Incidence of Serum Creatinine Monitoring and Outpatient Visit Follow-Up among Acute Kidney Injury Survivors after Discharge: A Population-Based Cohort Study

<b><i>Introduction:</i></b> Acute kidney injury (AKI) affects 20% of hospitalized patients and worsens outcomes. To limit complications, post-discharge follow-up and kidney function testing are advised. The objective of this study was to evaluate the frequency of follow-up after discharge among AKI survivors. <b><i>Methods:</i></b> This was a population-based cohort study of adult Olmsted County residents hospitalized with an episode of stage II or III AKI between 2006 and 2014. Those dismissed from the hospital on dialysis, hospice, or who died within 30 days after discharge were excluded. The frequency and predictors of follow-up, defined as an outpatient serum creatinine (SCr) level or an in-person healthcare visit after discharge were described. <b><i>Results:</i></b> In the 627 included AKI survivors, the 30-day cumulative incidence of a follow-up outpatient SCr was 80% (95% confidence interval [CI]: 76% and 83%), a healthcare visit was 82% (95% CI: 79 and 85%), or both was 70% (95% CI: 66 and 73%). At 90 days and 1 year after discharge, the cumulative incidences of meeting both follow-up criteria rose to 82 and 91%, respectively. Independent predictors of receiving both an outpatient SCr assessment and healthcare visit within 30 days included lower estimated glomerular filtration rate at discharge, higher comorbidity burden, longer length of hospitalization, and greater maximum AKI severity. Age, sex, race/ethnicity, education level, and socioeconomic status did not predict follow-up. <b><i>Conclusions:</i></b> Among patients with moderate to severe AKI, 30% did not have follow-up with a SCr and healthcare visit in the 30-day post-discharge interval. Follow-up was associated with higher acuity of illness rather than demographic or socioeconomic factors.

Contemporary (2019) prevalence of cardiovascular disease in adults with type 2 diabetes in Brazil: the cross-sectional CAPTURE study

BackgroundType 2 diabetes (T2D) is a known risk factor for cardiovascular disease (CVD), and CVD is a major cause of mortality in patients with T2D. The CAPTURE study investigated the contemporary (2019) prevalence of established CVD in adults with T2D around the world. We report the findings from Brazil.MethodsThe multinational, non-interventional, cross-sectional CAPTURE study was conducted across 13 countries from five continents. The current manuscript explores data for the CAPTURE study sample in Brazil. Standardized demographic and clinical data were collected from adults with T2D aged ≥ 18 years attending a single routine healthcare visit in primary or specialized care between December 2018 and September 2019. Data were analyzed descriptively.ResultsData from 912 adults with T2D were collected in the CAPTURE study in Brazil, with 822 patients from primary care and 90 patients from specialized care. Median (interquartile range [IQR]) patient characteristics were as follows: age 64 years (57; 71), diabetes duration 11 years (6; 19), glycated hemoglobin 7.7% (6.7; 9.1), and body mass index 29.5 kg/m2 (26.4; 33.5); 59% were female. The CVD prevalence and atherosclerotic CVD prevalence in the Brazil sample were 43.9% (95% confidence interval [CI] 40.9; 46.8) and 37.6% (95% CI 34.7; 40.5), respectively. The majority of patients with CVD had atherosclerotic CVD (85.8%). For the specific CVD subtypes, coronary heart disease prevalence was 27.9% (95% CI 25.2; 30.5), heart failure was 12.4% (95% CI 10.4; 14.4), cerebrovascular disease was 8.7% (95% CI 6.8; 10.5), and carotid artery disease was 3.4% (95% CI 2.3; 4.5). Glucagon-like peptide-1 receptor agonists and/or sodium-glucose co-transporter-2 inhibitors with proven cardiovascular benefit were prescribed to 15.5% of patients with CVD, compared with 18.4% of patients without CVD.ConclusionsCAPTURE was the first multinational, standardized study to provide contemporary data on CVD prevalence in adults with T2D in Brazil, and it demonstrated that almost one in two adults with T2D had established CVD. Except for carotid artery disease, the prevalence of all CVD subtypes in adults with T2D in Brazil appeared higher than the global CAPTURE prevalence.Trial registration: NCT03786406, NCT03811288.

Abstract P091: Reasons For Uncontrolled Blood Pressure Among US Adults

Introduction: In October 2020, the US Surgeon General issued a Call to Action on hypertension control. We investigated the contribution of lack of awareness, not taking antihypertensive medication and an inadequate antihypertensive medication regimen to uncontrolled blood pressure (BP) among US adults. Methods: We analyzed data for 2,282 participants ≥18 years of age with uncontrolled BP from the 2015-2016 and 2017-2018 National Health and Nutrition Examination Surveys (NHANES). BP was measured three times by a trained physician following a standardized protocol. Uncontrolled BP was defined by systolic BP ≥140 mm Hg or diastolic BP ≥90 mm Hg. Being aware of having hypertension and antihypertensive medication use were defined by self-report. An inadequate antihypertensive medication regimen was defined as taking antihypertensive medication with uncontrolled BP. Data were weighted to represent the non-institutionalized US population. Results: Among US adults with uncontrolled BP, 34.8% were not aware they had hypertension, 13.8% were aware but not taking antihypertensive medication and 51.4% were aware but taking inadequate antihypertensive medication regimen. US adults 18-39 and 40-49 years of age were more likely to be unaware they had hypertension compared to their counterparts ≥70 years of age (multivariable-adjusted prevalence ratios [PR]: 1.62 [95% CI: 1.26-2.07] and 1.41 [95% CI: 1.02-1.95], respectively). Participants who had a healthcare visit in the past year (PR: 0.60 [95% CI: 0.47-0.77]) and who were obese (PR: 0.69 [95% CI: 0.56-0.85]), had diabetes (PR: 0.56 [95% CI: 0.42-0.76]), chronic kidney disease (PR: 0.59 [95% CI: 0.46-0.75]) and a history of cardiovascular disease (PR: 0.41 [95% CI: 0.27-0.61]) were less likely to be unaware they had hypertension. Among those who were aware they had hypertension, US adults who were 18-39 and 40-49 years of age as compared to those ≥70 years of age were more likely to be not taking antihypertensive medication versus taking inadequate antihypertensive medication regimen (multivariable-adjusted PR: 5.48 [95% CI: 3.17-9.48] and 5.14 [95% CI: 2.28-10.26], respectively). In contrast, non-Hispanic blacks and Hispanics as compared to non-Hispanic whites (PR: 0.71 [95% CI: 0.53-0.94] and 0.72 [95% CI: 0.54-0.96], respectively) and those without a usual place to receive healthcare (PR: 0.70 [95% CI 0.51-0.96]) and who had a healthcare visit in past year (PR: 0.47 [95% CI: 0.35-0.62]) were less likely to be not taking antihypertensive medication versus taking inadequate antihypertensive medication regimen. Conclusion: The majority of US adults with uncontrolled BP were either unaware they had hypertension or were taking an inadequate antihypertensive medication regimen. Interventions are needed to increase hypertension awareness and assess and titrate patients’ antihypertensive medication regimen.

Identity cues influence sexual minorities’ anticipated treatment and disclosure intentions in healthcare settings: Exploring a multiple pathway model

The present work experimentally examines how identity cues that signal minority inclusion contribute to sexual minorities’ (SM) healthcare visit expectations. We find that minority representation cues reduced SM’s ( N = 188) expectations of a healthcare provider’s bias and increased perceived provider cultural competency which was, in turn, associated with lower anticipated identity-based devaluation and greater sexual orientation disclosure comfort. Providers’ diversity-valuing statements had mixed effects highlighting the importance of more concrete indicators of inclusion in this context. This work suggests that a lack of identity safety cues in healthcare settings may contribute to disparate health outcomes for sexual minority populations.

Adverse Events Among Young Adults Following a Third Dose of Measles-Mumps-Rubella Vaccine

Background A third measles-mumps-rubella vaccine (MMR) dose (MMR3) is recommended in the United States for persons at increased risk for mumps during outbreaks. MMR3 is also likely given to persons who might have received 2 doses of MMR but lack documentation. Since MMR3 safety data are limited, we describe adverse events in persons receiving MMR3 in a nonoutbreak setting. Methods Young adults with 2 documented MMR doses were administered MMR3. From 2 weeks before until 4 weeks after MMR3 receipt, participants reported daily on 11 solicited, common symptoms potentially associated with MMR. Weekly rate differences in post- vs prevaccination (baseline) were evaluated by Poisson regression. Baseline rates were subtracted from postvaccination rates of significantly different symptoms to estimate the number and percentage of participants with excess risk for symptoms post-MMR3. Descriptive analyses were performed for 3 postvaccination injection-site symptoms. Results The 662 participants were aged 18–28 years (median = 20 years); 56% were women. Headache, joint problems, diarrhea, and lymphadenopathy rates were significantly higher postvaccination vs baseline. We estimate that 119 participants (18%) reported more symptoms after MMR3 than prevaccination. By symptom, 13%, 10%, 8%, and 6% experienced increased symptoms of headache, joint problems, diarrhea, and lymphadenopathy, respectively, after MMR3. The median onset was Days 3–6 postvaccination; the median duration was 1–2 days. One healthcare visit for a potential vaccination-related symptom (urticaria) was reported. Injection-site symptoms were reported by 163 participants (25%); the median duration was 1–2 days. Conclusions Reported systemic and local events were mild and transient. MMR3 is safe and tolerable among young adults.

Healthcare trajectory of children with rare bone disease attending pediatric emergency departments

Background Children with rare bone diseases (RBDs), whether medically complex or not, raise multiple issues in emergency situations. The healthcare burden of children with RBD in emergency structures remains unknown. The objective of this study was to describe the place of the pediatric emergency department (PED) in the healthcare of children with RBD. Methods We performed a retrospective single-center cohort study at a French university hospital. We included all children under the age of 18 years with RBD who visited the PED in 2017. By cross-checking data from the hospital clinical data warehouse, we were able to trace the healthcare trajectories of the patients. The main outcome of interest was the incidence (IR) of a second healthcare visit (HCV) within 30 days of the index visit to the PED. The secondary outcomes were the IR of planned and unplanned second HCVs and the proportion of patients classified as having chronic medically complex (CMC) disease at the PED visit. Results The 141 visits to the PED were followed by 84 s HCVs, giving an IR of 0.60 [95% CI: 0.48–0.74]. These second HCVs were planned in 60 cases (IR = 0.43 [95% CI: 0.33–0.55]) and unplanned in 24 (IR = 0.17 [95% CI: 0.11–0.25]). Patients with CMC diseases accounted for 59 index visits (42%) and 43 s HCVs (51%). Multivariate analysis including CMC status as an independent variable, with adjustment for age, yielded an incidence rate ratio (IRR) of second HCVs of 1.51 [95% CI: 0.98–2.32]. The IRR of planned second HCVs was 1.20 [95% CI: 0.76–1.90] and that of unplanned second HCVs was 2.81 [95% CI: 1.20–6.58]. Conclusion An index PED visit is often associated with further HCVs in patients with RBD. The IRR of unplanned second HCVs was high, highlighting the major burden of HCVs for patients with chronic and severe disease.

Crizanlizumab Treatment Is Associated with Clinically Significant Reductions in Hospitalization in Patients with Sickle Cell Disease: Results from the Sustain Study

Background: Sickle cell disease (SCD) is characterized by the presence of sickle hemoglobin (HbS), chronic hemolysis, recurrent pain episodes called vaso-occlusive crises (VOCs), multiorgan dysfunction and early death. VOCs decrease quality of life, are the main cause of healthcare encounters in SCD, and increase the risk of death. New therapies that reduce SCD hospitalizations are desirable given the potential to impact healthcare utilization, but also to reduce disease burden and decrease mortality and morbidity. The SUSTAIN study (Ataga et al. NEJM 2017), was a Phase 2, multicenter, randomized, placebo-controlled, double-blind, 12-month study to assess safety and efficacy of crizanlizumab (2.5 and 5 mg/kg) with or without hydroxyurea therapy, in patients with SCD and a history of 2-10 VOCs in the previous 12 months (NCT01895361). The primary efficacy endpoint was annual rate of SCD-related pain crises (VOCs) leading to healthcare visit. The key secondary endpoint was annual rate of days hospitalized, regardless of cause. There was a statistically significant 45.3% reduction in median annual rate of VOCs leading to healthcare visit with crizanlizumab 5 mg/kg compared with placebo (1.63 vs 2.98 VOCs/year, P=0.01). There was a 41.8% reduction in median rate of days hospitalized with crizanlizumab 5 mg/kg compared with placebo (4.00 vs 6.87 days/year). Although this difference was not statistically significant (P=0.45), it appears to be clinically relevant. Methods: A post-hoc analysis of the SUSTAIN data was performed to better characterize the difference in the annual rate of days hospitalized between the crizanlizumab 5 mg/kg and placebo arms, and to compare the distribution of hospitalizations and time to first hospitalization. Results: As illustrated in Figure 1, a greater proportion of patients in the crizanlizumab arm (46%) were not hospitalized during the trial period (up to end of treatment) than in the placebo arm (35%). Correspondingly, the percentage of patients with ≥1 hospitalization was lower in the crizanlizumab (54%) than the placebo arm (65%). In addition, a trend for delayed time to first hospitalization shown in Figure 1 was further explored with a Kaplan-Meier (KM) analysis (Figure 2). Figure 2 shows clear separation of the curves, evident from Month 1 of treatment. The median time to first hospitalization was greater with crizanlizumab 5 mg/kg than with placebo (6.3 vs 3.2 months; hazard ratio [HR] 0.683 [95% CI 0.437-1.066]). The apparent improvement in time to first hospitalization is consistent with previously published SUSTAIN results regarding median time to first VOC leading to healthcare visit. Patients treated with crizanlizumab 5 mg/kg were found to experience a longer median time to first VOC leading to healthcare visit than patients on placebo (4.07 vs 1.38 months; HR 0.50 [95% CI 0.33-0.74]). Conclusions: The primary SUSTAIN results showed that crizanlizumab reduced VOCs leading to a healthcare visit. This analysis demonstrates additional positive trends associated with crizanlizumab treatment compared to placebo, regarding the percentage of patients with no hospitalizations and a delayed time to first hospitalization. Together, these findings provide further evidence that crizanlizumab may have a beneficial impact on reducing hospitalizations. Disclosures Ataga: Novartis: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Global Blood Therapeutics: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Emmaus Life Sciences: Honoraria, Membership on an entity's Board of Directors or advisory committees; Bioverativ: Honoraria, Membership on an entity's Board of Directors or advisory committees; Pfizer: Research Funding; Modus Therapeutics: Honoraria. Kutlar:Micelle Biopharma: Other: DSMB Chair; Novartis: Consultancy; Global Blood Therapeutics, Inc. (GBT): Research Funding; Novo Nordisk: Research Funding; Bluebird Bio: Other: DSMB Member. DeBonnett:Novartis Pharmaceuticals Corporation: Employment. Lincy:NOVARTIS PHARMA AG: Employment. Kanter:Novartis: Consultancy, Honoraria; Imara: Consultancy; Sangamo: Consultancy, Honoraria; Modus: Consultancy, Honoraria; Guidepoint Global: Consultancy; GLG: Consultancy; Cowen: Consultancy; Jeffries: Consultancy; Medscape: Honoraria; Rockpointe: Honoraria; Peerview: Honoraria; SCDAA: Membership on an entity's Board of Directors or advisory committees; NHLBI: Membership on an entity's Board of Directors or advisory committees; bluebird bio, Inc.: Consultancy.

Crizanlizumab Versus Placebo, with or without Hydroxyurea/Hydroxycarbamide, in Adolescent and Adult Patients with Sickle Cell Disease and Vaso-Occlusive Crises: A Randomized, Double-Blind, Phase III Study (STAND)

Background: Sickle cell disease (SCD) comprises a group of genetic blood disorders caused by a single missense mutation (Glu6Val) in the β-globin gene. In early childhood, SCD progresses into a systemic disease resulting in complications that include vaso-occlusion, multi-organ damage, and early death. P-selectin, an adhesion molecule expressed on activated vascular endothelial cells and platelets, contributes to the cell-to-cell and cell-to-endothelium interactions that are involved in the pathogenesis of vaso-occlusive crisis (VOC) in SCD. Crizanlizumab is an investigational, humanized, anti-P-selectin monoclonal antibody under evaluation for the prevention of VOCs in patients with SCD. In the Phase II SUSTAIN study, crizanlizumab 5.0 mg/kg significantly reduced the median annual rate of VOCs compared with placebo (P=0.010). The purpose of the randomized, double-blind, Phase III placebo-controlled STAND study is to compare the efficacy and safety of two doses of crizanlizumab (5.0 and 7.5 mg/kg) versus placebo in adolescent and adult patients with SCD and a history of VOCs leading to a healthcare visit. Methods: The STAND study aims to randomize 240 patients with SCD (all SCD genotypes eligible) aged ≥12 years (including at least 48 adolescents), who experienced ≥2 VOCs leading to a healthcare visit in the 12 months prior to screening, and who are not planning to initiate hydroxyurea (HU)/hydroxycarbamide (HC) or erythropoietin-stimulating agents (ESAs) or L-glutamine during the trial. Patients who have been taking HU/HC, ESAs or L-glutamine for ≥6 months and plan to continue the same dose at least until they reach 1 year of investigational treatment will be permitted. Exclusion criteria include: history of stem cell transplant; receipt of blood products within 30 days of the first dose; participation in a chronic exchange or transfusion program; and receipt of therapeutic anticoagulation or antiplatelet therapy within the 10 days prior to the first dose. Patients in the study will be randomized into 1 of 3 treatment arms: crizanlizumab 5.0 mg/kg, 7.5 mg/kg, or placebo administered intravenously over a period of 30 minutes on week 1 day 1, week 3 day 1, and day 1 of every 4-week cycle thereafter. Primary analysis cut-off date will occur once all patients have reached 1 year of treatment or discontinued within year 1. An open-label extension will offer the possibility to switch treatment (Figure). The primary endpoint is the annualized rate of VOCs leading to a healthcare visit in each treatment group over the first year of treatment. The key secondary endpoint is the annualized rate of all VOCs (leading to a healthcare visit or treated at home) over the first year post randomization. Other objectives include the rate of patients free from VOCs leading to a healthcare visit, time to first and second VOC leading to a healthcare visit, number of days with VOCs leading to a healthcare visit, healthcare resource utilization, SCD-related renal damage, pharmacokinetics and pharmacodynamics (P-selectin inhibition), immunogenicity, biomarkers and quality of life. The primary efficacy endpoint will be analyzed based on the data from the full analysis set comprising all randomized patients. A negative binomial regression model with treatment and randomization stratification factors as covariates will be used for analysis, with the logarithm of observation time as offset. The estimates of annualized VOC rates between treatment groups and their 95% confidence intervals will be provided [NCT03814746, EudraCT 2017-001746-10]. Conclusion: This study is designed to confirm the efficacy and safety of crizanlizumab 5 mg/kg and assess the safety and efficacy of a higher dose (7.5 mg/kg) in patients with SCD and history of VOCs. Figure. Disclosures Abboud: GBT: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Amgen: Other: Travel support; AstraZeneca: Membership on an entity's Board of Directors or advisory committees, Research Funding; CRSPR Therapeutics: Membership on an entity's Board of Directors or advisory committees; Modus: Research Funding; Eli Lilly: Research Funding; Novartis: Consultancy, Honoraria, Research Funding; Novo Nordisk: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees. Howard:Resonance Health: Other: Travel grant; Global Blood Therapeutics: Consultancy, Membership on an entity's Board of Directors or advisory committees, Other: Travel grant; Imara: Consultancy, Other: Travel grant. Cançado:Novartis: Membership on an entity's Board of Directors or advisory committees. Smith:Novartis: Consultancy, Honoraria. Espurz:Novartis Pharma AG: Employment. Weill:Novartis Pharma AG: Employment. de Montalembert:bluebird bio, Inc: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Novartis: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; AddMedica: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees.

Presentation and healthcare delays among people with tuberculosis in London, and the impact on treatment outcome

BackgroundA quarter of London’s pulmonary tuberculosis (TB) patients have over 4 months of delay. Late diagnosis increases disease severity and the risk of transmission. We aim to classify delays, identify associated risk factors and assess treatment outcome.MethodsWe conducted a retrospective cohort study using London surveillance data, 2012–2018 on adults aged ≥18 years with pulmonary TB. We defined presentation delay (days from symptom onset to first healthcare visit) and healthcare delay (first healthcare visit to treatment commencement) as dichotomous variables; positive delay being days equal or greater than the third quartile. We applied logistic regression models to identify risk factors associated with delays and treatment outcome at 12 months.ResultsOf 7216 people, 4539 reported presentation and 5193 healthcare delays. The third quartiles for presentation and healthcare delay were 84 and 61 days, respectively. Presentation delay was associated with female sex (adjusted OR (aOR)=1.21; 95% CI 1.04 to 1.39), increasing age (aOR=1.004; 95% CI 1.001 to 1.008), white compared to Asian ethnicity (aOR=1.35; 95% CI 1.12 to 1.62), previous imprisonment (aOR=1.66; 95% CI 1.22 to 2.26) and alcohol misuse (aOR=1.44; 95% CI 1.04 to 1.89). Healthcare delay was associated with female sex (aOR=1.39; 95% CI 1.21 to 1.59), increasing age (aOR=1.014; 95% CI 1.009 to 1.018) and white ethnicity (aOR=1.41; 95% CI 1.19 to 1.68). 16% of 5678 people with known outcome did not complete treatment. Neither delay was associated with non-completion (p value <0.05).ConclusionsFemale, white and older people with TB were more likely to experience both presentation and healthcare delays. Social risk factors were also associated with delay in presentation. Early diagnosis and treatment remain critical to reduce transmission, regardless of whether delay affected completion.

HUBUNGAN KEPATUHAN DALAM KUNJUNGAN POSYANDU TERHADAP STATUS GIZI BALITA DI DESA MLILIR KECAMATAN BANDUNGAN KABUPATEN SEMARANG

The cases of malnutrition in Indonesia are still very high at 1.1 million toddler from 21,436,940 in the number of toddler who are registered in Pediatric Healthcare. The village of Mlilir in the Public Health Center Jimbaran in the last three months had increase for the number of malnutrition for toddler. Efforts to prevent the problems of nutrition toward toddler are participating in Pediatric Healthcare activities. The obedience in visits to each Pediatric Healthcare activity will certainly affect the nutritional status of the toddler. Because one of the objectives of Pediatric Healthcare is to monitor the improvement of nutritional status of toddler.This research aimed to analyze the relation of the obedience Pediatric Healthcare visit toward toddler nutrition status. This research used a quantitative design analytic survey with a Case Control approach. The population in this research was all the mothers who had children aged 12-59 months in Mlilir Village, Bandungan district, Semarang Regency in April 2018, 242 respondents. Case samples used were taken with accidentall sampling technique, 18 respondents and control samples using matching sample technique, in the education and occupation of mothers around 36 respondents with a ratio of 1: 2. The results of the study using the chi square test showed , there was a relationship between obedience in the Pediatric Healthcare visit to the nutritional status of toddler.There was a relationship between obedience in Pediatric Healthcare visits to the nutritional status of toddler.Health workers provide media counseling that can be brought home like leaflets so that the information is reachable to the parents of the toddler.