Use of Antihypertensive Agents and Association With Risk of Adverse Outcomes in Chronic Kidney Disease: Focus on Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers.

Background Our objective was to determine patterns of antihypertensive agent use by stage of chronic kidney disease (CKD) and to evaluate the association between different classes of antihypertensive agents with nonrenal outcomes, especially in advanced CKD . Methods and Results We studied 3939 participants of the CRIC (Chronic Renal Insufficiency Cohort) study. Predictors were time-dependent angiotensin-converting enzyme inhibitor or angiotensin receptor blocker , β-blocker, and calcium channel blocker use (versus nonuse of agents in each class). Outcomes were adjudicated heart failure events or death. Adjusted Cox models were used to determine the association between predictors and outcomes. We also examined whether the associations differed based on the severity of CKD (early [stage 2-3 CKD ] versus advanced disease [stage 4-5 CKD ]). During median follow-up of 7.5 years, renin-angiotensin-aldosterone system inhibitor use plateaued during CKD stage 3 (75%) and declined to 37% by stage 5, while β-blocker, calcium channel blocker, and diuretic use increased steadily with advancing CKD . Renin-angiotensin-aldosterone system inhibitor use was associated with lower risk of heart failure (hazard ratio, 0.79; 95% confidence interval, 0.67-0.97) and death (hazard ratio, 0.78; 95% confidence interval, 0.67-0.90), regardless of severity of CKD . Calcium channel blocker use was not associated with risk of heart failure or death, regardless of the severity of CKD . β-Blocker use was associated with higher risk of heart failure (hazard ratio, 1.62; 95% confidence interval, 1.29-2.04) and death (hazard ratio, 1.22; 95% confidence interval, 1.03-1.43), especially during early CKD ( P<0.05 for interaction). Conclusions Angiotensin-converting enzyme inhibitor and angiotensin receptor blocker use decreased, while use of other agents increased with advancing CKD . Use of agents besides angiotensin-converting enzyme inhibitors or angiotensin receptor blockers may be associated with suboptimal outcomes in patients with CKD

Volunteer Participation in the Health eHeart Study: A Comparison with the US Population.

Direct volunteer "eCohort" recruitment can be an efficient way of recruiting large numbers of participants, but there is potential for volunteer bias. We compared self-selected participants in the Health eHeart Study to participants in the National Health And Nutrition Examination Survey (NHANES) 2013-14, a cross-sectional survey of the US population. Compared with the US population (represented by 5,769 NHANES participants), the 12,280 Health eHeart participants with complete survey data were more likely to be female (adjusted odds ratio (ORadj) = 3.1; 95% confidence interval (CI) 2.9-3.5); less likely to be Black, Hispanic, or Asian versus White/non-Hispanic (ORadj's = 0.4-0.6, p < 0.01); more likely to be college-educated (ORadj = 15.8 (13-19) versus ≤high school); more likely to have cardiovascular diseases and risk factors (ORadj's = 1.1-2.8, p < 0.05) except diabetes (ORadj = 0.8 (0.7-0.9); more likely to be in excellent general health (ORadj = 0.6 (0.5-0.8) for "Good" versus "Excellent"); and less likely to be current smokers (ORadj = 0.3 (0.3-0.4)). While most self-selection patterns held for Health eHeart users of Bluetooth blood pressure cuff technology, there were some striking differences; for example, the gender ratio was reversed (ORadj = 0.6 (0.4-0.7) for female gender). Volunteer participation in this cardiovascular health-focused eCohort was not uniform among US adults nor for different components of the study

Applying machine learning to predict future adherence to physical activity programs.

BackgroundIdentifying individuals who are unlikely to adhere to a physical exercise regime has potential to improve physical activity interventions. The aim of this paper is to develop and test adherence prediction models using objectively measured physical activity data in the Mobile Phone-Based Physical Activity Education program (mPED) trial. To the best of our knowledge, this is the first to apply Machine Learning methods to predict exercise relapse using accelerometer-recorded physical activity data.MethodsWe use logistic regression and support vector machine methods to design two versions of a Discontinuation Prediction Score (DiPS), which uses objectively measured past data (e.g., steps and goal achievement) to provide a numerical quantity indicating the likelihood of exercise relapse in the upcoming week. The respective prediction accuracy of these two versions of DiPS are compared, and then numerical simulation is performed to explore the potential of using DiPS to selectively allocate financial incentives to participants to encourage them to increase physical activity.Resultswe had access to a physical activity trial data that were continuously collected every 60 sec every day for 9 months in 210 participants. By using the first 15 weeks of data as training and test on weeks 16-30, we show that both versions of DiPS have a test AUC of 0.9 with high sensitivity and specificity in predicting the probability of exercise adherence. Simulation results assuming different intervention regimes suggest the potential benefit of using DiPS as a score to allocate resources in physical activity intervention programs in reducing costs over other allocation schemes.ConclusionsDiPS is capable of making accurate and robust predictions for future weeks. The most predictive features are steps and physical activity intensity. Furthermore, the use of DiPS scores can be a promising approach to determine when or if to provide just-in-time messages and step goal adjustments to improve compliance. Further studies on the use of DiPS in the design of physical activity promotion programs are warranted.Trial registrationClinicalTrials.gov NCT01280812 Registered on January 21, 2011

Antibiotics in acute bronchitis: a meta-analysis.

PurposeMost patients with acute bronchitis who seek medical care are treated with antibiotics, although the effectiveness of this intervention is uncertain. We performed a meta-analysis of randomized, controlled trials to estimate the effectiveness of antibiotics in the treatment of acute bronchitis.Subjects and methodsEnglish-language studies published January 1966 to April 1998 were retrieved using MEDLINE, bibliographies, and consultation with experts. Only randomized trials that enrolled otherwise healthy patients with a diagnosis of acute bronchitis, used an antibiotic in the treatment group and a placebo in the control group, and provided sufficient data to calculate an effect size were included.ResultsWe identified eight randomized controlled trials that satisfied all inclusion criteria. These studies used one of three antibiotics (erythromycin, doxycycline, trimethoprim/sulfamethoxazole). The use of antibiotics decreased the duration of cough and sputum production by approximately one-half day (summary effect size 0.21; 95% CI, 0.05 to 0.36). For specific symptoms, there were nonsignificant trends favoring the use of antibiotics: a decrease of 0.4 days of purulent sputum (95% CI, -0.1 to 0.8), a decrease of 0.5 days of cough (95% CI, -0.1 to 1.1), and a decrease of 0.3 days lost from work (95% CI, -0.6 to 1.1).ConclusionThis meta-analysis suggests a small benefit from the use of the antibiotics erythromycin, doxycycline, or trimethoprim/sulfamethoxazole in the treatment of acute bronchitis in otherwise healthy patients. As this small benefit must be weighed against the risk of side effects and the societal cost of increasing antibiotic resistance, we believe that the use of antibiotics is not justified in these patients

Modifiable predictors of ventricular ectopy in the community

Background Premature ventricular contractions (PVCs) predict heart failure and death. Data regarding modifiable risk factors for PVCs are scarce. Methods and Results We studied 1424 Cardiovascular Health Study participants randomly assigned to 24-hour Holter monitoring. Demographics, comorbidities, habits, and echocardiographic measurements were examined as predictors of PVC frequency and, among 845 participants, change in PVC frequency 5 years later. Participants exhibited a median of 0.6 (interquartile range, 0.1-7.1) PVCs per hour. Of the more directly modifiable characteristics and after multivariable adjustment, every SD increase in systolic blood pressure was associated with 9% more PVCs (95% confidence interval [CI], 2%-17%; P=0.01), regularly performing no or low-intensity exercise compared with more physical activity was associated with ≈15% more PVCs (95% CI, 3-25%; P=0.02), and those with a history of smoking exhibited an average of 18% more PVCs (95% CI, 3-36%; P=0.02) than did never smokers. After 5 years, PVC frequency increased from a median of 0.5 (IQR, 0.1-4.7) to 1.2 (IQR, 0.1-13.8) per hour ( P<0.0001). Directly modifiable predictors of 5-year increase in PVCs, described as the odds per each quintile increase in PVCs, included increased diastolic blood pressure (odds ratio per SD increase, 1.16; 95% CI, 1.02-1.31; P=0.02) and a history of smoking (OR, 1.31; 95% CI, 1.02-1.68; P=0.04). Conclusions Enhancing physical activity, smoking cessation, and aggressive control of blood pressure may represent fruitful strategies to mitigate PVC frequency and PVC-associated adverse outcomes

Past alcohol consumption and incident atrial fibrillation: The Atherosclerosis Risk in Communities (ARIC) Study.

BackgroundAlthough current alcohol consumption is a risk factor for incident atrial fibrillation (AF), the more clinically relevant question may be whether alcohol cessation is associated with a reduced risk.Methods and resultsWe studied participants enrolled in the Atherosclerosis Risk in Communities Study (ARIC) between 1987 and 1989 without prevalent AF. Past and current alcohol consumption were ascertained at baseline and at 3 subsequent visits. Incident AF was ascertained via study ECGs, hospital discharge ICD-9 codes, and death certificates. Of 15,222 participants, 2,886 (19.0%) were former drinkers. During a median follow-up of 19.7 years, there were 1,631 cases of incident AF, 370 occurring in former consumers. Former drinkers had a higher rate of AF compared to lifetime abstainers and current drinkers. After adjustment for potential confounders, every decade abstinent from alcohol was associated with an approximate 20% (95% CI 11-28%) lower rate of incident AF; every additional decade of past alcohol consumption was associated with a 13% (95% CI 3-25%) higher rate of AF; and every additional drink per day during former drinking was associated with a 4% (95% CI 0-8%) higher rate of AF.ConclusionsAmong former drinkers, the number of years of drinking and the amount of alcohol consumed may each confer an increased risk of AF. Given that a longer duration of abstinence was associated with a decreased risk of AF, earlier modification of alcohol use may have a greater influence on AF prevention

Gaps in Treatment and Surveillance: Head and Neck Cancer Care in a Safety-Net Hospital.

Objective:Treatment delays and suboptimal adherence to posttreatment surveillance may adversely affect head and neck cancer (HNC) outcomes. Such challenges can be exacerbated in safety-net settings that struggle with limited resources and serve a disproportionate number of patients vulnerable to gaps in care. This study aims to characterize treatment delays and adherence with posttreatment surveillance in HNC care at an urban tertiary care public hospital in San Francisco. Study Design:Retrospective chart review. Setting:Urban tertiary care public hospital in San Francisco. Subjects and Methods:We identified all cases of HNC diagnosed from 2008 to 2010 through the electronic medical record. We abstracted data, including patient characteristics, disease characteristics, pathology and radiology findings, treatment details, posttreatment follow-up, and clinical outcomes. Results:We included 64 patients. Median time from diagnosis to treatment initiation (DTI) was 57 days for all patients, 54 days for patients undergoing surgery only, 49 days for patients undergoing surgery followed by adjuvant radiation ± chemotherapy, 65 days for patients undergoing definitive radiation ± chemotherapy, and 29 days for patients undergoing neoadjuvant chemotherapy followed by radiation or chemoradiation. Overall, 69% of patients completed recommended treatment. Forty-two of 61 (69%) patients demonstrated adherence to posttreatment visits in year 1; this fell to 14 out of 30 patients (47%) by year 5. Conclusion:DTI was persistently prolonged in this study compared with prior studies in other public hospital settings. Adherence to posttreatment surveillance was suboptimal and continued to decline as the surveillance period progressed