increase for two conditions between the 2014-2017 and 2017-2019 periods: pneumonia 0.34%, p < 0.001; and HF 0.24%, p = 0.002. CONCLUSION: Long-term readmission rates are lower than pre-HRRP rates, with recent trends decreasing further for AMI, stabilizing for pneumonia, and increasing for HF.