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Objective: The aim of this study was to examine relationships between ileostomy formation and subsequent kidney disease. Summary and background data: Colonic absorptive capacity loss from ileostomy formation can cause volume depletion and could result in kidney disease. Methods: We conducted a population-based cohort study comparing patients who underwent ileostomy formation with or without bowel resection (ileostomy group) to patients who underwent bowel resection without ileostomy formation (reference group). Adjusted odds ratios (aORs) for community-onset acute kidney injury (AKI) within 3 months and new-onset chronic kidney disease (CKD) within 1 year following hospital discharge were determined. Results: Among 19,889 patients, 4136 comprised the ileostomy group and 15,753 comprised the reference group; 1350 patients experienced community-onset AKI and 464 developed new-onset CKD. The aOR for community-onset AKI with ileostomy formation was 4.08 [95% confidence interval (CI) = 3.62-4.61] for any stage AKI, 7.08 (95% CI = 5.66-8.85) for stage ≥2 injury, and 7.67 (95% CI = 5.06-11.63) for stage 3 injuries. Community-onset AKI modified associations between ileostomy formation and new-onset CKD (P = 0.002). Odds of new-onset CKD were increased in the ileostomy group relative to the reference group for patients both with (aOR = 4.99; 95% CI = 3.42-7.28) and without (aOR = 2.45; 95% CI = 1.85-2.23) previous community-onset AKI episodes. In analyses comparing patients that underwent ileostomy formation and subsequent reversal within 1 year to the reference group without ileostomy, the relationship with new-onset CKD was attenuated for patients both with (aOR = 2.49; 95% CI = 1.50-4.12) and without (aOR = 0.97; 95% CI = 0.67-1.40) previous community-onset AKI episodes. Conclusions: Ileostomy formation is strongly associated with subsequent kidney disease. Vigilance for this complication and new strategies for prevention and treatment are necessary. [ABSTRACT FROM AUTHOR]

Abstract Background Administrative health care databases offer an efficient and accessible, though as-yet unvalidated, approach to studying outcomes of patients with chronic kidney disease and end-stage renal disease (ESRD). The objective of this study is to determine the validity of outpatient physician billing derived algorithms for defining chronic dialysis compared to a reference standard ESRD registry. Methods A cohort of incident dialysis patients (Jan. 1 - Dec. 31, 2008) and prevalent chronic dialysis patients (Jan 1, 2008) was selected from a geographically inclusive ESRD registry and administrative database. Four administrative data definitions were considered: at least 1 outpatient claim, at least 2 outpatient claims, at least 2 outpatient claims at least 90 days apart, and continuous outpatient claims at least 90 days apart with no gap in claims greater than 21 days. Measures of agreement of the four administrative data definitions were compared to a reference standard (ESRD registry). Basic patient characteristics are compared between all 5 patient groups. Results 1,118,097 individuals formed the overall population and 2,227 chronic dialysis patients were included in the ESRD registry. The three definitions requiring at least 2 outpatient claims resulted in kappa statistics between 0.60-0.80 indicating "substantial" agreement. "At least 1 outpatient claim" resulted in "excellent" agreement with a kappa statistic of 0.81. Conclusions Of the four definitions, the simplest (at least 1 outpatient claim) performed comparatively to other definitions. The limitations of this work are the billing codes used are developed in Canada, however, other countries use similar billing practices and thus the codes could easily be mapped to other systems. Our reference standard ESRD registry may not capture all dialysis patients resulting in some misclassification. The registry is linked to on-going care so this is likely to be minimal. The definition utilized will vary with the research objective.

Abstract Background The Alberta Kidney Disease Network is a collaborative nephrology research organization based on a central repository of laboratory and administrative data from the Canadian province of Alberta. Description The laboratory data within the Alberta Kidney Disease Network can be used to define patient populations, such as individuals with chronic kidney disease (using serum creatinine measurements to estimate kidney function) or anemia (using hemoglobin measurements). The administrative data within the Alberta Kidney Disease Network can also be used to define cohorts with common medical conditions such as hypertension and diabetes. Linkage of data sources permits assessment of socio-demographic information, clinical variables including comorbidity, as well as ascertainment of relevant outcomes such as health service encounters and events, the occurrence of new specified clinical outcomes and mortality. Conclusion The unique ability to combine laboratory and administrative data for a large geographically defined population provides a rich data source not only for research purposes but for policy development and to guide the delivery of health care. This research model based on computerized laboratory data could serve as a prototype for the study of other chronic conditions.

Background: Obstructive sleep apnea (OSA) is associated with increased morbidity and mortality, and decreased quality of life. Treatment with continuous positive airway pressure (CPAP) or mandibular advancement devices (MADs) is effective for many symptoms of OSA. However, it remains controversial whether treatment with CPAP or MAD also improves depressive symptoms. Methods and Findings: We performed a systematic review and meta-analysis of randomized controlled trials that examined the effect of CPAP or MADs on depressive symptoms in patients with OSA. We searched Medline, EMBASE, the Cochrane Central Registry of Controlled Trials, and PsycINFO from the inception of the databases until August 15, 2014, for relevant articles. In a random effects meta-analysis of 19 identified trials, CPAP treatment resulted in an improvement in depressive symptoms compared to control, but with significant heterogeneity between trials (Q statistic, p < 0.001; [I.sup.2] = 71.3%, 95% CI: 54%, 82%). CPAP treatment resulted in significantly greater improvement in depressive symptoms in the two trials with a higher burden of depression at baseline (meta-regression, p < 0.001). The pooled standardized mean difference (SMD) in depressive symptoms with CPAP treatment in these two trial populations with baseline depression was 2.004 (95% CI: 1.387, 2.621), compared to 0.197 (95% CI: 0.059, 0.334) for 15 trials of populations without depression at baseline. Pooled estimates of the treatment effect of CPAP were greater in parallel arm trials than in crossover trials (meta-regression, p = 0.076). Random effects meta-analysis of five trials of MADs showed a significant improvement in depressive symptoms with MADs versus controls: SMD = 0.214 (95% CI: 0.026, 0.401) without significant heterogeneity ([I.sup.2] = 0%, 95% Ci: 0%, 79%). Studies were limited by the use of depressive symptom scales that have not been validated specifically in people with OSA. Conclusions: CPAP and MADs may be useful components of treatment of depressive symptoms in individuals with OSA and depression. The efficacy of CPAP and MADs compared to standard therapies for depression is unknown. Please see later in the article for the Editors' Summary., Introduction Obstructive sleep apnea (OSA), characterized by repetitive upper airway obstruction during sleep, is associated with increased morbidity and mortality and decreased quality of life [1,2]. OSA has multiple mechanisms [...]

Abstract Background Resident-led morning report is an integral part of most residency programs and is ranked among the most valuable of educational experiences. The objectives of this study were to evaluate the effect of a resident-as-teacher educational intervention on the educational and teaching experience of morning report. Methods All senior internal medicine residents were invited to participate in this study as teaching participants. All internal medicine residents and clerks were invited to participate as audience participants. The educational intervention included reading material, a small group session and feedback after teaching sessions. The educational and teaching experiences were rated prior to and three months after the intervention using questionnaires. Results Forty-six audience participants and 18 teaching participants completed the questionnaires. The degree to which morning report met the educational needs of the audience was higher after the educational intervention (effect size, d = 0.26, p = 0.01). The perceptions of the audience were that delivery had improved and that the sessions were less intimidating and more interactive. The perception of the teaching participants was that delivery was less stressful, but this group now reported greater difficulty in engaging the audience and less confidence in their medical knowledge. Conclusion Following the educational intervention the audience's perception was that the educational experience had improved although there were mixed results for the teaching experience. When evaluating such interventions it is important to evaluate the impact on both the educational and teaching experiences as results may differ.

Objectives: Despite advances in medical therapy, reperfusion, and mechanical support, cardiogenic shock remains associated with excess morbidity and mortality. Accurate risk stratification may improve patient management. We compared the accuracy of established risk scores for cardiogenic shock. Methods: Patients admitted to tertiary care center cardiac care units in the province of Alberta in 2015 were assessed for cardiogenic shock. The Acute Physiology and Chronic Health Evaluation-II (APACHE-II), CardShock, intra-aortic balloon pump (IABP) Shock II, and sepsis-related organ failure assessment (SOFA) risk scores were compared. Receiver operating characteristic curves were used to assess discrimination of in-hospital mortality and compared using DeLong's method. Calibration was assessed using the Hosmer-Lemeshow goodness-of-fit test. Results: The study included 3021 patients, among whom 510 (16.9%) had cardiogenic shock. Patients with cardiogenic shock had longer median hospital stays (median 11.0 vs 4.1 days, P < .001) and were more likely to die (29.0% vs 2.5%, P < .001). All risk scores were adequately calibrated for predicting hospital morality except for the APACHE-II score (Hosmer-Lemeshow P < .001). Discrimination of in-hospital mortality with the APACHE-II (area under the curve [AUC]: 0.72, 95% confidence interval [CI]: 0.66-0.76) and IABP-Shock II (AUC: 0.73, 95% CI: 0.68-0.77) scores were similar, while the CardShock (AUC: 0.76, 95% CI: 0.72-0.81) and SOFA (AUC: 0.76, 95%CI: 0.72-0.81) scores had better discrimination for predicting in-hospital mortality. Conclusions: In a real-world population of patients with cardiogenic shock, existing risk scores had modest prognostic accuracy, with no clear superior score. Further investigation is required to improve the discriminative abilities of existing models or establish novel methods. [ABSTRACT FROM AUTHOR]

Background: We developed and validated laboratory test--based risk scores (i.e., lab risk scores) to reclassify mortality risk among patients undergoing their first coronary catheterization. Methods: Patients were catheterized between 2009 and 2015 in Calgary, Alberta, Canada (n=14 135, derivation cohort), and in Edmonton, Alberta, Canada (n=12 143, validation cohort). Logistic regression with group LASSO (least absolute shrinkage and selection operator) penalty was used to select quintiles of the last laboratory tests (red blood cell count, mean corpuscular hemoglobin concentration, mean corpuscular hemoglobin, mean corpuscular volume, red cell distribution width, platelet count, total white blood cell count, plasma sodium, potassium, chloride, CO2, international normalized ratio, estimated glomerular filtration rate) performed <30 days before catheterization and by age and sex that were significantly associated with death ≤60 and >60 days after catheterization. Follow-up was until 2016. Risk scores were developed from significant tests, internally validated in Calgary among bootstrap samples and externally validated in Edmonton after recalibration using coefficients developed in Calgary. Interaction tests were performed, and net reclassification improvement vs conventional demographic and clinical risk factors was determined. Results: Lab risk scores were strongly associated with mortality (29-40x for top vs bottom quintile, P for trends <0.01), had good discrimination and were well calibrated in Calgary (C=0.80-0.85, slope=0.99-1.01) and Edmonton (C=0.80-0.82; slope=1.02-1.05)--similar to demographic and clinical risk factors alone. Associations were attenuated by several comorbidities; however, scores appropriately reclassified 11%-20% of deaths (both follow-up periods) and 6%-9% of survivors (>60 days) after catheterization vs demographic and clinical risk factors. [ABSTRACT FROM AUTHOR]