Faculty Bibliography

Introduction Most persons on hemodialysis (HD) are older, and many have trouble with walking and self-care. Yet data are sparse on how mobility is shaped by personal factors such as motivation in this group. Our goal was to identify what personal factors impact the mobility of older adults on HD. Methods We included 1) older adults on HD (inclusion criteria: >=60 years; on outpatient HD) and 2) care partners (inclusion criteria: >=18 years; routinely helping an older adult on HD). Each had a single in-person assessment. We administered the Short Physical Performance Battery (SPPB, range 0-12 points) to assess mobility, and audio-recorded one-on-one semi-structured key informant interviews regarding personal factors for mobility. Unless requested, older adults and care partners were interviewed separately. Transcripts underwent descriptive and focused coding; the codebook was revised iteratively until consensus on all code definitions was reached. We identified codes that were personal factors using International Classification of Function criteria. A combined inductive and deductive approach extracted major themes. Results We enrolled 31 older adults on HD (42% female, 50% Black) with a mean age of 72.5+/-8.1(S.D.) years and a mean history on HD for 4.6+/-3.5 years. For the older adults on HD, mean SPPB was 3.6+/-2.8 points. Twelve care partners enrolled (75% female, 50% Black) with a mean age of 53.8+/-15.7 years. TheTable lists the themes that emerged. Conclusion Our diverse sample of older adults on HD had poor mobility, and had a mean SPPB score that is associated with 20% one-year mortality in other groups. They want mobility and independence, but mobility frequently flutuates, causing distress. They and their care partners have learned to be flexible in their expectations. Future studies should incorporate these insights in interventions to improve the mobility of older adults on HD

AIMS/OBJECTIVE:Sacubitril/valsartan combines renin-angiotensin-aldosterone system inhibition with amplification of natriuretic peptides. In addition to well-described effects, natriuretic peptides exert direct effects on pulmonary vasculature. The effect of sacubitril/valsartan on pulmonary artery pressure (PAP) has not been fully defined. METHODS AND RESULTS/RESULTS:This was a retrospective case-series of PAP changes following transition from angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) to sacubitril/valsartan in patients with heart failure reduced ejection fraction and a previously implanted CardioMEMS™ sensor. Pre-sacubitril/valsartan and post-sacubitril/valsartan PAPs were compared for each patient by examining averaged consecutive daily pressure readings from 1 to 5 days before and after sacubitril/valsartan exposure. PAP changes were also compared between patients based on elevated trans-pulmonary gradients (trans-pulmonary gradient ≥ 12 mmHg) at time of CardioMEMS™ sensor implantation. The cohort included 18 patients, 72% male, mean age 60.1 ± 13.6 years. There was a significant decrease in PAPs associated with transition from ACEI/ARB to sacubitril/valsartan. The median (interquartile range) pre-treatment and post-treatment change in mean, systolic and diastolic PAPs were -3.6 (-9.8, -0.7) mmHg (P < 0.001), -6.5 (-15.0, -2.0) mmHg (P = 0.001), and -2.5 (-5.7, -0.7) (P = 0.001), respectively. The decrease in PAPs was independent of trans-pulmonary gradient (F(1,16) = 0.49, P = 0.49). CONCLUSIONS:In this retrospective case series, transition from ACEI/ARB to sacubitril/valsartan was associated with an early and significant decrease in PAPs.

Background: Home blood pressure measurement (HBPM) has been a time-honored supplement to periodic in-office measurement to facilitate primary care physician (PCP) diagnosis of hypertension (HTN), its ongoing control and medication management. PCPs, in response to COVID-19, adopted telemedicine as the sole means of care, elevating HBPM as the essential HTN surveillance tool. We assessed the feasibility of this approach in a Veteran Affairs (VA) geriatric clinic.
Method(s): Study subjects included all the Veterans seen by New York Harbor VA geriatrics fellows' clinic between January 1, 2019 and March 1, 2020 and who have HTN listed as an electronic health record (EHR) diagnosis. Those with systolic blood pressure (SBP) > 140 mmHg were prioritized. We called these patients to assess adherence to BP self-care and reconcile medications, to identify reasons for poor adherence and to offer solutions. Patients were called again within two months to re-assess adherence, collect BP measures and adjust medications as needed.
Result(s): Among 102 patients diagnosed with HTN, 41 had not achieved the goal of SBP <140 mmHg prior to this intervention. We reached 78% (n=32) of these 41 patients (requiring 1-3 phone calls). All reported medical adherence, but none were found to consistently check BP at home with any frequency or proper technique. For the 14 patients having no BP monitor at home, we sent a monitor to 10 through prescription and enrolled 4 in a home telehealth (HT) program that uses daily remote measurement. We provided detailed instruction of proper HBPM during the initial interview. At follow-up, 47% (n=15) practiced HBPM and reported BP readings within goal, indicating no need for change in care. Of these 15, 11 had their own BP monitors; 2 achieved control through the HT program. However, only 2 of the 10 patients who received the prescribed BP monitor started HBPM and demonstrated good control.
Conclusion(s): Given our reliance on telemedicine, HBPM is feasible for outpatient HTN management. Close PCP follow-up to encourage consistent HBPM practice may improve and sustain the success of this strategy. The quality of self-reported data should be assessed during office visits

SOURCE CITATION:N Engl J Med. 2021;384:216-28. 33186492.

Introduction/UNASSIGNED:Reports from the United States suggest that acute kidney injury (AKI) frequently complicates COVID-19, but understanding of AKI risks and outcomes is incomplete. Additionally, whether kidney outcomes have evolved during the course of the pandemic is unknown. Methods/UNASSIGNED:We used electronic records to identify COVID-19 patients with and without AKI admitted to 3 New York Hospitals between March 2 and August 25, 2020. Outcomes included AKI overall and according to admission week, AKI stage, the requirement for new renal replacement therapy (RRT), mortality and recovery of kidney function. Logistic regression was utilized to assess associations of patient characteristics and outcomes. Results/UNASSIGNED:Out of 4732 admissions 1386 (29.3%) patients had AKI. Among those with AKI, 717 (51.7%) had Stage 1, 132 (9.5%) Stage 2, 537 (38.7%) stage 3, and 237 (17.1%) required RRT initiation. In March 536/1648 (32.5%) of patients developed AKI compared with 15/87 (17.2%) in August (P<0.001 for monthly trend) whereas RRT initiation was required in 6.9% and 0% of admission, in March and August respectively. Mortality was higher with than without AKI (51.6% vs 8.6%) and was 71.9% in individuals requiring RRT. However, most patients with AKI who survived hospitalization (77%) recovered to within 0.3 mg/dL of baseline creatinine. Among those surviving to discharge, 62% discontinued RRT. Conclusions/UNASSIGNED:AKI impacts a high proportion of admitted COVID-19 patients and is associated with high mortality, particularly when RRT is required. AKI incidence appears to be decreasing over time and kidney function frequently recovers in those who survive.

PURPOSE/OBJECTIVE:The National Death Index (NDI) is an important resource for mortality ascertainment. Methods selected to process NDI search results are rarely described in studies using linked data and can have an impact on resources and mortality ascertainment. We evaluate methods to process NDI search results among a 9/11-exposed cohort-the World Trade Center Health Registry (Registry). METHODS:We describe three approaches to process search results (NDI-recommended cutoff points [NDIc]; National Program of Cancer Registries [NPCR] algorithm, and modified National Institute of Occupational Safety and Health algorithm [mNIOSH]). We calculate percent agreement, positive predictive value, sensitivity, specificity, and quantify the burden of manual review to compare the approaches. RESULTS:Of 51,158 Registry enrollees submitted for linkage, 9449 enrollee-level and 17,909 record-level matches were identified. NPCR and mNIOSH were highly concordant (97.1%); more record pairs required manual review for mNIOSH (mNIOSH: 2.7% and NPCR: 1.8%). NDIc sensitivity was 82.9%, with differences observed by race and ethnicity (Asian: 74.4% and White: 86.1%). CONCLUSIONS:NPCR algorithm minimized false matches and reduced the manual review burden. NDIc had nonrandom distribution of missed matches and low sensitivity. NDI search processing methods have important implications for resulting linked data; measures of linkage quality should be available to data users.

Kratom is an unregulated kappa-opioid receptor agonist available for order on the internet that is used as a remedy for chronic pain. We present a case of a middle-aged man who suffered a cardiac arrest in the setting of kratom ingestion.