Correction: The Story of #GetMePPE and GetUsPPE.org to Mobilize Health Care Response to COVID-19 : Rapidly Deploying Digital Tools for Better Health Care

[This corrects the article DOI: 10.2196/20469.].

Association Between Utilization of Digital Prenatal Services and Vaginal Birth After Cesarean

INTRODUCTION

Digital health services are a promising but understudied method for reducing common barriers to vaginal birth after cesarean (VBAC), including connection to facilities offering labor after cesarean and patient-centered counseling about mode of birth. This study assesses the relationship between use of digital prenatal services and VBAC.

METHODS

In this retrospective cohort study, we analyzed the use of digital prenatal services and mode of birth among users of an employer-sponsored digital women's and family digital health platform. All users had a prior cesarean birth. Users' self-reported data included demographics, medical history, and birth preferences. We used basic descriptive statistics and logistic regression models to assess the association between digital services utilization and VBAC, adjusting for key patient characteristics.

RESULTS

Of 271 included users, 44 (16.2%) had a VBAC and 227 (83.8%) had a cesarean birth. Users of both groups were similar in age, race, and ethnicity. Fewer users in the VBAC group (5/44, 11.4%) as compared with the cesarean birth group (62/227, 27.3%) had a prepregnancy body mass index greater than or equal to 30 (P = 0.02). Likewise, more users in the VBAC group preferred vaginal birth (34/44, 77.3% vs 55/227, 24.2%; P < 0.01). In adjusted models, the services associated with VBAC were care advocate appointments (adjusted odds ratio [aOR], 7.67; 95% CI, 1.99-54.4), health care provider appointments (aOR, 1.12; 95% CI, 1.02-1.25), and resource reads (aOR, 1.05, 95% CI, 1.00-1.09). VBAC rates were higher for users who reported the digital health platform influenced aspects of their pregnancy and birth.

DISCUSSION

Reducing cesarean birth rates is a national priority. Digital health services, particularly care coordination and education, are promising for accomplishing this goal through increasing rates of trial of labor after cesarean and subsequent VBAC rates.

Utilization of National Cancer Institute-Designated Cancer Centers by Medicare Beneficiaries with Cancer

BACKGROUND

Little is known about which patients use National Cancer Institute-designated cancer centers (NCICCs) nationally. This study aimed to identify sociodemographic characteristics associated with decreased NCICC use among Medicare beneficiaries.

METHODS

This study examined a national cohort of 534,008 Medicare beneficiaries with cancer in 2017 using multivariable logistic regressions for NCICC use. The covariates in the study were sex, age, cancer type, race/ethnicity, dual-eligibility status for Medicaid and Medicare, and NCICC presence in the home state.

RESULTS

In 2017, 19.5 % of Medicare beneficiaries with cancer used an NCICC at least once. Dual-eligible beneficiaries had 29 % lower adjusted odds of NCICC use than non-dual-eligible beneficiaries (adjusted odds ratio [aOR], 0.71; 95 % confidence interval [CI], 0.70-0.73; p < 0.001). American Indian/Alaska Native beneficiaries had 40 % lower odds of NCICC use than non-Hispanic white (NHW) beneficiaries (aOR, 0.60; 95 % CI, 0.53-0.68; p < 0.001). Compared with NHW beneficiaries, the odds of NCICC use were higher for black beneficiaries by 15 % (aOR, 1.15; 95 % CI, 1.12-1.18; p < 0.001), for Hispanic beneficiaries by 31 % (aOR, 1.31; 95 % CI, 1.26-1.35; p < 0.001), and for Asian/Pacific Islander beneficiaries by 126 % (aOR, 2.26; 95 % CI, 2.16-2.36; p < 0.001). Utilization declined steadily in older groups, with beneficiaries older than 95 years showing 73 % lower odds of NCICC use than beneficiaries younger than 65 years (aOR, 0.27; 95 % CI, 0.24-0.29; p < 0.001).

CONCLUSIONS

Medicaid-eligible, American Indian/Alaska Native, and older patients are substantially less likely to use NCICCs. Future research should focus on defining and addressing the barriers to NCICC access for these populations.

Reproductive Justice: A Case-Based, Interactive Curriculum

INTRODUCTION

Reproductive injustices such as forced sterilization, preventable maternal morbidity and mortality, restricted access to family planning services, and policy-driven environmental violence undermine reproductive autonomy and health outcomes, with disproportionate impact on historically marginalized communities. However, curricula focused on reproductive justice (RJ) are lacking in medical education.

METHODS

We designed a novel, interactive, case-based RJ curriculum for postclerkship medical students. This curriculum was created using published guidelines on best practices for incorporating RJ in medical education. The session included a prerecorded video on the history of RJ, an article, and four interactive cases. Students engaged in a 2-hour small-group session, discussing key learning points of each case. We evaluated the curriculum's impact with a pre- and postsurvey and focus group.

RESULTS

Sixty-eight students participated in this RJ curriculum in October 2020 and March 2021. Forty-one percent of them completed the presurvey, and 46% completed the postsurvey. Twenty-two percent completed both surveys. Ninety percent of respondents agreed that RJ was relevant to their future practice, and 87% agreed that participating in this session would impact their clinical practice. Most respondents (81%) agreed that more RJ content is needed. Focus group participants appreciated the case-based, interactive format and the intersectionality within the cases.

DISCUSSION

This interactive curriculum is an innovative and effective way to teach medical students about RJ and its relevance to clinical practice. Walking alongside patients as they accessed reproductive health care in a case-based curriculum improved students' comfort and self-reported knowledge on several RJ topics.

A high-touch outreach model to re-engage patients in mammogram screening

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Background: Disparities in cancer screening have been well documented during the Covid-19 pandemic. However, there are limited patient-reported data describing the prevalence and drivers of patient hesitancy towards cancer screening and willingness to resume screening. As health systems continue to experience pandemic-related capacity strain, there is an urgent need for innovative models of re-engaging patients in preventive screening. To address this issue, we developed a medical student-led, high-touch outreach model to re-engage primary care patients at Brookside Community Health Center in cancer screening. Methods: We iteratively optimized semi-structured call scripts and surveys in English and Spanish to contact patients overdue for mammography screening. Student callers included medical and pre-medical students with native Spanish fluency. Using the call script, students identified patient-reported barriers and facilitated mammogram scheduling for consenting patients. For consenting patients, student callers placed a telephone encounter with a pended screening mammogram order in the electronic medical record. PCP confirmation of the order triggered outreach by the radiology department for mammogram scheduling. Patients also received reminder calls from students the week of their appointment. Primary outcomes include screening consent rates, mammogram scheduling and completion rates, and screening results. Patient survey responses were securely recorded using the REDCap survey platform. Results: 198 patients were eligible for the intervention. 60% are primarily Spanish-speaking and 81% are insured by Medicaid. 145 patients (73%) have successfully been contacted, of which 129 (89%) consented for mammogram screening. 74 (57%) of the consenting patients have scheduled their mammogram and 38 (29%) have completed their mammogram. 36% of consenting Spanish-speaking patients with active mammogram orders did not have a mammogram scheduled, compared to 9% of consenting English-speaking. To date, 6 patients had abnormal mammograms requiring subsequent diagnostic imaging, and 1 patient was diagnosed with ductal carcinoma in situ requiring oncologic care. Qualitative analysis of patient surveys found that primary barriers to screening included factors associated with the Covid-19 pandemic (32.9% of contacted patients), lack of awareness of overdue status (25.9%) and patient unavailability (e.g. outside of country) (20%). Conclusions: In this single-center quality improvement study, we found that patients had a high willingness to engage in cancer screening during the pandemic and that trainees can play a vital role in re-engaging patients in preventative care. The disparity between Spanish and English-speaking patients’ ability to schedule a mammogram after the consent process suggests that patients with limited English proficiency face additional challenges in accessing screenings.

Ask Me Anything": Lessons learned in implementing a COVID-19 vaccine information initiative in Massachusetts jails

As a group of medical professionals, faith-community leaders, and jail staff, we launched a COVID-19 vaccine Q&A initiative across Massachusetts county jails to increase COVID-19 vaccine confidence and uptake among detained individuals. Here we describe the lessons learned in developing and implementing this initiative.

Fatty acid profiles of Phaseolus species

The aim of this study was to identify and profile the fatty acids present in the Phaseolus species using an online Osiris server software. Phaseolus species (pinto beans, lima beans and kidney beans) were bought in King’s market, Akure, Ondo State, Nigeria and were air -dried and ground. The Association of Official Analytical Chemists protocol were used for proximate; mineral analysis was done using atomic absorption spectrophotometer; extraction of oil was done using Soxhlet apparatus and the extracts were characterized using gas chromatography mass spectrophotometer and identified compounds were screened for their chemical properties using online Osiris server. The oil extract for pinto beans revealed fatty acids in increasing order of percentage quality: Myristic acid, octadecenoic acid, stearic acid and palmitic acid. Identified fatty acids in kidney beans were in decreasing order of palmitic acid, linoleic acid, lauric acid, myristic acid and capric acid. Lima beans had highest palmitic acid and arachidic acid the lowest. However, from the results of all the Phaseolus species, linoleic acid was found only in kidney beans with quality of 11.87%. The identified fatty acids showed high toxicity properties and they exhibited negative drug-likeness. The chemistry of the identified compounds all showed that they exhibited various chemical properties. In conclusion, this study had revealed the presence of fatty acids in the selected food crops and their various chemical profiles have been discovered

Risk Assessment of Organochlorine Pesticide Residue in Phaseolus vulgaris Purchased in Igbara-oke, Ondo State, Nigeria

&lt;b&gt;Background and Objective:&lt;/b&gt; Preservation of agricultural products remains a hallmark of all farmers as a result, both pesticides and herbicides are being applied during planting and after harvesting with the sole aim of maximizing profits. Research had shown the various degree of toxicity of organochlorine pesticides residues, the objective of the research was to identify the organochlorine pesticide residues, analyze their risk assessment vis-a-vis, Hazard Index (HI), Estimate Dietary Intake (EDI), Target Hazard Quotient (THQ) and compare the results with Acceptable Dietary Intake (ADI), Reference dose standard (Rfd) and Maximum Residue Limit (MRL) and characterized the identified organochlorine pesticides residue for their toxicological properties. &lt;b&gt;Materials and Methods:&lt;/b&gt; &lt;i&gt;Phaseolus vulgaris&lt;/i&gt; were purchased in a local market in Igbara -Oke, Ondo state Nigeria, the sample was powdered using a grinder (Sumeet CM/L 2128945) and solid phase extraction techniques were employed, the extract was subjected to fractionation into two fractions of aliphatic hydrocarbons and the pesticides. The pesticide extract was subjected to characterization using gas chromatography-mass spectrophotometer. &lt;b&gt;Results:&lt;/b&gt; Total 4 organochlorine pesticide residues were identified and the contaminant rates (mg kg&lt;sup&gt;1&lt;/sup&gt;) were less than 1. Furthermore, EDI values were lower than the ADI, MRL, also, the THQ values were less than 1, an indication that the &lt;i&gt;Phaseolus vulgaris&lt;/i&gt; was safe for consumption. &lt;b&gt;Conclusion:&lt;/b&gt; The research had shown no toxicity of the &lt;i&gt;Phaseolus vulgaris&lt;/i&gt; purchased from the local market and it shows compliance by the local farmers on the application of pesticides to the food crop by obeying the recommended dose.

Ensuring Racial Equity in Pregnancy Care During the COVID-19 Pandemic and Beyond

Background

The COVID-19 pandemic provoked sweeping changes in practice to care for pregnant and birthing people, and highlighted inequities that threaten to exacerbate racial disparities in maternal outcomes. Moreover, social distancing measures have made it harder for pregnant people to access support.

Assessment

Prioritizing widespread access to COVID-19 testing and vaccination for pregnant people is critical to ensuring they receive safe and equitable care. Transparency in reporting outcomes including race and pregnancy status is key. Expanding telemedicine services to provide mental healthcare and labor support is necessary to maintain access to critical social networks. Additionally, resources must be allocated to pregnant people with complex social needs and are the most vulnerable.

Conclusion

Policy centered on maintaining equity and agency in the care of pregnant people is imperative now and should continue as the standard moving forward to narrow racial disparities in maternal health outcomes.

How Health Care Workers Wield Influence Through Twitter Hashtags: Retrospective Cross-sectional Study of the Gun Violence and COVID-19 Public Health Crises

BACKGROUND

Twitter has emerged as a novel way for physicians to share ideas and advocate for policy change. #ThisIsOurLane (firearm injury) and #GetUsPPE (COVID-19) are examples of nationwide health care-led Twitter campaigns that went viral. Health care-initiated Twitter hashtags regarding major public health topics have gained national attention, but their content has not been systematically examined.

OBJECTIVE

We hypothesized that Twitter discourse on two epidemics (firearm injury and COVID-19) would differ between tweets with health care-initiated hashtags (#ThisIsOurLane and #GetUsPPE) versus those with non-health care-initiated hashtags (#GunViolence and #COVID19).

METHODS

Using natural language processing, we compared content, affect, and authorship of a random 1% of tweets using #ThisIsOurLane (Nov 2018-Oct 2019) and #GetUsPPE (March-May 2020), compared to #GunViolence and #COVID19 tweets, respectively. We extracted the relative frequency of single words and phrases and created two sets of features: (1) an open-vocabulary feature set to create 50 data-driven-determined word clusters to evaluate the content of tweets; and (2) a closed-vocabulary feature for psycholinguistic categorization among case and comparator tweets. In accordance with conventional linguistic analysis, we used a P<.001, after adjusting for multiple comparisons using the Bonferroni correction, to identify potentially meaningful correlations between language features and outcomes.

RESULTS

In total, 67% (n=4828) of #ThisIsOurLane tweets and 36.6% (n=7907) of #GetUsPPE tweets were authored by health care professionals, compared to 16% (n=1152) of #GunViolence and 9.8% (n=2117) of #COVID19 tweets. Tweets using #ThisIsOurLane and #GetUsPPE were more likely to contain health care-specific language; more language denoting positive emotions, affiliation, and group identity; and more action-oriented content compared to tweets with #GunViolence or #COVID19, respectively.

CONCLUSIONS

Tweets with health care-led hashtags expressed more positivity and more action-oriented language than the comparison hashtags. As social media is increasingly used for news discourse, public education, and grassroots organizing, the public health community can take advantage of social media's broad reach to amplify truthful, actionable messages around public health issues.

Toxicological Characterization of Pesticide Residue in <i>Phaseolus vulgaris</i>

BACKGROUND AND OBJECTIVE

The health implications associated with consumption of food crops preserved with pesticides such as diarrhea, food poisons have been a major challenge to health practitioners and the concerned authorities, the objective of the research was to analyze the pesticide residues and compare the contamination rate with Acceptable Dietary Intake (ADI) and Maximum Residue Limit (MRL).

MATERIALS AND METHODS

Phaseolus vulgaris were purchased in two different locations, the samples were powdered using a grinder (Sumeet CM/L 2128945). Fifty grams of powdered flour were soaked in 200 mL of Methanol and the crude extracts were concentrated using a rotary evaporator. The extracts were Characterized using GC-MS and percentage compositions of identified pesticide residues were converted into mg/g as contamination rate and the toxic analysis was done by using the Osiris Online server.

RESULTS

In chromatogram A, identified pesticides residue include Dieldrin (96.1 mg g-1), Indolizine (67.9 mg g-1), permethrin (99.4 mg g-1) and compounds identified in chromatogram B include dichlorvos (8.2 mg g-1), Diazinon (52.3 mg g-1), fenitrothion (17.8 mg g-1) and permethrin (122.0 mg g-1). These pesticide residues exhibited various toxicological effects, such as; mutagenic, tumorigenic effects. Moreover, the contamination rates of the identified residues were higher than both MRL and ADI.

CONCLUSION

The research work had shown that the two samples had contamination rates higher than both the ADI and MRL, this could pose health hazards to the populace if consumed and it is recommended that the applications of pesticides in foods should be regulated and MRL and ADI should be adhered to.

The Story of #GetMePPE and GetUsPPE.org to Mobilize Health Care Response to COVID-19 : Rapidly Deploying Digital Tools for Better Health Care

Physicians, nurses, and other health care providers initiated the #GetMePPE movement on Twitter to spread awareness of the shortage of personal protective equipment (PPE) during the coronavirus disease (COVID-19) pandemic. Dwindling supplies, such as face masks, gowns and goggles, and inadequate production to meet increasing demand have placed health care workers and patients at risk. The momentum of the #GetMePPE Twitter hashtag resulted in the creation of a petition to urge public officials to address the PPE shortage through increased funding and production. Simultaneously, the GetUsPPE.org website was launched through the collaboration of physicians and software engineers to develop a digital platform for the donation, request, and distribution of multi-modal sources of PPE. GetUsPPE.org and #GetMePPE were merged in an attempt to combine public engagement and advocacy on social media with the coordination of PPE donation and distribution. Within 10 days, over 1800 hospitals and PPE suppliers were registered in a database that enabled the rapid coordination and distribution of scarce and in-demand materials. One month after its launch, the organization had distributed hundreds of thousands of PPE items and had built a database of over 6000 PPE requesters. The call for action on social media and the rapid development of this digital tool created a productive channel for the public to contribute to the health care response to COVID-19 in meaningful ways. #GetMePPE and GetUsPPE.org were able to mobilize individuals and organizations outside of the health care system to address the unmet needs of the medical community. The success of GetUsPPE.org demonstrates the potential of digital tools as a platform for larger health care institutions to rapidly address urgent issues in health care. In this paper, we outline this process and discuss key factors determining success.

Self-reported Sleep Disorder and Ambulatory Blood Pressure Phenotypes in Patients with or without Chronic Kidney Disease: Findings from Ibadan CRECKID Study

BACKGROUND

Sleep disordered breathing has been closely linked to pathogenesis, poor control of hypertension, and progression of chronic kidney disease (CKD). Though hypertension and CKD are highly prevalent in Nigeria, the effects of sleep disorders on CKD and hypertension phenotypes have not been widely studied. This study investigated the relationship between self-reported sleep disorders, and ambulatory blood pressure phenotypes in patients with hypertension and those with or without CKD.

METHODS

Participants aged 18 years and above who consented were recruited into the study. Anthropometric measurements including height, weight, and waist and hip circumferences were obtained, Office/clinic hypertension was defined as SBP =140mmHg and/or DBP =90mmHg or being on pharmacological treatment for hypertension. 24-hour ambulatory blood pressure monitoring were done. Obstructive sleep apnea was assessed using Stop Bang questionnaire. Estimated GFR was calculated using CKD-EPI Creatinine 2Equation and CKD was defined as eGFR<60ml/min/1.73m .

RESULTS

A total of three hundred and forty-nine (349) patients were enrolled for the study: 175 males and 174 females. Moderate to severe risk for obstructive sleep apnea (OSA) was observed in 51.4% of patients with CKD, 58.5% of hypertensive and 17.3% of apparently healthy participants. Male participants were more likely than female patients to have moderate and high OSA risk (41.7% vs 32.8%) and (10.3% vs 4.6%) respectively. Compared with other groups, CKD patients had the highest office and ambulatory blood pressure parameters; p<0.0001.

CONCLUSION

This study has demonstrated that obstructive sleep apnoea is prevalent among patients with chronic kidney disease and hypertension. Furthermore, the phenotypes of hypertension are accentuated in CKD and therefore, OSA may well be an important risk factor for CKD.

A Cost-Benefit Analysis of Government Compensation of Kidney Donors

From 5000 to 10 000 kidney patients die prematurely in the United States each year, and about 100 000 more suffer the debilitating effects of dialysis, because of a shortage of transplant kidneys. To reduce this shortage, many advocate having the government compensate kidney donors. This paper presents a comprehensive cost-benefit analysis of such a change. It considers not only the substantial savings to society because kidney recipients would no longer need expensive dialysis treatments--$1.45 million per kidney recipient--but also estimates the monetary value of the longer and healthier lives that kidney recipients enjoy--about $1.3 million per recipient. These numbers dwarf the proposed $45 000-per-kidney compensation that might be needed to end the kidney shortage and eliminate the kidney transplant waiting list. From the viewpoint of society, the net benefit from saving thousands of lives each year and reducing the suffering of 100 000 more receiving dialysis would be about $46 billion per year, with the benefits exceeding the costs by a factor of 3. In addition, it would save taxpayers about $12 billion each year.

Proceedings from an international consensus meeting on posttransplantation diabetes mellitus: recommendations and future directions

A consensus meeting was held in Vienna on September 8-9, 2013, to discuss diagnostic and therapeutic challenges surrounding development of diabetes mellitus after transplantation. The International Expert Panel comprised 24 transplant nephrologists, surgeons, diabetologists and clinical scientists, which met with the aim to review previous guidelines in light of emerging clinical data and research. Recommendations from the consensus discussions are provided in this article. Although the meeting was kidney-centric, reflecting the expertise present, these recommendations are likely to be relevant to other solid organ transplant recipients. Our recommendations include: terminology revision from new-onset diabetes after transplantation to posttransplantation diabetes mellitus (PTDM), exclusion of transient posttransplant hyperglycemia from PTDM diagnosis, expansion of screening strategies (incorporating postprandial glucose and HbA1c) and opinion-based guidance regarding pharmacological therapy in light of recent clinical evidence. Future research in the field was discussed with the aim of establishing collaborative working groups to address unresolved questions. These recommendations are opinion-based and intended to serve as a template for planned guidelines update, based on systematic and graded literature review, on the diagnosis and management of PTDM.

Efficacy of Valganciclovir in the Treatment of Cytomegalovirus Disease in Kidney and Pancreas Transplant Recipients

Cytomegalovirus (CMV) disease is relatively common following solid organ transplant, particularly if a serologically negative recipient receives an organ from a serologically positive donor (D+/R-). Although valganciclovir is approved for the treatment of CMV retinitis in AIDS patients and is used for the prophylaxis against CMV infection in solid organ transplant patients, the current standard treatment for CMV disease in solid organ transplant recipients remains intravenous ganciclovir. We retrospectively reviewed our experience using valganciclovir as treatment for CMV disease in CMV D+/R- kidney and/or pancreas transplant recipients from March 2002 to June 2005. A total of 37 cases with primary CMV disease were diagnosed and treated with either intravenous ganciclovir as induction followed with valganciclovir or valganciclovir from the beginning. We compared clinical outcomes and viremia between the two groups. Our data suggest that valganciclovir is an effective treatment modality for primary CMV disease in kidney and/or pancreas transplant recipients. It led to the resolution of disease and undetectable viremia. Valganciclovir allowed for early initiation of treatment and for treatment to be given as an outpatient. These advantages of valganciclovir have both health and economic impact for patients with CMV disease.

Meningioma - a review of 52 cases

Meningiomas are extra-axial neoplasms representing 15 - 20% of primary intracranial neoplasms. Incidence peaks in patients aged 40 - 60 years, and they more commonly affect women than men. Most meningiomas arise from arachnoidal cells on the inner surface of the dura and they thefore grow inward toward the brain to form bulky intradural tumour masses. Most meningiomas are benign, but ~6% are atypical or aggressive, and 1 - 2% are frankly malignant. Common locations for meningiomas include the cerebral convexity, parasagittal region, sphenoid wing, olfactory groove, tuberculum sella, posterior fossa, and cavernous sinus.

Comparison of cross-sectional renal function measurements in African Americans with hypertensive nephrosclerosis and of primary formulas to estimate glomerular filtration rate

Renal function measurements were obtained in 1,703 African Americans with presumed hypertensive nephrosclerosis who were screened for entry into the African-American Study of Hypertension and Kidney Disease (AASK). We examined the effect of race on relationships involving renal variables by comparing African Americans enrolled into the AASK with non-African Americans enrolled into the Modification of Diet in Renal Disease (MDRD) study. We examined the effect of gender on renal variables by comparing African American men and women. We compared various methods for estimating glomerular filtration rate (GFR) with iodine 125-labeled ((125)I)-iothalamate GFR. AASK data were also used to derive a new formula for estimating GFR in African Americans. After adjusting for age, sex, and baseline GFR, African American patients on the AASK study were heavier and had larger body surface areas and body mass indices than either MDRD African Americans or non-African Americans. African Americans had greater serum creatinine levels and urinary creatinine excretions for any given level of GFR. Mean GFR was greater in African American men than African American women (59.7 versus 51.7 mL/min/1.73 m(2)), although serum creatinine levels were also greater in men (1.91 versus 1.73 mg/dL). Seventy-eight percent of women with serum creatinine levels between 1.2 and 1.5 mg/dL had GFRs less than 65 mL/min/1.73 m(2). For African Americans in the AASK, GFR was overestimated by the 24-hour creatinine clearance and underestimated by the Cockcroft-Gault formula. A prediction formula developed in the MDRD study more accurately predicted GFR in AASK patients than these measurements. AASK data were also used to derive a new five-term formula for estimating GFR that was slightly more accurate in the African Americans in the AASK than the MDRD formula (median percentage of error, 12.4% for the MDRD formula versus 12.1% for the AASK formula). Important differences exist in renal variables between African Americans and non-African Americans and between African American men and African American women. Formulas using demographic data and readily measured serum values estimate (125)I-iothalamate GFR.

Effect of ramipril vs amlodipine on renal outcomes in hypertensive nephrosclerosis: a randomized controlled trial

CONTEXT

Incidence of end-stage renal disease due to hypertension has increased in recent decades, but the optimal strategy for treatment of hypertension to prevent renal failure is unknown, especially among African Americans.

OBJECTIVE

To compare the effects of an angiotensin-converting enzyme (ACE) inhibitor (ramipril), a dihydropyridine calcium channel blocker (amlodipine), and a beta-blocker (metoprolol) on hypertensive renal disease progression.

DESIGN, SETTING, AND PARTICIPANTS

Interim analysis of a randomized, double-blind, 3 x 2 factorial trial conducted in 1094 African Americans aged 18 to 70 years with hypertensive renal disease (glomerular filtration rate [GFR] of 20-65 mL/min per 1.73 m(2)) enrolled between February 1995 and September 1998. This report compares the ramipril and amlodipine groups following discontinuation of the amlodipine intervention in September 2000.

INTERVENTIONS

Participants were randomly assigned to receive amlodipine, 5 to 10 mg/d (n = 217), ramipril, 2.5 to 10 mg/d (n = 436), or metoprolol, 50 to 200 mg/d (n = 441), with other agents added to achieve 1 of 2 blood pressure goals.

MAIN OUTCOME MEASURES

The primary outcome measure was the rate of change in GFR; the main secondary outcome was a composite index of the clinical end points of reduction in GFR of more than 50% or 25 mL/min per 1.73 m(2), end-stage renal disease, or death.

RESULTS

Among participants with a urinary protein to creatinine ratio of >0.22 (corresponding approximately to proteinuria of more than 300 mg/d), the ramipril group had a 36% (2.02 [SE, 0.74] mL/min per 1.73 m(2)/y) slower mean decline in GFR over 3 years (P =.006) and a 48% reduced risk of the clinical end points vs the amlodipine group (95% confidence interval [CI], 20%-66%). In the entire cohort, there was no significant difference in mean GFR decline from baseline to 3 years between treatment groups (P =.38). However, compared with the amlodipine group, after adjustment for baseline covariates the ramipril group had a 38% reduced risk of clinical end points (95% CI, 13%-56%), a 36% slower mean decline in GFR after 3 months (P =.002), and less proteinuria (P<.001).

CONCLUSION

Ramipril, compared with amlodipine, retards renal disease progression in patients with hypertensive renal disease and proteinuria and may offer benefit to patients without proteinuria.

African-American renal transplant recipients experience decreased risk of death due to infection: possible implications for immunosuppressive strategies

INTRODUCTION

African-American renal transplant recipients tend to experience more acute rejection episodes and have shorter graft survival than Caucasian renal transplant recipients. Various factors have been posited to be responsible for this difference, including relative under immunosuppression. We reasoned that by looking at the balance of acute rejections versus death due to infection, we could ascertain whether African-American renal recipients might have more reserve to tolerate an increase in pharmacological immunosuppression.

METHODS

We analyzed the United States Renal Data System (USRDS) data from 1987 to 1997 regarding acute rejection episodes and infectious deaths. All other pertinent factors were gathered for a multivariate analysis. A total number of 68,885 adult renal transplant recipients were analyzed.

RESULTS

When corrected for all covariates, the relative risk for acute rejection (1.3) was higher although the relative risk for infectious death was lower (0.7) in African-Americans as compared with Caucasians (P<0.01).

CONCLUSION

Our study would indicate that relative to Caucasians, African-American renal transplant recipients are at decreased risk for infectious death and therefore may tolerate the more intensive immunosuppression that may be necessary to narrow the gap in acute rejection rates between African-Americans and Caucasian renal transplant recipients.

Excellent outcome of renal transplantation in patients with Fabry's disease

INTRODUCTION

Fabry's disease is an X-linked error of glycosphingolipid metabolism. Clinical manifestations of the disease are secondary to accumulation of glycosphingolipids in various tissues. Renal failure and vascular complications are common. There are conflicting reports regarding the outcomes of patients with Fabry's disease after renal transplantation.

METHODS

We reviewed the United States Renal Data System Registry database from 1988 and 1998, and found 93 patients with Fabry's disease who had received a renal transplant. Case-matched patients were identified to serve as controls.

RESULTS

Patients with Fabry's disease demonstrated equivalent 5-year patient and graft survival, compared with controls (83% and 75%, respectively, for those with Fabry's disease vs. 82% and 67% for controls).

CONCLUSION

Despite their high risk for cardiovascular complications, patients with Fabry's disease have excellent outcomes after renal transplantation.

Prognosis after primary renal transplant failure and the beneficial effects of repeat transplantation: multivariate analyses from the United States Renal Data System

BACKGROUND

Survival of transplant recipients after primary renal allograft failure has not been well studied.

METHODS

A cohort of 19,208 renal transplant recipients with primary allograft failure between 1985 and 1995 were followed from the date of allograft loss until death, repeat transplantation, or December 31, 1996. The mortality, wait-listing, and repeat transplantation rates were assessed. The mortality risks associated with repeat transplantation were estimated with a time-dependent survival model.

RESULTS

In total, 34.5% (n=6,631) of patients died during follow-up. Of these deaths, 82.9% (n=5,498) occurred in patients not wait-listed for repeat transplantation, 11.9% (n=789) occurred in wait-listed patients, and 5.2% (n=344) occurred in second transplant recipients. Before repeat transplantation, the adjusted 5-year patient survival was 36%, 49%, and 65% for type I diabetes mellitus (DM), type II DM, and nondiabetic end-stage renal disease, respectively (P<0.001; DM vs. nondiabetics). The adjusted 5-year patient survival was lower in Caucasians (57%, P<0.001) compared with African-Americans (67%) and other races (64%). The 5-yr repeat transplantation rate was 29%, 15%, and 19%, whereas the median waiting time for a second transplant was 32, 90, and 81 months for Caucasians, African-Americans, and other races, respectively (P<0.0001 each). Repeat transplantation was associated with 45% and 23% reduction in 5-year mortality for type I DM and nondiabetic end-stage renal disease, respectively, when compared with their wait-listed dialysis counterparts with prior transplant failure.

CONCLUSIONS

The loss of a primary renal allograft was associated with significant mortality, especially in recipients with type I DM. Repeat transplantation was associated with a substantial improvement in 5-year patient survival. Recipients with type I DM achieved the greatest proportional benefit from repeat transplantation.

Influence of race and gender on related donor renal transplantation rates

Racial differences in kidney transplantation have received recent attention both in the medical community and in the general public. Most efforts to improve renal transplantation among minority groups have been directed toward cadaveric donation and transplantation. Since evaluation of the comparative trends by race of living related donor (LRD) kidney transplantation have been lacking, we examined trends of LRD transplantation from 1983 through 1990 using national data from the US Renal Data System. The total number of LRDs in blacks did not change during the 8-year period between 1983 and 1990 (198 in 1983 and 197 in 1990). During this same period, the total number of LRDs in whites increased by 11% (1,390 in 1983 and 1,548 in 1990). Rates of LRD transplantation per nontransplanted dialysis patients were consistently lower in blacks and females compared with whites and males, respectively. White males have a fivefold higher rate of LRD transplantation than black males, whereas white females have a fourfold higher rate then black females. When intraracial gender differences were examined, black males were transplanted with LRD kidneys at a rate 20% higher than black females. This difference was present between 1983 and 1989, but was nonexistent in 1990. Among whites, males also had a higher rate of LRD transplantation than females, which gradually decreased from 34% in 1983 to 20% in 1990. In view of the ever-increasing demand for cadaver organs, additional effort in the medical community and society toward increasing LRD transplantation rates represents a more promising approach to increasing organ donation in all groups than a single focus on cadaveric donation.(ABSTRACT TRUNCATED AT 250 WORDS)

Who is the elderly primigravida in Nigeria?

A retrospective study of 792 primigravidae, divided into four age-groups, was made in order to detect which group showed features of the elderly primigravida. Adolescent primigravidae showed significantly highest incidences of pre-eclampsia, anemia, premature labor and cephalopelvic disproportion. The 20-24 year age-group showed the least incidence of pregnancy and labor complications. The 25-29 year age-group showed significantly increased incidences of uterine fibroids, pre-eclampsia, post-term pregnancy, premature labor, slow labor, fetal distress, failed induction, vacuum and cesarean section deliveries, when compared with the 20-24 year age-group. Most of the complications in the 25-29 year age-group were continued into 30-34 years. A woman 25 years and above in her first pregnancy in Nigeria should be termed "elderly primigravida".