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BACKGROUND: Residence in rural areas is often a barrier to health care access. To date, differences in access to kidney transplantation among children who reside in rural and micropolitan areas of the US have not been explored. METHODS: A retrospective cohort study of children

BACKGROUND: There is a paucity of data on the risk factors for the hyperosmolar hyperglycemic state (HHS) compared with diabetic ketoacidosis (DKA) in pediatric type 2 diabetes (T2D). METHODS: We used the national Kids Inpatient Database to identify pediatric admissions for DKA and HHS among those with T2D in the years 2006, 2009, 2012, and 2019. Admissions were identified using ICD codes. Those aged

ObjectiveThis observational study explores the association between palliative care (PC) involvement and high-cost imaging utilisation for patients with cancer patients during the last 3 months of life.MethodsAdult patients with cancer who died between 1 January 2012 and 31 May 2015 were identified. Referral to PC, intensity of PC service use, and non-emergent oncological imaging utilisation were determined. Associations between PC utilisation and proportion of patients imaged and mean number of studies per patient (mean imaging intensity (MII)) were assessed for the last 3 months and the last month of life. Similar analyses were performed for randomly matched case-control pairs (n = 197). Finally, the association between intensity of PC involvement and imaging utilisation was assessed.Results3784 patients were included, with 3523 (93%) never referred to PC and 261 (7%) seen by PC, largely before the last month of life (61%). Similar proportions of patients with and without PC referral were imaged during the last 3 months, while a greater proportion of patients with PC referral were imaged in the last month of life. PC involvement was not associated with significantly different MII during either time frame. In the matched-pairs analysis, a greater proportion of patients previously referred to PC received imaging in the period between the first PC encounter and death, and in the last month of life. MII remained similar between PC and non-PC groups. Finally, intensity of PC services was similar for imaged and non-imaged patients in the final 3 months and 1 month of life. During these time periods, increased PC intensity was not associated with decreased MII.ConclusionsPC involvement in end-of-life oncological care was not associated with decreased use of non-emergent, high-cost imaging. The role of advanced imaging in the PC setting requires further investigation.

There are limited data on the degree of variability in practices surrounding prioritization of referrals for transplant evaluation and criteria for transplant candidacy and their association with transplantation rates. We surveyed transplant programs across the United States between January 2020 and May 2020 to determine current pre-transplantation practices. We examined the relation between these reported practices and the outcomes of waitlisted patients at responding programs between January 2015 and March 2021 using Scientific Registry of Transplant Recipients data. We used adjusted Cox models with random effects to accommodate clustering by program. Primary outcomes included living or deceased donor transplantation. Of 172 surveyed programs, 90 participated. Substantial variations were noted in when the candidacy evaluation began (13% reported when eGFR was

Background and objectivesThough patient factors are frequently linked to hemodialysis vascular access selection and outcomes, variability by surgeon and surgeon specialty may play a role as well. The objective of this study is to examine the extent to which individual surgeons influence selection of vascular access type, removal of tunneled hemodialysis catheter (THC), and repeat vascular access.Design, setting, participants, & measurementsA national claims database was used to identify patients initiating hemodialysis via a THC between 2011 and 2017. Likelihood of repeat AVF/AVG was analyzed using mixed-effects logistic regression. Time from initial arteriovenous fistula (AVF)/graft (AVG) to THC removal and time to repeat AVF/AVG were analyzed using Weibull proportional hazard models. Individual surgeon identifier served as the random effect in all models.Results6,908 AVF/AVG met the inclusion criteria: 5366 (78%) AVF and 1,542 (22%) AVG. Surgeon specialty only had a significant influence on access type, with vascular surgeons having 26% greater odds of performing AVG compared to general surgeons (P = 0.006). Relative to the other independent variables, individual surgeon identifier had the greatest magnitude of effect on access type (median odds ratio, 2.36; 95% CI, 2.09-2.72). Individual surgeon identifier had the second greatest magnitude of effect likelihood of THC removal (median hazard ratio, 1.66; 95% CI, 1.58-1.77) and second access (median hazard ratio, 1.83; 95% CI, 1.66-2.05), in both cases second only to the effect of AVG, which was associated with greater likelihood of THC removal (hazard ratio 1.91; 95% CI, 1.77-2.07) and lower likelihood of second access (hazard ratio 0.44; 95% CI, 0.38-0.52).ConclusionIndividual surgeons are associated with greater variation in vascular access type and likelihood of repeat access than surgeon specialty and measurable patient demographics/co-morbidities. Future research should focus on identifying which surgeon factors are associated with improved outcomes.

BackgroundKidney replacement therapy is controversial for patients with hepatorenal syndrome who may not be liver transplant candidates. Data surrounding the likelihood of recovery of kidney function and mortality after outpatient dialysis initiation in patients with dialysis-requiring hepatorenal syndrome could inform discussions between patients and providers.MethodsWe performed a retrospective cohort study of patients with hepatorenal syndrome who were registered in the United States Renal Data System between 1996 and 2015 (n=7830) as receiving maintenance dialysis. We characterized patients with hepatorenal syndrome by recovery of kidney function using Fine and Gray models. We also examined hazard of recovery of kidney function and death among those with hepatorenal syndrome versus those with acute tubular necrosis (n=48,861) using adjusted Fine-Gray and Cox models, respectively.ResultsOf the patients with hepatorenal syndrome, 11% recovered kidney function. Those with higher likelihood of recovery were younger, non-Hispanic White, and had a history of alcohol use. Compared with patients with acute tubular necrosis, patients with hepatorenal syndrome as the attributed cause of kidney disease had a lower hazard of recovery (HR, 0.22; 95% CI, 0.21 to 0.24) and higher hazard of death within 1 year (HR, 3.10; 95% CI, 2.99 to 3.23) in fully adjusted models.ConclusionsPatients with hepatorenal syndrome receiving chronic maintenance dialysis had a lower likelihood of recovery of kidney function and higher mortality risk compared with patients with acute tubular necrosis. Among patients with hepatorenal syndrome, those most likely to recover kidney function were younger, had a history of alcohol use, and lacked comorbid conditions. These data may inform prognosis and discussions surrounding treatment options when patients with hepatorenal syndrome need chronic maintenance dialysis therapy.

While the influenza vaccine is recommended for all pregnant women, influenza vaccine coverage among this high-risk population remains inadequate. Factors associated with vaccine coverage among pregnant women, including insurance status, are poorly understood. In a cross-sectional study of the National Health Interview Survey (NHIS) data from 2012 to 2018, we evaluated predictors of self-reported influenza vaccine coverage in pregnant women. Among 1,942 pregnant women surveyed, 39% reported receiving the influenza vaccine in accordance with national recommendations. Influenza vaccine coverage increased by 8 percentage points from 2012 to 2018. Only 15% of uninsured pregnant women received the influenza vaccine, compared to 41% of those with insurance (design-corrected F-test, p-value

Purpose To develop and validate a deep learning algorithm that predicts the final diagnosis of Alzheimer disease (AD), mild cognitive impairment, or neither at fluorine 18 (18F) fluorodeoxyglucose (FDG) PET of the brain and compare its performance to that of radiologic readers. Materials and Methods Prospective 18F-FDG PET brain images from the Alzheimer's Disease Neuroimaging Initiative (ADNI) (2109 imaging studies from 2005 to 2017, 1002 patients) and retrospective independent test set (40 imaging studies from 2006 to 2016, 40 patients) were collected. Final clinical diagnosis at follow-up was recorded. Convolutional neural network of InceptionV3 architecture was trained on 90% of ADNI data set and tested on the remaining 10%, as well as the independent test set, with performance compared to radiologic readers. Model was analyzed with sensitivity, specificity, receiver operating characteristic (ROC), saliency map, and t-distributed stochastic neighbor embedding. Results The algorithm achieved area under the ROC curve of 0.98 (95% confidence interval: 0.94, 1.00) when evaluated on predicting the final clinical diagnosis of AD in the independent test set (82% specificity at 100% sensitivity), an average of 75.8 months prior to the final diagnosis, which in ROC space outperformed reader performance (57% [four of seven] sensitivity, 91% [30 of 33] specificity; P < .05). Saliency map demonstrated attention to known areas of interest but with focus on the entire brain. Conclusion By using fluorine 18 fluorodeoxyglucose PET of the brain, a deep learning algorithm developed for early prediction of Alzheimer disease achieved 82% specificity at 100% sensitivity, an average of 75.8 months prior to the final diagnosis. © RSNA, 2018 Online supplemental material is available for this article. See also the editorial by Larvie in this issue.

Key Points: Question: Is dialysis facility staffing associated with access to waitlisting and kidney transplant among adolescents and young adults receiving dialysis? Findings: In this cohort of individuals aged 12 to 30 years receiving maintenance dialysis, treatment at facilities with the highest (vs lowest) quartile of patient to social worker ratios was associated with 5% lower incidence of waitlisting. Treatment at facilities with the highest (vs lowest) quartile of patient to nurse or patient to social worker ratios was associated with a 14% to 15% lower incidence of transplant. Meaning: Higher staffing ratios at dialysis facilities were associated with lower access to waitlisting and transplant for adolescents and young adults. Importance: Patient to staff ratios vary across US dialysis facilities and have been associated with patient outcomes in older adults. Objective: To determine whether patient to nurse or patient to social worker staff ratios are associated with access to kidney transplant for adolescents and young adults. Design, Setting, and Participants: Retrospective cohort study including patients aged 12 to 30 years who started dialysis between 2005 and 2019 at 8490 US facilities according to the US Renal Data System, the national end-stage kidney disease registry. Exposures: Time-updated quartile of patient to nurse and patient to social worker ratios at dialysis facilities. Main Outcomes and Measures: Fine-Gray models were used to relate the exposure to the incidence of waitlisting and kidney transplant, accounting for the competing risk of death. Subgroup analysis by age at dialysis initiation (<22 vs ≥22 years) was performed. Follow-up was censored in January 2020. Results: A total of 54 141 participants were included (median age, 25 years [IQR, 21-28]; 54.4% male; 4.3% of Asian race, 35.3% of non-Hispanic Black race). The median patient to staff ratios were 14.4 patients per nurse (IQR, 10.3-18.9) and 91.0 patients per social worker (IQR, 65.2-115.0). During a median follow-up of 2.6 years, 39.9% of patients (n = 21 598) received a transplant. In adjusted analysis, the highest (vs lowest) quartile of patient to nurse ratios was associated with 14% lower incidence of transplant (subhazard ratio [SHR], 0.86 [95% CI, 0.82-0.91]). The highest (vs lowest) quartile of patient to social worker ratios was associated with lower incidence of waitlisting (SHR, 0.95 [95% CI, 0.91-0.99]) and transplant (SHR, 0.85 [95% CI, 0.81-0.89]). For both staff ratios, there was an interaction with age at dialysis initiation, such that the association was more pronounced in patients starting dialysis at younger than 22 years (SHR, 0.71 [95% CI, 0.65-0.78] for the highest vs lowest quartile for nursing; SHR, 0.74 [95% CI, 0.68-0.80] for social work) compared with those 22 years and older (SHR, 1.00 [95% CI, 0.94-1.06] for nursing; SHR, 0.96 [95% CI, 0.91-1.02] for social work) for the outcome of transplant. Conclusions and Relevance: Adolescents and young adults receiving care at dialysis facilities with higher patient to staff ratios had reduced access to waitlisting and transplant, particularly if they were younger than 22 years of age at dialysis initiation. This cohort study aims to determine whether patient to nurse or patient to social worker staff ratios are associated with access to kidney transplant for adolescents and young adults. [ABSTRACT FROM AUTHOR]

Anadromous fishes rely on abundant prey in the ocean to grow large quickly, but prey limitation leads to interspecific competition. When species interactions are difficult to observe, growth can be studied to detect otherwise cryptic signals of competition. We describe a previously undocumented 2-year cycle in the lengths of adult natural-origin steelhead (Oncorhynchus mykiss) returning to spawn in the Snake River Basin. Returning steelhead were 38 mm shorter on odd return years, not accounting for sex, stock, and years of ocean residence. The well-known cycle in abundance of pink salmon (Oncorhynchus gorbuscha) from eastern Kamchatka and North America had statistically significant negative effects on returning steelhead lengths that depended on sex and the number of years of ocean residence. These results suggest that competition for limited resources occurs well after initial ocean entry and that interactions during later stages of ocean residence can be influential. Interspecific competition has implications for future returns of steelhead from the ocean, especially as metabolic demands for steelhead increase as the ocean warms. [ABSTRACT FROM AUTHOR]

Radiomics is an emerging technology for imaging biomarker discovery and disease-specific personalized treatment management. This paper aims to determine the benefit of using multi-modality radiomics data from PET and MR images in the characterization breast cancer phenotype and prognosis. Eighty-four features were extracted from PET and MR images of 113 breast cancer patients. Unsupervised clustering based on PET and MRI radiomic features created three subgroups. These derived subgroups were statistically significantly associated with tumor grade (p = 2.0 × 10-6), tumor overall stage (p = 0.037), breast cancer subtypes (p = 0.0085), and disease recurrence status (p = 0.0053). The PET-derived first-order statistics and gray level co-occurrence matrix (GLCM) textural features were discriminative of breast cancer tumor grade, which was confirmed by the results of L2-regularization logistic regression (with repeated nested cross-validation) with an estimated area under the receiver operating characteristic curve (AUC) of 0.76 (95% confidence interval (CI) = [0.62, 0.83]). The results of ElasticNet logistic regression indicated that PET and MR radiomics distinguished recurrence-free survival, with a mean AUC of 0.75 (95% CI = [0.62, 0.88]) and 0.68 (95% CI = [0.58, 0.81]) for 1 and 2 years, respectively. The MRI-derived GLCM inverse difference moment normalized (IDMN) and the PET-derived GLCM cluster prominence were among the key features in the predictive models for recurrence-free survival. In conclusion, radiomic features from PET and MR images could be helpful in deciphering breast cancer phenotypes and may have potential as imaging biomarkers for prediction of breast cancer recurrence-free survival.

Objective: We sought to evaluate the risk of preterm labor and hypertensive disorders in adolescent pregnancies with and without diabetes. Methods: We evaluated 1,843,139 adolescents (≤20 years old) with labor and delivery admissions in the national Kids' Inpatient Database (KID) in years 2006, 2009, 2012, 2016, and 2019. International classification of disease codes was used to identify diabetes and medical factors affecting pregnancy. Weighted logistic regression was used to evaluate the association between diabetes and complications. Results: Among admissions, 0.2% had type 1 diabetes (T1D), 0.2% had type 2 diabetes (T2D), and 0.7% had gestational diabetes (GDM); 10.1% of admissions were complicated by hypertensive disorders and 5.8% by preterm labor. Compared to adolescents without diabetes, those with diabetes had a higher prevalence of hypertensive disorders (T1D: 35.4%, T2D: 37.8%, GDM: 24.9%, None: 9.9%; p < 0.001) and preterm labor (T1D: 21.5%, T2D: 16.8%, GDM: 6.8%, none: 5.7%; p < 0.001). In adjusted models, odds of hypertensive disorders were higher in later study years (2019 vs. 2006 OR 1.85, 95% CI 1.77–1.94), among those with T1D (OR 4.32, 95% CI 3.94–4.74), with T2D (OR 4.18, 95% CI 3.79–4.61), and with GDM (OR 1.99, 95% CI 1.89–2.10). Adjusted odds of preterm labor were higher among those with T1D (OR 4.53, 95% CI 4.09–5.02), with T2D (OR 3.35, 95% CI 2.96–3.78), and with GDM (OR 1.18, 95% CI 1.08–1.28); disparities were seen by race/ethnicity, insurance, and income. Conclusions: Diabetes, which is increasing among adolescents, is a significant risk factor for preterm labor and hypertensive disorders. Though the absolute number of adolescent pregnancies is decreasing, rates of hypertensive disorders have increased. Appropriate interventions are needed to ensure healthy outcomes for adolescents who are pregnant. [ABSTRACT FROM AUTHOR]

Evaluation of goals is crucial for effective management to conserve viable and diverse fish populations and to support harvest. Management of wild Chinook Salmon Oncorhynchus tshawytscha in the Snake River basin exemplifies the struggle to meet fisheries goals. Considering contemporary production of juvenile emigrants, it is imperative to determine the survival from emigration to adult (Se‐a) required to meet abundance goals. Increased anthropogenic impact on spawning and rearing habitats leads to higher Se‐a required to attain goals. Wilderness populations exhibit viability and could sustain fisheries with Se‐a lower than required elsewhere. Conversely, populations targeted for habitat restoration demand higher Se‐a to fulfill goals, indicating a need to enhance egg‐to‐smolt survival. However, Se‐a has fallen below the threshold needed for replacement in all populations, even at current low abundances. Despite these challenges, most populations still possess the potential to achieve abundance goals, emphasizing the importance of strategic interventions to bolster their resilience. [ABSTRACT FROM AUTHOR]

The 'shifting baseline syndrome' (SBS) is the paradigm whereby recent species abundances and environmental conditions are accepted as reflecting historical conditions. This leads to false impressions of the past, inaccurate baselines, and unrealistic recovery goals. Idaho biologists have counted Chinook salmon redds for >60 consecutive years, generating an invaluable database; however, inaccurate historical baselines compromise the utility of even such high-quality, long-term databases. To develop an accurate baseline, we integrated archival (1951-1964), maximum redd counts with contemporary (1995-2017), continuous counts and spawn timing datasets to estimate historical (1950s-1960s) wild Chinook salmon production potential. Current salmon populations average 3% of 1950s-1960s abundances, which may have been 30% of precommercial fishery (1880s) populations. Notably, the SBS has influenced contemporary managers as reflected in minimum viable abundance, sustainable escapement, and adequate seeding objectives equaling 10.4%, 17.9%, and 20.4%, respectively, of 1950s-1960s potential. Our approach provides a framework for utilizing archival and contemporary data to reconstruct historical baselines and repress SBS. Contrasting contemporary goals with maximum production potential provides new reference points and perspectives for managers to consider. Le <> (SRC) est un paradigme selon lequel il est accepte que les abondances d'especes et conditions ambiantes recentes refletent les conditions passees. II mene a des impressions erronees du passe, des etats de reference inexacts et des objectifs de retablissement irrealistes. Des biologistes en Idaho ont compte les nids de frai de saumons chinooks pendant plus de 60 annees consecutives, produisant une base de donnees d'une valeur inestimable. Des etats de reference passes inexacts compromettent toutefois l'utilite de bases de donnees de longue duree, meme de cette qualite. Afin d'etablir un etat de reference exact, nous avons integre les nombres maximums de nids de frai passes (1951-1964) aux resultats de denombrements continus recents (1995-2017) et a des ensembles de donnees sur le moment du frai afin d'estimer le potentiel de production passe (annees 1950 et 1960) de saumons chinooks sauvages. Les populations de saumons actuelles representent en moyenne 3 % des abondances des annees 1950 et 1960, qui representaient possiblement 30 % des populations avant le debut de la peche commerciale (annees 1880). Fait a noter, le SRC a influence les gestionnaires actuels, comme en font foi les objectifs d'abondance viable minimum, d'echappement durable et d'ensemencement adequat qui correspondent a 10,4 %, 17,9 % et 20,4 %, respectivement, du potentiel des annees 1950 et 1960. Notre approche fournit un cadre d'utilisation des donnees d'archive et recentes pour reconstituer les etats de reference passes et restreindre le SRC. La comparaison des objectifs actuels et du potentiel de production maximum fournit de nouveaux points de reference et de nouvelles perspectives que les gestionnaires devraient prendre en consideration. [Traduit par la Redaction], Introduction Long-term datasets represent a baseline against which one may examine current population status (Claro et al. 2009). Additional information is required, however, to accurately reflect historical potential. Pauly (1995) [...]

Snorkel surveys are widely used for monitoring fish populations because they are a versatile and cost-effective technique. However, snorkel surveys provide instantaneous measurements that might not describe continuous processes, such as the emigration of juvenile anadromous salmonids. A model capable of assessing the level of potential production of emigrating juvenile steelhead (anadromous Oncorhynchus mykiss) from watersheds in Idaho on the basis of snorkel surveys would be useful. Our objective was to determine the relationship between abundance of emigrants estimated from rotary screw traps (RSTs) and parr densities from snorkel surveys. We analyzed over 1,000 snorkel surveys and 70 year-watershed combinations of emigrant estimates. Density was positively related to emigrant abundance. The most reasonable model included a common slope among watersheds, a common year effect, and varying intercepts, supporting a hypothesis that some watersheds produce more emigrating juveniles at similar observed densities. This model explained 82.7% of the variation observed in emigrant abundance. Uncertainty was greater among watersheds than within a watershed. The model can be used to translate mean densities observed in snorkel surveys to abundance of steelhead emigrants and thus to infer the effects of a habitat restoration program or other management actions. This work is important as a step toward understanding juvenile emigrant abundance in watersheds without RSTs and to aid understanding of steelhead emigrant productivity in Idaho watersheds. [ABSTRACT FROM AUTHOR]

Objective: The potential influence (i.e., impact rate) of catch‐and‐release fisheries on wild steelhead Oncorhynchus mykiss is poorly understood and is a function of the abundance of wild fish, how many fish are encountered by anglers (i.e., encounter rate), and the mortality of fish that are caught and released. In Idaho, estimates of wild steelhead encounter rates have been derived using the number of wild and hatchery steelhead passing Lower Granite Dam, the number of hatchery steelhead harvested, and the number of hatchery steelhead caught and released. The method includes assumptions that hatchery and wild steelhead have equal encounter rates and catch‐and‐release mortality is 5% for wild steelhead. Here, we investigated wild and hatchery steelhead encounter rates by anglers, estimated catch‐and‐release mortality, and concatenated both aspects to examine how existing recreational steelhead fisheries influence wild steelhead mortality. Methods: We sampled, tagged, and released 1,251 spawn‐year 2020 (SY2020) and 1,956 spawn‐year 2021 (SY2021) adult steelhead at Lower Granite Dam with T‐bar anchor tags and passive integrated transponder (PIT) tags to estimate steelhead encounter rates and catch‐and‐release mortality. Differences in survival of caught steelhead and those not reported as caught were evaluated using detections at various locations (e.g., PIT arrays, weirs). Result: Estimated encounter rates were 43.7% (95% credible interval; 28.2%, 100.0%) for wild fish and 46.7% (29.6%, 100.0%) for adipose‐clipped fish in SY2020. In SY2021, encounter rates were 47.2% (32.4%, 100.0%) for wild fish and 52.3% (37.1%, 100.0%) for adipose‐clipped fish. Based on detections of caught fish and those not reported as caught, catch‐and‐release mortality of wild steelhead was estimated to be 1.6% (0.0%, 5.2%). Wild steelhead impact rates were 0.7% (0.0%, 2.7%) in SY2020 and 0.7% (0.0%, 2.8%) in SY2021. Conclusion: Estimated rates of impact on wild steelhead were consistent and low across years despite major differences in the structure of the fisheries. Our results suggest assuming that encounter rates are equal between hatchery and wild steelhead, and that steelhead catch‐and‐release mortality is 5%, will likely lead to a conservative estimate of the wild steelhead impact occurring from catch‐and‐release fisheries. Impact statementWith wild steelhead numbers declining in many parts of North America, a dilemma between providing angling opportunity and wild steelhead conservation can develop. We show that encounter rate plays a larger role than mortality regarding catch‐and‐release angling on overall impact rates. Our method provides a direct, reliable estimate of encounter rates across multiple scales. [ABSTRACT FROM AUTHOR]