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BACKGROUND: A cost-effectiveness model that accurately represents disease progression, outcomes, and associated costs is necessary to evaluate the cost-effectiveness of interventions for chronic kidney disease (CKD). STUDY DESIGN: We developed a microsimulation model of the incidence, progression, and treatment of CKD. The model was validated by comparing its predictions with survey and epidemiologic data sources. SETTING & POPULATION: US patients. MODEL, PERSPECTIVE, & TIMEFRAME: The model follows up disease progression in a cohort of simulated patients aged 30 until age 90 years or death. The model consists of 7 mutually exclusive states representing no CKD, 5 stages of CKD, and death. Progression through the stages is governed by a person's glomerular filtration rate and albuminuria status. Diabetes, hypertension, and other risk factors influence CKD and the development of CKD complications in the model. Costs are evaluated from the health care system perspective. INTERVENTION: Usual care, including incidental screening for persons with diabetes or hypertension. OUTCOMES: Progression to CKD stages, complications, and mortality. RESULTS: The model provides reasonably accurate estimates of CKD prevalence by stage. The model predicts that 47.1% of 30-year-olds will develop CKD during their lifetime, with 1.7%, 6.9%, 27.3%, 6.9%, and 4.4% ending at stages 1-5, respectively. Approximately 11% of persons who reach stage 3 will eventually progress to stage 5. The model also predicts that 3.7% of persons will develop end-stage renal disease compared with an estimate of 3.0% based on current end-stage renal disease lifetime incidence. LIMITATIONS: The model synthesizes data from multiple sources rather than a single source and relies on explicit assumptions about progression. The model does not include acute kidney failure. CONCLUSION: The model is well validated and can be used to evaluate the cost-effectiveness of CKD interventions. The model also can be updated as better data for CKD progression become available. [ABSTRACT FROM AUTHOR]

STUDY OBJECTIVE: Beta-blocker use is associated with coronary artery spasm after cocaine administration but also decreases mortality in patients with myocardial infarction or systolic dysfunction. We conduct a retrospective cohort study to analyze the safety of beta-blockers in patients with positive urine toxicology results for cocaine. METHODS: The cohort consisted of 363 consecutive telemetry and ICU patients who were admitted to a municipal hospital and had positive urine toxicology results for cocaine during a 5-year period (307 patients). Fifteen patients with uncertain history of beta-blocker use before admission were excluded. The primary outcome measure was myocardial infarction; secondary outcome measure was inhospital mortality. Logistic regression analysis using generalized estimating equations models and propensity scores compared outcomes. RESULTS: Beta-blockers were given in 60 of 348 admissions. The incidence of myocardial infarction after administration of beta-blocker was significantly lower than without treatment (6.1% versus 26.0%; difference in proportion 19.9%; 95% confidence interval [CI] 10.3% to 30.0%). One of 14 deaths occurred in patients who received beta-blockade (incidence 1.7% versus 4.5% without beta-blockade; difference in proportion 2.8%; 95% CI -1.2% to 6.7%). Multivariate analysis showed that use of beta-blockers significantly reduced the risk of myocardial infarction (odds ratio 0.06; 95% CI 0.01 to 0.61). CONCLUSION: In our cohort, administration of beta-blockers was associated with reduction in incidence of myocardial infarction after cocaine use. The benefit of beta-blockers on myocardial function may offset the risk of coronary artery spasm. [ABSTRACT FROM AUTHOR]

Objective: The objective of the study was to evaluate whether lactation duration is associated with lower prevalence of metabolic syndrome (MetSyn) in midlife, parous women.Study Design: This was a cross-sectional cohort analysis of 2516 parous, midlife women using multivariable logistic regression to determine the independent association of lactation and lactation duration on prevalence of MetSyn.Results: One thousand six hundred twenty women (64.4%) reported a history of breast-feeding, with average lifetime duration of lactation of 1.16 (+/- 1.04) years. MetSyn was present in 536 women (21.3%). Adjusting for age, smoking history, parity, ethnicity, socioeconomic status, study site, physical activity, caloric intake, and high school body mass index, women with prior lactation had significantly lower odds of MetSyn (odds ratio [OR] 0.79, 95% confidence interval [CI] 0.63 to 0.99). Furthermore, increasing duration of lactation was similarly associated with lower odds of MetSyn (OR 0.88, 95% CI 0.77 to 0.99).Conclusion: Duration of lactation is associated with lower prevalence of MetSyn in a dose-response manner in midlife, parous women. [ABSTRACT FROM AUTHOR]

Background: Lower extremity amputation is common among patients with ESRD, and often portends a poor prognosis. However, little is known about end-of-life care among patients with ESRD who undergo amputation., Methods: We conducted a mortality follow-back study of Medicare beneficiaries with ESRD who died in 2002 through 2014 to analyze patterns of lower extremity amputation in the last year of life compared with a parallel cohort of beneficiaries without ESRD. We also examined the relationship between amputation and end-of-life care among the patients with ESRD., Results: Overall, 8% of 754,777 beneficiaries with ESRD underwent at least one lower extremity amputation in their last year of life compared with 1% of 958,412 beneficiaries without ESRD. Adjusted analyses of patients with ESRD showed that those who had undergone lower extremity amputation were substantially more likely than those who had not to have been admitted to-and to have had prolonged stays in-acute and subacute care settings during their final year of life. Amputation was also associated with a greater likelihood of dying in the hospital, dialysis discontinuation before death, and less time receiving hospice services., Conclusions: Nearly one in ten patients with ESRD undergoes lower extremity amputation in their last year of life. These patients have prolonged stays in acute and subacute health care settings and appear to have limited access to hospice services. These findings likely signal unmet palliative care needs among seriously ill patients with ESRD who undergo amputation as well as opportunities to improve their care., (Copyright © 2019 by the American Society of Nephrology.)

Importance: Patients with end-stage renal disease are less likely to use hospice services than other patients with advanced chronic illness. Little is known about the timing of hospice referral in this population and its association with health care utilization and costs., Objective: To examine the association between hospice length of stay and health care utilization and costs at the end of life among Medicare beneficiaries who had received maintenance hemodialysis., Design, Setting, and Participants: This cross-sectional observational study was conducted via the United States Renal Data System registry. Participants were all 770 191 hemodialysis patients in the registry who were enrolled in fee-for-service Medicare and died between January 1, 2000, and December 31, 2014. The dates of analysis were April 2016 to December 2017., Main Outcomes and Measures: Hospital admission, intensive care unit (ICU) admission, and receipt of an intensive procedure during the last month of life; death in the hospital; and costs to the Medicare program in the last week of life., Results: Among 770 191 patients, the mean (SD) age was 74.8 (11.0) years, and 53.7% were male. Twenty percent of cohort members were receiving hospice services when they died. Of these, 41.5% received hospice for 3 days or fewer. In adjusted analyses, compared with patients who did not receive hospice, those enrolled in hospice for 3 days or fewer were less likely to die in the hospital (13.5% vs 55.1%; P < .001) or to undergo an intensive procedure in the last month of life (17.7% vs 31.6%; P < .001) but had higher rates of hospitalization (83.6% vs 74.4%; P < .001) and ICU admission (54.0% vs 51.0%; P < .001) and similar Medicare costs in the last week of life ($10 756 vs $10 871; P = .08). Longer lengths of stay in hospice beyond 3 days were associated with progressively lower rates of utilization and costs, especially for those referred more than 15 days before death (35.1% hospitalized and 16.7% admitted to an ICU in the last month of life; the mean Medicare costs in the last week of life were $3221)., Conclusions and Relevance: Overall, 41.5% of hospice enrollees who had been treated with hemodialysis for their end-stage renal disease entered hospice within 3 days of death. Although less likely to die in the hospital and to receive an intensive procedure, these patients were more likely than those not enrolled in hospice to be hospitalized and admitted to the ICU, and they had similar Medicare costs. Without addressing barriers to more timely referral, greater use of hospice may not translate into meaningful changes in patterns of health care utilization, costs, and quality of care at the end of life in this population.

Infrequent and late referral to hospice among patients on dialysis likely reflects the impact of a Medicare payment policy that discourages the concurrent receipt of these services, but it may also reflect these patients' less predictable illness trajectories. Among a national cohort of patients on hemodialysis, we identified four distinct spending trajectories during the last year of life that represented markedly different intensities of care. Within the cohort, 9 percent had escalating spending and 13 percent had persistently high spending throughout the last year of life, while 41 percent had relatively low spending with late escalation, and 37 percent had moderate spending with late escalation. Across the four groups, the percentages of patients enrolled in hospice at the time of death were uniformly low ranging from only 19 percent of those with persistently high costs to 21 percent of those with moderate costs and the median number of days spent in hospice during the last year of life was virtually the same (either five or six days). These findings signal the need for greater flexibility in the provision of end-of-life care in this population.

Importance: Left ventricular assist devices (LVADs) are widely used both as a bridge to heart transplant and as destination therapy in advanced heart failure. Although heart failure is common in patients with end-stage renal disease (ESRD), little is known about outcomes after LVAD implantation in this population., Objective: To determine the utilization of and outcomes associated with LVADs in nationally representative cohorts of patients with and without ESRD., Design, Setting and Participants: We described LVAD utilization and outcomes among Medicare beneficiaries after ESRD onset (defined as having received maintenance dialysis or a kidney transplant) from 2003 to 2013 based on Medicare claims linked to data from the United States Renal Data System (USRDS), a national registry for ESRD. We compared Medicare beneficiaries with ESRD to a 5% sample of Medicare beneficiaries without ESRD., Exposures: ESRD (vs no ESRD) among patients who underwent LVAD placement., Main Outcomes and Measures: The primary outcome was survival after LVAD placement., Results: Among the patients with ESRD, the mean age was 58.4 (12.1) years and 62.0% (96) were male. Among those without ESRD, the mean age was 62.2 (12.6) years and 75.1% (196) were male. From 2003 to 2013, 155 Medicare beneficiaries with ESRD (median and interquartile range [IQR] days from ESRD onset to LVAD placement were 1655 days [453-3050 days]) and 261 beneficiaries without ESRD in the Medicare 5% sample received an LVAD. During a median follow-up of 762 days (IQR, 92-3850 days), 127 patients (81.9%) with and 95 (36.4%) without ESRD died. more than half of patients with ESRD (80 [51.6%]) compared with 11 (4%) of those without ESRD died during the index hospitalization. The median time to death was 16 days (IQR 2-447 days) for patients with ESRD compared with 2125 days (IQR, 565-3850 days) for those without ESRD. With adjustment for demographics, comorbidity and time period, patients with ESRD had a markedly increased adjusted risk of death (hazard ratio, 36.3; 95% CI, 15.6-84.5), especially in the first 60 days after LVAD placement., Conclusions and Relevance: Patients with ESRD at the time of LVAD placement had an extremely poor prognosis, with most surviving for less than 3 weeks. This information may be crucial in supporting shared decision-making around treatments for advanced heart failure for patients with ESRD.

Background: Many dialysis patients receive intensive procedures intended to prolong life at the very end of life. However, little is known about trends over time in the use of these procedures. We describe temporal trends in receipt of inpatient intensive procedures during the last 6 months of life among patients treated with maintenance dialysis., Study Design: Mortality follow-back study., Setting & Participants: 649,607 adult Medicare beneficiaries on maintenance dialysis therapy who died in 2000 to 2012., Predictors: Period of death (2000-2003, 2004-2008, or 2009-2012), age at time of death (18-59, 60-64, 65-69, 70-74, 75-79, 80-84, and ≥85 years), and race/ethnicity (Hispanic, non-Hispanic black, or non-Hispanic white)., Outcome: Receipt of an inpatient intensive procedure (defined as invasive mechanical ventilation/intubation, tracheostomy, gastrostomy/jejunostomy tube insertion, enteral or parenteral nutrition, or cardiopulmonary resuscitation) during the last 6 months of life., Results: Overall, 34% of cohort patients received an intensive procedure in the last 6 months of life, increasing from 29% in 2000 to 36% in 2012 (with 2000-2003 as the referent category; adjusted risk ratios [RRs] were 1.06 [95% CI, 1.05-1.07] and 1.10 [95% CI, 1.09-1.12] for 2004-2008 and 2009-2012, respectively). Use of intensive procedures increased more markedly over time in younger versus older patients (comparing 2009-2012 to 2000-2003, adjusted RR was 1.18 [95% CI, 1.15-1.20] for the youngest age group as opposed to 1.00 [95% CI, 0.96-1.04] for the oldest group). Comparing 2009 to 2012 to 2000 to 2003, the use of intensive procedures increased more dramatically for Hispanic patients than for non-Hispanic black or non-Hispanic white patients (adjusted RRs of 1.18 [95% CI, 1.14-1.22], 1.09 [95% CI, 1.07-1.11], and 1.10 [95% CI, 1.08-1.12], respectively)., Limitations: Data sources do not provide insight into reasons for observed trends in the use of intensive procedures., Conclusions: Among patients treated with maintenance dialysis, there is a trend toward more frequent use of intensive procedures at the end of life, especially in younger patients and those of Hispanic ethnicity., (Copyright © 2016 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Approximately 20% of children with sickle cell disease (SCD) have microalbuminuria (MA). Very little is known about the progression of MA in children and young adults with SCD., Methods: In this study, we analyzed 5-year EMR data of 373 children [with ≥2 microalbumin-to-creatinine (MA/Cr) ratio measurements] followed at the Medical University of South Carolina to determine the rate, direction, magnitude, and predictors of MA/Cr change over time., Results: Age range was 1-22 years; mean 10.2 ± 5.2 years, 49.5% were males. Median follow-up duration was 3.12 ± 1.16 years. At baseline, 328 children had normal (<20 mg/L) MA level. Forty-five (12.1%) of children had MA (≥20 mg/L), of which 91% were ≥8 years and 21 (47%) continued to have MA at the end of the study period. On the other hand, during the study period, 24 new patients developed MA and 24 normalized their MA to levels <20 mg/L. In multivariate logistic regression model, age and bilirubin levels were predictive of MA/Cr increase in patients who received at least one blood transfusion during the study period. Baseline MA level was not predictive of the change in MA/Cr., Conclusion: In children and young adults, microalbuminuria is considered a marker of early renal injury. Over time, MA/Cr levels may increase or decrease. Further studies are needed to confirm our findings, assess the reliability of MA as marker of long-term renal injury, and identify high risk patients with SCD likely to have worsening of MA over time.

It is estimated that 2-3% of children in the US have hypertension (HTN) and 8% of children ages 4-17 carry the diagnosis of attention-deficit hyperactivity disorder (ADHD). The prevalence of HTN and cardiovascular (CV) risk factors in children with ADHD on CNS stimulant treatment (stimulants) compared to no treatment and compared to their healthy counterparts is not well described. Using National Health and Nutrition Survey data, we examined demographic, blood pressure (BP) and CV risk factors of 4,907 children aged 12-18 years with and without the diagnosis of ADHD, and further examined the CV risk in a subgroup of ADHD patients on stimulants. Three hundred eighty-three (10.7%) children were reported to have ADHD, of whom 111 (3.4%) were on stimulants. Children with ADHD on stimulants were significantly younger, male, and white compared to those with ADHD not on medication and those without ADHD. Body mass index (BMI), eGFR, cholesterol, the prevalence of albuminuria, and poverty were not significantly different between the three groups. One hundred sixty (2.7%) had BP in the hypertensive and 637 (12.4%) in the pre-hypertensive range. The prevalence of elevated BP (HTN and/or pre-HTN range) was not different between children with ADHD on stimulants compared to ADHD without medication and those without ADHD. Heart rate (HR) was significantly higher in the ADHD group on stimulants vs. the groups ADHD on no stimulants and without ADHD. When the relationship between stimulants and the risk of abnormal BP was examined, there was a significant interaction between having BP in the HTN range and sex. After adjusting for BMI, race, and age, females with ADHD on stimulants tended to be older and had significantly more BP in the hypertensive range. On the other hand, males were more likely to be of a white race and older, but not hypertensive. Children with ADHD on stimulants have significantly higher HR than children with ADHD on no stimulants and children without ADHD. On the other hand, the prevalence of abnormal BP classification is comparable between the three groups.

Background: Intravenous (IV) hydralazine is frequently used for the treatment of elevated blood pressure (BP) in hospitalized children. Its safety and efficacy have not been examined., Methods: This is a retrospective chart review of IV hydralazine use in hospitalized children (birth to 17 years) over a 3-year period. Demographic data and data on adverse effects (AE), BP, and heart rate (HR) prior to and after each first dose were collected., Results: The patient cohort comprised 110 children admitted to the hospital during the study period, of whom 77 received the recommended dose. Mean age of the children was 8.5 ± 5.4 years; 33 % were male, and 32.5 % were white. Pre-dose systolic and diastolic BP indexes were 1.3 and 1.2, respectively. The median reduction in systolic and diastolic BP was 8.5 and 11.5 %, respectively. Sixteen (21 %) children achieved a 25 % reduction in systolic or diastolic BP, and BP increased in 30 % of patients; 10 % of children had a BP of <95th percentile for age, sex, and height after one dose. Seven (9 %) children had a documented AE. HR increased by a median of 3.5 %. In the multivariable models examining percentage change in systolic and diastolic BP, male gender was significantly associated with a change in systolic BP., Conclusions: In hospitalized children, IV hydralazine was well tolerated, BP response was variable, and 21 % of the patients achieved a ≥25 % reduction of systolic or diastolic BP. Further studies are needed to compare the safety and efficacy of IV hydralazine to other short-acting antihypertensive agents.

The common assumption is that blood pressure (BP) will decrease on subsequent readings. The objective of this study is to examine the prevalence and direction of BP classification change with repeat measurements and compare common clinical characteristics of groups of patients who do and do not have a change in BP classification. A nationally representative subsample of 1725 adolescents aged 13 to 18 years from the National Health and Nutrition Survey were analyzed. Three BP measurements were obtained. Patients were classified based on the first and the average of 3 BP measurements as having normal BP, hypertension, and/or prehypertension. Of the 1725 adolescents, 1569 (90.9%) maintained BP classification, 107 (6.2%) had a reduction in their classification, and 49 (2.9%) had an increase in their classification. Comparing the two groups that changed BP classification to the group without change, C-reactive protein and body mass index (BMI) z score were significantly higher in the groups that had a change in BP classification (P=.02 and <.001, respectively). After adjusting for other variables, higher BMI value was significantly associated with change in BP classification. With repeat measurements, the majority (~91%) did not have a change in classification. Obesity was a significant predictor of the 9% that had a change in classification. Repeat BP measurements in obese adolescents may lead to more accurate classification of BP status., (©2013 Wiley Periodicals, Inc.)

Background: Despite being associated with multiple disease processes and cardiovascular outcomes, uric acid (UA) reference ranges for adolescents are lacking. We sought to describe the distribution of UA and its relationship to demographic, clinical, socioeconomic, and dietary factors among U.S. adolescents., Methods: A nationally representative subsample of 1,912 adolescents aged 13-18 years in NHANES 2005-2008 representing 19,888,299 adolescents was used for this study. Percentiles of the distribution of UA were estimated using quantile regression. Linear regression models examined the association of UA and demographic, socioeconomic, and dietary factors., Results: Mean UA level was 5.14 ± 1.45 mg/dl. Mean UA increased with increasing age and was higher in non-Hispanic white race, male sex, higher body mass index (BMI) Z-score, and with higher systolic blood pressure. In fully adjusted linear regression models, sex, age, race, and BMI were independent determinants of higher UA., Conclusions: This study defines serum UA reference ranges for adolescents. Also, it reveals some intriguing relationships between UA and demographic and clinical characteristics that warrant further studies to examine the pathophysiological role of UA in different disease processes.

Objective: To evaluate whether ethnicity is associated with involuntary childlessness and perceived reasons for difficulties in becoming pregnant., Design: Cross-sectional analysis of baseline data from a longitudinal cohort., Setting: Multiethnic, community-based observational study of US women., Patient(s): Women in midlife (3,149), aged 42-52 years., Intervention(s): None., Main Outcome Measure(s): Involuntary childlessness and perceived etiology of infertility., Result(s): One hundred thirty-three subjects (4.2%) were involuntarily childless, defined by a reported history of infertility and nulliparity. Ethnicity was significantly associated with self-reported involuntary childlessness. After controlling for economic and other risk factors, African American (odds ratio [OR] 0.30; 95% confidence interval [CI] 0.15-0.59) and Chinese women (OR 0.36; 95% CI 0.14-0.90) were less likely to suffer from involuntary childlessness compared with non-Hispanic white women. In addition, 302 subjects reported a perceived etiology of infertility. An unexpectedly large proportion of these women (24.5%, 74 of 302) reported etiologies not known to cause infertility (i.e., tipped uterus, ligaments for tubes were stretched), with African American women having been most likely to report these etiologies (OR 2.81; 95% CI 1.26-6.28) as the reason for not becoming pregnant., Conclusion(s): Ethnicity is significantly associated with involuntary childlessness and perceived etiology of infertility. Misattribution of causes of infertility is common and merits further consideration with respect to language or cultural barriers, as well as possible physician misattribution., (Copyright © 2011 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Context: An increasing number of older adults are being treated for end-stage renal disease (ESRD) with long-term dialysis., Objectives: To determine how ESRD treatment practices for older adults vary across regions with differing end-of-life intensity of care., Design, Setting, and Participants: Retrospective observational study using a national ESRD registry to identify a cohort of 41,420 adults (of white or black race), aged 65 years or older, who started long-term dialysis or received a kidney transplant between June 1, 2005, and May 31, 2006. Regional end-of-life intensity of care was defined using an index from the Dartmouth Atlas of Healthcare., Main Outcome Measures: Incidence of treated ESRD (dialysis or transplant), preparedness for ESRD (under the care of a nephrologist, having a fistula [vs graft or catheter] at time of hemodialysis initiation), and end-of-life care practices., Results: Among whites, the incidence of ESRD was progressively higher in regions with greater intensity of care and this trend was most pronounced at older ages. Among blacks, a similar relationship was present only at advanced ages (men aged > or = 80 years and women aged > or = 85 years). Patients living in regions in the highest compared with lowest quintile of end-of-life intensity of care were less likely to be under the care of a nephrologist before the onset of ESRD (62.3% [95% confidence interval {CI}, 61.3%-63.3%] vs 71.1% [95% CI, 69.9%-72.2%], respectively) and less likely to have a fistula (vs graft or catheter) at the time of hemodialysis initiation (11.2% [95% CI, 10.6%-11.8%] vs 16.9% [95% CI, 15.9%-17.8%]). Among patients who died within 2 years of ESRD onset (n = 21,190), those living in regions in the highest compared with lowest quintile of end-of-life intensity of care were less likely to have discontinued dialysis before death (22.2% [95% CI, 21.1%-23.4%] vs 44.3% [95% CI, 42.5%-46.1%], respectively), less likely to have received hospice care (20.7% [95% CI, 19.5%-21.9%] vs 33.5% [95% CI, 31.7%-35.4%]), and more likely to have died in the hospital (67.8% [95% CI, 66.5%-69.1%] vs 50.3% [95% CI, 48.5%-52.1%]). These differences persisted in adjusted analyses., Conclusion: There are pronounced regional differences in treatment practices for ESRD in older adults that are not explained by differences in patient characteristics.

Background: Albuminuria is associated with an increased risk of death independent of level of renal function. Whether this association is similar for adults of all ages is not known., Methods: We examined the association between the albumin to creatinine ratio (ACR) and all-cause mortality after stratification by estimated glomerular filtration rate (eGFR) and age group in 94 934 veterans with diabetes mellitus. Cohort members had at least 1 ACR recorded in the Veterans Affairs Health Care System between October 1, 2002, and September 30, 2003, and were followed up for death through October 15, 2009., Results: From the youngest to the oldest age group, the prevalence of an eGFR less than 60 mL/min/1.73 m(2) ranged from 11% to 41%; microalbuminuria (ACR 30-299 mg/g) ranged from 19% to 28%; and macroalbuminuria (ACR > or =300 mg/g) ranged from 3.2% to 3.7%. Of patients with an eGFR less than 60 mL/min/1.73 m(2), 72% of those younger than 65 years, 74% of those 65 to 74 years old, and 59% of those 75 years and older had an eGFR of 45 to 59 mL/min/1.73 m(2). In all age groups, less than 35% of these patients had albuminuria (ie, ACR > or =30 mg/g). In patients 75 years and older, the ACR was independently associated with an increased risk of death at all levels of eGFR after adjusting for potential confounders. In younger age groups, this association was present at higher levels of eGFR but seemed to be attenuated at lower levels [corrected]., Conclusion: The ACR is independently associated with mortality at all levels of eGFR in older adults with diabetes and may be particularly helpful for risk stratification in the large group with moderate reductions in eGFR.

Objective: To evaluate whether adolescent obesity is associated with difficulties in becoming pregnant later in life., Design: Cross-sectional analysis of baseline data from a longitudinal cohort., Setting: Multiethnic, community-based observational study of U.S. women., Patient(s): Three thousand one hundred fifty-four midlife women., Main Outcome Measure(s): Lifetime nulliparity and lifetime nulligravidity., Result(s): Five hundred twenty-seven women (16.7%) women had never delivered a baby. Participants were categorized by self-reported high school body mass index (BMI): underweight (<18.5 kg/m(2)), normal (18.5-24.9 kg/m(2)), overweight (25-29.9 kg/m(2)), and obese (>30 kg/m(2)). The prevalence of lifetime nulliparity increased progressively across the high school BMI categories: 12.7%, 16.7%, 19.2%, and 30.9%, respectively. Multivariable logistic regression analysis confirmed that women who were obese adolescents had significantly higher odds of remaining childless compared with normal weight women (odds ratio [OR] 2.84; 95% confidence interval [CI], 1.59-5.10) after adjusting for adult BMI, history of nongestational amenorrhea, marital status, ethnicity, study site, and measures of socioeconomic status. Furthermore, adolescent obesity was associated with lifetime nulligravidity (OR = 3.93; 95% CI, 2.12-7.26)., Conclusion(s): Adolescent obesity is associated with lifetime nulliparity and nulligravidity in midlife U.S. women., (Copyright 2010 American Society for Reproductive Medicine. All rights reserved.)

Context: Bronx, New York, an urban county with a large low-income, immigrant and minority population, has a prevalence of diabetes that is among the highest in the United States., Objective: The aim of the study was to evaluate the utility of hemoglobin A1c (HbA1c) in identifying patients at risk for diabetes on an in-patient medical service of a hospital serving a high prevalence community., Design and Setting: We conducted a prospective cohort study at an urban public hospital., Patients: The study included 971 patients (1132 admissions) admitted to the general medicine service over 4 months., Main Outcome Measures: HbA1c was measured on all patients. Records were checked for prior diagnosis of diabetes and other clinical data. Follow-up data were obtained for those with repeat HbA1c testing or glucose within 1 yr after admission., Results: We found that 35.2% of the patients (n = 342) had an established diagnosis of diabetes. The remaining 629 patients defined the study cohort of patients without known diabetes. Mean HbA1c was 6.05 +/- 0.87%. A total of 152 patients (24%) had admission HbA1c of at least 6.5% and 62 (9.9%) had HbA1c of at least 7.0%. Fifty-five patients with HbA1c of at least 6.5% had follow-up HbA1c within 1 yr. Of those, 44 (80.0%) met the criteria for diabetes as proposed by The International Expert Committee using repeated HbA1c testing., Conclusion: In communities with high prevalence of diabetes, a large percentage of patients without a diagnosis of diabetes who are admitted as in-patients have HbA1c of at least 6.5% and 7.0%. Hospital-based HbA1c testing might identify patients for whom further testing is indicated to make the diagnosis of diabetes.

Background: Microalbuminuria screening may detect chronic kidney disease in its early stages, allowing for treatment that delays or prevents disease progression. The cost-effectiveness of microalbuminuria screening has not been determined., Study Design: A cost-effectiveness model simulating disease progression and costs., Setting & Population: US patients. MODEL, PERSPECTIVE, AND TIMEFRAME: The microsimulation model follows up disease progression and costs in a cohort of simulated patients from age 50 to 90 years or death. Costs are evaluated from the health care system perspective., Intervention: Microalbuminuria screening at 1-, 2-, 5-, or 10-year intervals followed by treatment with angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers. We considered universal screening, as well as screening targeted at persons with diabetes, persons with hypertension but no diabetes, and persons with neither diabetes nor hypertension., Outcomes: Costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios., Results: For the full model population, universal screening increases costs and increases QALYs. Universal annual screening starting at age 50 years has a cost-effectiveness ratio of $73,000/QALY relative to no screening and $145,000/QALY relative to usual care. Cost-effectiveness ratios improved with longer screening intervals. Relative to no screening, targeted annual screening has cost-effectiveness ratios of $21,000/QALY, $55,000/QALY, and $155,000/QALY for persons with diabetes, those with hypertension, and those with neither current diabetes nor current hypertension, respectively., Limitations: Results necessarily are based on a microsimulation model because of the long time horizon appropriate for chronic kidney disease. The model includes only health care costs., Conclusions: Microalbuminuria screening is cost-effective for patients with diabetes or hypertension, but is not cost-effective for patients with neither diabetes nor hypertension unless screening is conducted at longer intervals or as part of existing physician visits., (Copyright 2010 National Kidney Foundation, Inc. All rights reserved.)

Whether persistent human papillomavirus (HPV) IgG antibodies following natural infection are protective against subsequent infection is unknown. In a cohort of 508 college women followed for 3 y, persistent seropositivity was defined as the presence of type-specific HPV virus-like particle (VLP) antibodies at > or = 2 consecutive visits 1 y apart. Protection from incident infection with any HPV was conferred by persistent antibodies to HPV16 (p = 0.02), HPV31 (p < 0.001), HPV33 (p = 0.03), HPV35 (p = 0.002), HPV52 (p = 0.007), HPV45 (p = 0.003), and HPV53 (p = 0.01). The risk of incident infection with species-specific HPV types was also decreased in women with persistent antibodies to any HPV type in that group, suggesting that exposure to HPV with persistent development of antibody response can be protective, and may explain the decreased efficacy of HPV vaccine in women with prior exposure.

Objectives: To determine the prevalence of 25-hydroxyvitamin D (25[OH]D) deficiency and associations between 25(OH)D deficiency and cardiovascular risk factors in children and adolescents., Methods: With a nationally representative sample of children aged 1 to 21 years in the National Health and Nutrition Examination Survey 2001-2004 (n = 6275), we measured serum 25(OH)D deficiency and insufficiency (25[OH]D <15 ng/mL and 15-29 ng/mL, respectively) and cardiovascular risk factors., Results: Overall, 9% of the pediatric population, representing 7.6 million US children and adolescents, were 25(OH)D deficient and 61%, representing 50.8 million US children and adolescents, were 25(OH)D insufficient. Only 4% had taken 400 IU of vitamin D per day for the past 30 days. After multivariable adjustment, those who were older (odds ratio [OR]: 1.16 [95% confidence interval (CI): 1.12 to 1.20] per year of age), girls (OR: 1.9 [1.6 to 2.4]), non-Hispanic black (OR: 21.9 [13.4 to 35.7]) or Mexican-American (OR: 3.5 [1.9 to 6.4]) compared with non-Hispanic white, obese (OR: 1.9 [1.5 to 2.5]), and those who drank milk less than once a week (OR: 2.9 [2.1 to 3.9]) or used >4 hours of television, video, or computers per day (OR: 1.6 [1.1 to 2.3]) were more likely to be 25(OH)D deficient. Those who used vitamin D supplementation were less likely (OR: 0.4 [0.2 to 0.8]) to be 25(OH)D deficient. Also, after multivariable adjustment, 25(OH)D deficiency was associated with elevated parathyroid hormone levels (OR: 3.6; [1.8 to 7.1]), higher systolic blood pressure (OR: 2.24 mmHg [0.98 to 3.50 mmHg]), and lower serum calcium (OR: -0.10 mg/dL [-0.15 to -0.04 mg/dL]) and high-density lipoprotein cholesterol (OR: -3.03 mg/dL [-5.02 to -1.04]) levels compared with those with 25(OH)D levels > or =30 ng/mL., Conclusions: 25(OH)D deficiency is common in the general US pediatric population and is associated with adverse cardiovascular risks.

Objectives: We sought to examine the combined effect of hospital and physician volume of primary percutaneous coronary intervention (PCI) on in-hospital mortality., Background: An inverse relationship between volume and outcome has been observed for both hospitals and physicians after primary PCI for acute myocardial infarction., Methods: Using the New York State PCI registry, we examined yearly hospital volume, physician volume, and risk-adjusted mortality in 7,321 patients undergoing primary PCI for acute myocardial infarction. Risk-adjusted mortality rates for high-volume hospitals (>50 cases/year) and high-volume physicians (>10 cases/year) were compared with their respective low-volume counterparts., Results: Primary PCI by high-volume hospitals (odds ratio [OR]: 0.58; 95% confidence interval [CI]: 0.38 to 0.88) and high-volume physicians (OR: 0.66; 95% CI: 0.48 to 0.92) was associated with lower odds of mortality. Furthermore, there was a significant interaction between hospital and physician volume on adjusted mortality (p = 0.02). Although unadjusted mortality was lower when primary PCI was performed by high-volume physicians in high-volume hospitals compared with low-volume physicians in low-volume hospitals (3.2% vs. 6.7%, p = 0.03), the risk-adjusted mortality rate was not statistically significant (3.8% vs. 8.4%, p = 0.09). In low-volume hospitals, the average risk-adjusted mortality rate for low-volume physicians was 8.4% versus 4.8% for high-volume physicians (OR: 1.44; 95% CI: 0.68 to 3.03). However, in high-volume hospitals, the risk-adjusted mortality rate for high-volume physicians was 3.8% versus 6.5% for low-volume physicians (OR: 0.58; 95% CI: 0.39 to 0.86)., Conclusions: During primary PCI, physician experience significantly modifies the hospital volume-outcome relationship. Therefore, policymakers need to consider physician experience when developing strategies to improve access to primary PCI.

Persistent cervicovaginal infection with high-risk types of HPV is the major risk factor for subsequent cervical neoplasia. HPV53, part of the alpha 6 species group along with HPV types 30, 56, and 66, is one of the most prevalent high risk-related HPV types, yet little is known about the molecular basis of its benign behavior. We generated and utilized HPV53 virus-like particles (VLPs) to investigate risk factors for its seroprevalence in a population of young college women. Seropositivity to HPV53 VLPs was determined using a polymer-based ELISA to measure IgG reactive antibodies. Cervicovaginal cells were collected for HPV DNA detection and typing by MY09/11 PCR. A questionnaire queried for HPV risk factors to estimate odds ratios (ORs). Prevalence of cervicovaginal HPV DNA was 26% (n = 148); 3% of women (n = 17) had HPV53 DNA and 7% (n = 40) were seropositive to HPV53. Seroprevalence of IgG to HPV53 VLPs in women with cervicovaginal HPV53, HPV53-related types (HPV30, 55, and 66), other HPV types, and no HPV was 41%, 11%, 7%, and 6%, respectively (p(trend) < 0.001). Risk factors independently associated with HPV53 VLP seropositivity included use of oral contraceptive pills (OCPs) (OR: 4; 95% CI: 1.8, 9), having >or=2 regular partners in the last 6 months (OR: 2.5; 95 % CI: 1.1, 5.8), having a regular male partner with >or=4 lifetime sex partners (OR: 2.6; 95% CI: 1.1 6), seropositivity to HPV16 (OR: 6.7; 95% CI: 3.1, 14.5), and isolation of HPV53 DNA from cervicovaginal lavage (OR: 17.3; 95% CI: 5.3, 55.9). In conclusion, host serological responses to HPV53 VLPs are strongly type-specific, and subjects' risk for HPV53 seropositivity is independently associated with sexual behavior and OCP use.

Background: Sodium restriction is commonly recommended as a measure to lower blood pressure and thus reduce cardiovascular disease (CVD) and all-cause mortality. However, some studies have observed higher mortality associated with lower sodium intake., Objective: To test the hypothesis that lower sodium is associated with subsequent higher cardiovascular disease (CVD) and all cause mortality in the Third National Health and Nutrition Examination Survey (NHANES III)., Design: Observational cohort study of mortality subsequent to a baseline survey., Participants: Representative sample (n = 8,699) of non-institutionalized US adults age > or = 30, without history of CVD events, recruited between 1988-1994., Measurements and Main Results: Dietary sodium and calorie intakes estimated from a single baseline 24-h dietary recall. Vital status and cause of death were obtained from the National Death Index through the year 2000. Hazard ratio (HR) for CVD mortality of lowest to highest quartile of sodium, adjusted for calories and other CVD risk factors, in a Cox model, was 1.80 (95% CI 1.05, 3.08, p = 0.03). Non-significant trends of an inverse association of continuous sodium (per 1,000 mg) intake with CVD and all-cause mortality were observed with a 99% CI of 0.73, 1.06 (p = 0.07) and 0.86, 1.04 (p = 0.11), respectively, while trends for a direct association were not observed., Conclusion: Observed associations of lower sodium with higher mortality were modest and mostly not statistically significant. However, these findings also suggest that for the general US adult population, higher sodium is unlikely to be independently associated with higher CVD or all-cause mortality.

Objective: To confirm that fever with localized findings is less prevalent among febrile postoperative myomectomy patients than it is among hysterectomy patients., Methods: Hospital records of 341 hysterectomy patients and 250 myomectomy patients were reviewed. Rate of overall febrile morbidity, proportion of fever with localized findings, proportion of febrile patients worked-up, and other perioperative parameters were recorded. Fever was prospectively defined both inclusively (temperature at least 38.0 degrees C occurring at least 4 hours postoperatively) and in standard fashion (temperature at least 38.0 degrees C after 24 hours postoperatively). A localized fever required a positive laboratory, radiologic, or clinical finding. Chi-square, Student t test, and multivariable logistic regression were used., Results: The proportion of patients who developed postoperative fever after at least 4 hours was identical between myomectomy and hysterectomy patients (39.2% compared with 39.3%, P=.98). However, the proportion of febrile myomectomy patients with localized findings was significantly lower than hysterectomy patients (14.3% compared with 31.3%, P=.003). Likewise, when comparing respective rates of overall and localized fever after at least 24 hours postoperatively, similar results were obtained. Multivariable analysis confirmed the lower likelihood of localized findings among febrile postoperative myomectomy patients compared with hysterectomy patients (odds ratio of localized fever 0.30, 95% confidence interval 0.12-0.75, P=.01). Additionally, obesity raised the likelihood of localized findings in each group by 6% per unit of body mass index (odds ratio 1.06, 95% confidence interval 1.01-1.10, P=.03)., Conclusion: Overall postoperative fever rates are similar, but myomectomy is independently associated with fewer localized fevers than hysterectomy. Given the relatively low likelihood of localized fever, clinicians may consider simplifying the fever workup of postoperative myomectomy patients., Level of Evidence: II.

Introduction: Diabetes is known to be a prothrombotic state. Since serotonin uptake plays a role in both platelet activation and depression, we undertook to examine a hypothesis that aspirin resistance (AR) may be associated with both HbA1c and depressive symptoms and to assess other potential determinants of AR in diabetic patients., Methods: A whole-blood desktop platelet function analyzer (PFA-100) with an epinephrine agonist was used to assess AR among patients with type 2 diabetes. AR was defined as PFA closure times <192 s. Depression symptoms were assessed with the Physicians Health Questionnaire. Patients being treated for type 2 diabetes (N=48) who took aspirin within the past 24 h constituted the study sample. Associations with AR were assessed with the use of the Mann-Whitney test and Fisher's Exact Test as well as with logistic regression models., Results: AR was observed in 11 patients (23%) and was not significantly associated with age, sex, or race. AR was significantly associated with HbA1c > or = 8% (P=.002) and obesity (BMI> or = 30 kg/m(2); P=.01) and borderline associated with having > or = 1 depressive symptom (P=.07). Results were similar after multivariable adjustment in logistic regression models. No statistically significant associations of AR with age, sex, race, plasma glucose, blood pressure, cholesterol, or smoking were observed., Conclusion: These data suggest that AR may be of special concern for diabetic patients with poor glucose control and obesity. Whether the PFA-100 or any other practical measure of AR can be used in clinical practice to identify added cardiovascular disease risk and to inform platelet inhibition therapy needs further study.

Background: Academic medical centers are increasingly employing hospitalists to staff teaching wards. Although studies have demonstrated reduced lengths of stay (LOSs) associated with hospitalist care, it is unclear which patients are most likely to benefit. We sought to determine whether patients with specific diagnoses or discharge needs account for the association between hospitalist care and reduced LOS., Methods: Hospital admissions were divided into the following 2 groups based on type of attending physician: teaching hospitalist (full-time faculty hospitalist with no outpatient responsibilities) vs nonhospitalist (full-time or voluntary faculty contributing 1 or 2 months of teaching service per year). We included all patients discharged from an academic teaching service for a 2-year period. Data were extracted from the Montefiore Medical Center's clinical information system and the Social Security Death Registry., Results: Mean LOS was lower for teaching hospitalists than for nonhospitalists (5.01 vs 5.87 days [P < .02]). The reduction in LOS was greatest for patients requiring close clinical monitoring (patients with congestive heart failure, stroke, asthma, or pneumonia) and for those requiring complex discharge planning. There were no significant differences between the groups in readmission, in-hospital mortality, or 30-day mortality., Conclusion: Teaching hospitalist care was associated with shorter LOS in patients requiring close clinical monitoring and complex discharge planning, without adversely affecting readmission or mortality rates.

Previous studies among elderly suggest an association between chronic kidney disease (CKD) and cognitive impairment. The purpose of this study was to determine whether moderate CKD is associated with cognitive performance among young, healthy, ethnically diverse adults. Three computerized cognitive function tests of visual-motor reaction time (Simple Reaction Time), visual attention (Symbol Digit Substitution), and learning/concentration (Serial Digit Learning) were administered to a random sample of participants, aged 20 to 59 yr, who completed initial interviews and medical examination in the Third National Health and Nutrition Examination Survey (NHANES III). Participants for this study (n = 4849) completed at least one cognitive function test. GFR was estimated using the Modification of Diet in Renal Disease (MDRD) equation. Moderate CKD was defined as estimated GFR (eGFR) 30 to 59 ml/min per 1.73 m(2). Unadjusted, residual-adjusted, and multivariate-adjusted logistic regression models were used. The cohort was 49.0% male and 11.6% black, and median (interquartile range) age was 36 yr (27 to 45) and eGFR was 107.9 ml/min per 1.73 m(2) (95.0 to 125.4). There were 31 (0.8%) prevalent cases of moderate CKD. Models were adjusted for residual effects of age, gender, race, diabetes, and other known potential confounders. In multivariate models, moderate CKD was not significantly associated with reaction time but was significantly associated with poorer learning/concentration (odds ratio 2.41; 95% confidence interval 1.30 to 5.63) and impairment in visual attention (odds ratio 2.74; 95% confidence interval 1.01 to 7.40). In summary, among those in a large nationally representative sample of healthy, ethnically diverse 20- to 59-yr-old adults, moderate CKD, reflected by eGFR 30 to 59 ml/min per 1.73 m(2), was significantly associated with poorer performance in visual attention and learning/concentration.

Objective: There is no standard high-dose-rate (HDR) brachytherapy dose for locally advanced cervical cancer. The objective of this study was to determine the efficacy, toxicity and clinicopathologic predictive markers affecting survival using cisplatin (CDDP) concomitant with external beam pelvic radiotherapy (EBRT) and two 9-Gy HDR insertions for the treatment of locally advanced cervical cancer., Methods: 77 consecutive patients with Stage IB2-IV cervical cancer treated with CDDP, EBRT and two 9-Gy HDR insertions were included. Kaplan-Meier methods and Cox proportional hazards models were applied for survival statistics., Results: Median age was 53. 90% had squamous cell carcinoma. Median follow-up time was 3.5 years (range 0.5-12 years). Overall 5-year progression-free survival (PFS) was 75%. Local control rate and 5-year PFS were 88% and 83%, respectively, for Stages IB2/II, and 68% and 61%, respectively, for Stages III/IV. Grade 3/4 GI symptoms were the most common acute side effects (47%). Grade 3/4 late toxicities occurred in five (6%) patients., Conclusions: HDR brachytherapy regimens consisting of two 9-Gy HDR insertions have similar efficacy and side effect profiles as other brachytherapy regimens for the treatment of cervical cancer with improved safety and patient convenience.

Background: Cisplatin (CDDP) administration concomitant with radiotherapy (RT) for the treatment of locally advanced cervical cancer has evolved from an inpatient 5-day every 21-day regimen to a weekly outpatient regimen. This study was designed to test for differences in progression-free survival (PFS) and toxicity between the 2 regimens., Methods: In all, 77 consecutive patients at a single institution with stage IB2-IV cervical cancer were included in this analysis (using the International Federation of Gynecologists and Obstetricians staging system). All patients were treated with CDDP, external beam RT, and 2 9-Gy high-dose-rate brachytherapy treatments. Two cohorts were compared: 1) 5-day, patients treated from 1995 to 2001 with CDDP 20 mg/m(2) x 5 days every 21 days concomitant with RT; 2) weekly, treated after May 2001 with CDDP 40 mg/m(2) weekly concomitant with RT., Results: In all, 50 patients were treated with the 5-day regimen and 27 patients with the weekly regimen. There were no significant demographic differences between the groups. Overall 3-year PFS, controlling for stage, was 90% and 76% for 5-day and weekly groups, respectively (P = .01). Adjusting for stage, age, and completion of treatment, the risk of treatment failure among the weekly group was 3.46 times higher than the 5-day group (P = .02). The weekly group had a 3.43 times higher risk of developing acute toxicities than the 5-day group (P = .02) in advanced-stage patients., Conclusions: Patients who received weekly CDDP have a shorter 3-year PFS. Patients with advanced-stage cervical cancer who received weekly CDDP had significantly more acute toxicities. These data should be confirmed in a multi-institutional, randomized, controlled study., ((c) 2006 American Cancer Society.)

Background: Impaired fasting glucose (IFG) and renal dysfunction are recognized as independent risk factors for adverse heart outcomes. This study examines the interaction of renal dysfunction and IFG (>or=110 mg/dL) upon the risk of ischemic heart disease (IHD) mortality among treated hypertensive subjects., Methods: Subjects were 9918 participants in a worksite-based antihypertensive treatment program in New York City (1981 to 1999) with baseline estimated glomerular filtration rate (GFR) >30 mL/min/1.73 m2 (estimated by Cockcroft and Gault formula) observed for a mean follow-up of 9.6 +/- 5.0 years (range 0.5-20.0 years). Outcome events were IHD deaths (n = 337) ascertained from the National Death Index. Cox proportional hazard models were constructed for the entire cohort to assess the interaction and then stratified by moderate renal dysfunction (MRD; GFR 60-30 mL/min/1.73 m2). Age and sex adjusted rates were calculated within MRD and NKF-defined categories. Hazard ratios for IFG were calculated within MRD strata., Results: The interaction product term of MRD and IFG significantly improved (P = .001) a Cox proportional hazard model after adjusting for known cardiovascular risk factors. Among participants with GFR >or=60 mL/min/1.73 m2 the IHD mortality hazard ratio for IFG was 1.47 (95% CI = 1.09-1.99; P = .012). Conversely, among participants with MRD, the IHD mortality hazard ratio for IFG was 0.44 (95% CI = 0.21-0.94; P = .034)., Conclusions: These results suggest an attenuating effect modification of GFR on IHD mortality risk associated with IFG among treated hypertensive subjects. Whether the observed qualitative interaction is simply statistical or reflects a biological counter-regulatory mechanism requires additional study.

Purpose: US Dietary Guidelines recommend a daily sodium intake <2300 mg, but evidence linking sodium intake to mortality outcomes is scant and inconsistent. To assess the association of sodium intake with cardiovascular disease (CVD) and all-cause mortality and the potential impact of dietary sodium intake <2300 mg, we examined data from the Second National Health and Nutrition Examination Survey (NHANES II)., Methods: Observational cohort study linking sodium, estimated by single 24-hour dietary recall and adjusted for calorie intake, in a community sample (n = 7154) representing 78.9 million non-institutionalized US adults (ages 30-74). Hazard ratios (HR) for CVD and all-cause mortality were calculated from multivariable adjusted Cox models accounting for the sampling design., Results: Over mean 13.7 (range: 0.5-16.8) years follow-up, there were 1343 deaths (541 CVD). Sodium (adjusted for calories) and sodium/calorie ratio as continuous variables had independent inverse associations with CVD mortality (P = .03 and P = .008, respectively). Adjusted HR of CVD mortality for sodium <2300 mg was 1.37 (95% confidence interval [CI]: 1.03-1.81, P = .033), and 1.28 (95% CI: 1.10-1.50, P = .003) for all-cause mortality. Alternate sodium thresholds from 1900-2700 mg gave similar results. Results were consistent in the majority of subgroups examined, but no such associations were observed for those <55 years old, non-whites, or the obese., Conclusion: The inverse association of sodium to CVD mortality seen here raises questions regarding the likelihood of a survival advantage accompanying a lower sodium diet. These findings highlight the need for further study of the relation of dietary sodium to mortality outcomes.

The response to steroid therapy is used to characterize the idiopathic nephrotic syndrome (INS) of childhood as either steroid-sensitive (SSNS) or steroid-resistant (SRNS), a classification with a better prognostic capability than renal biopsy. The majority (approximately 80%) of INS is due to minimal change disease but the percentage of focal and segmental glomerulosclerosis is increasing. We applied a new technological platform to examine the urine proteome to determine if different urinary protein excretion profiles could differentiate patients with SSNS from those with SRNS. Twenty-five patients with INS and 17 control patients were studied. Mid-stream urines were analyzed using surface enhanced laser desorption and ionization mass spectrometry(SELDI-MS). Data were analyzed using multiple bioinformatic techniques. Patient classification was performed using Biomarker Pattern Software and a generalized form of Adaboost and predictive models were generated using a supervised algorithm with cross-validation. Urinary proteomic data distinguished INS patients from control patients, irrespective of steroid response, with a sensitivity of 92.3%, specificity of 93.7%, positive predictive value of 96% and a negative predictive value of 88.2%. Classification of patients as SSNS or SRNS was 100%. A protein of mass 4,144 daltons was identified as the single most important classifier in distinguishing SSNS from SRNS. SELDI-MS combined with bioinformatics can identify different proteomic patterns in INS. Characterization of the proteins of interest identified by this proteomic approach with prospective clinical validation may yield a valuable clinical tool for the non-invasive prediction of treatment response and prognosis., (Copyright 2006 S. Karger AG, Basel.)