Abstract Background and Aims Hypertension is prevalent in patients with advanced chronic kidney disease (CKD), and kidney transplantation (KT) can potentially improve hypertension. Although ...hypertension is expected to be resolved after KT in many recipients with pre-transplant hypertension, little is known about the hypertension resolution rate and its prognostic role in KT outcomes. Method We retrospectively identified KT recipients (between 2006 and 2015) who had pre-transplant hypertension using Health Insurance Review & Assessment Service and Korea National Health Insurance System. The recipients were categorized into two groups based on their post-KT hypertension status: “persistent hypertension” and “resolved hypertension”. Cox proportional hazard analyses were performed to assess the risk of death-censored graft failure and all-cause mortality with adjusting various clinical, immunological risk factors, and socioeconomic status. Results Among 11,342 KT recipients with pre-transplant hypertension, 8,233 (73%) remained hypertensive, while 3,109 (27%) experienced hypertension resolution after KT. Recipients with resolved hypertension had lower rates of delayed graft function and major comorbidities, including diabetes mellitus, ischemic heart disease, and stroke compared to recipients who remained hypertensive. After adjusting for multiple covariates, the resolved hypertension group had 0.59-fold (95% confidence interval CI 0.49–0.73) lower risk for graft failure and 0.59-fold (95% CI 0.48–0.73) lower risk for all-cause mortality compared to the persistent hypertension group. Subgroup analyses revealed that the protective effect of resolved hypertension on graft survival was more pronounced in females (P for interaction = 0.045), and on overall survival was weaker in recipients with diabetes (P for interaction = 0.033). Conclusion A significant proportion of patients experienced hypertension resolution after KT, which is associated with improved graft survival and overall patient survival. The post-KT hypertension status can be used as a prognostic indicator for predicting better outcomes in KT recipients with pre-transplant hypertension.
Abstract Background and Aims Proton pump inhibitors (PPI) are commonly used drugs worldwide and have been linked to worsening renal function and incident chronic kidney disease. Recently, ...potassium-competitive acid blockers (P-CAB) have emerged as alternative gastric acid-reducing agents with a comparable effect as PPIs. However, little is known about the renal safety of P-CAB. We aimed to compare the renal outcomes of patients treated with P-CAB and those treated with PPI. Method We retrospectively identified all patients who were prescribed P-CAB (tegoprazan) or PPI (esomeprazole) for 30 days or more in outpatient clinics of a tertiary care center between 2019 and 2023. Longitudinal serum creatinine data and various demographic and clinical variables were collected. Renal outcomes were defined as creatinine doubling or decline in estimated glomerular filtration rate (eGFR) of 30%. Patients with baseline eGFR < 15 mL/min/1.73 m2 and those who do not have sufficient creatinine measures to assess renal outcomes were excluded. Cox proportional hazard analyses were performed for renal outcomes with adjustment of multiple clinical covariates. Results Among 8 436 patients with a mean followup of 21 months, 2 214 and 6 222 patients were treated with P-CAB and PPI, respectively, for esophageal and gastric diseases. P-CAB group showed lower rates of creatinine doubling (Log-rank P = 0.001) and decline of eGFR (Log-rank P = 0.001) compared to PPI group. P-CAB use was associated with a 0.50-fold (95% confidence interval CI 0.33–0.75) lower risk for creatinine doubling and 0.58-fold (95% CI 0.42–0.81) lower risk for eGFR decline in unadjusted analysis. After adjusting multiple covariates including baseline eGFR, prescription days, major comorbidities, and concomitant use of other medications, hazard ratios for creatinine doubling and eGFR decline were 0.64 (95% CI 0.42–0.98) and 0.73 (95% CI 0.53–1.02), respectively. Conclusion Use of P-CAB is associated with a lower risk for renal function deterioration compared to PPI. Given the renal safety concerns of PPIs, using P-CAB could be a relatively safer strategy for preserving kidney function in patients who need long-term gastric acid suppression. Further studies with a larger cohort incorporating other P-CABs are required to validate this finding.
Health inequities have long defined health and the healthcare system in the USA. The clinical and research capacity across the USA is unparalleled, yet compared to other high and even some ...middle-income countries, the average health indicators of the population remain suboptimal in 2020, a finding at least in part explained by inequity in healthcare access. In this context, COVID-19 has rapidly emerged as a major threat to the public’s health. While it was initially thought that severe acute respiratory syndrome coronavirus 2 would be the great equaliser as it would not discriminate, it is clear that COVID-19 incidence and mortality have rapidly reinforced health disparities drawn by historical and contemporary inequities. Here, we synthesise the data highlighting specific risks among particular marginalised and under-resourced communities including those in jails, prisons and detention centers, immigrants and the undocumented, people with disabilities and people experiencing homelessness across the USA. The drivers of these disparities are pervasive structural risks including limited access to preventive services, inability to comply with physical distancing recommendations, underlying health disparities and intersecting stigmas particularly affecting racial and ethnic minorities across the country, including African Americans, Latinx Americans and Native Americans. Advancing the COVID-19 response, saving lives and restarting the economy necessitate rapidly addressing these inequities rather than ignoring and even reinforcing them.
Abstract
Background
Inflammatory bowel disease (IBD) guidelines recommend tumor necrosis factor-α inhibitors (TNFis) for patients who have not responded to conventional therapy, and vedolizumab in ...case of inadequate response to conventional therapy and/or TNFis. Recent studies have shown that vedolizumab may also be effective in the earlier treatment lines. Therefore, we conducted cost-effectiveness analyses to determine the optimal treatment sequence in patients with IBD.
Methods
A Markov model with a 10-year time horizon compared the cost-effectiveness of different biologic treatment sequences in patients with moderate to severe ulcerative colitis (UC) and Crohn’s disease (CD) from the UK and French perspectives. Subcutaneous formulations of infliximab, vedolizumab, and adalimumab were evaluated. Comparative effectiveness was based on a network meta-analysis of clinical trials and real-world evidence. Costs included pharmacotherapy, surgery, adverse events, and disease management.
Results
The results indicated that treatment sequences starting with infliximab were less costly and more effective than those starting with vedolizumab for patients with UC in the United Kingdom and France, and patients with just CD in France. For patients with CD in the United Kingdom, treatment sequences starting with infliximab resulted in better health outcomes with incremental cost-effectiveness ratios (ICERs) near the threshold.
Conclusions
Based on the ICERs, treatment sequences starting with infliximab are the dominant option for patients with UC in the United Kingdom, and patients with UC and CD in France. In UK patients with CD, ICERs were near the assumed “willingness to pay” threshold. These results reinforce the UK’s National Institute for Health and Care Excellence recommendations for using infliximab prior to using vedolizumab in biologics-naïve patients.
Lay Summary
A Markov model compared the cost-effectiveness of biologic treatment sequences in patients with moderate to severe inflammatory bowel diseases from a European perspective. The results indicated that treatment sequences starting with infliximab are the dominant option than those starting with vedolizumab.
Examine differences in cost between single stage (ss) versus double stage (ds) laryngotracheal reconstruction (LTR) for pediatric subglottic stenosis.
Retrospective chart review of children who ...underwent ssLTR or dsLTR from 2014 to 2018 at a single institution.
Costs related to LTR and post-operative care up to one year after tracheostomy decannulation were extrapolated from charges billed to the patient. Charges were obtained from the hospital finance department and the local medical supplies company. Patient demographics including baseline severity of subglottic stenosis and co-morbidities were noted. Variables assessed include duration of hospital admission, number of ancillary procedures, duration of sedation wean, cost of tracheostomy maintenance, and time to tracheostomy decannulation.
Fifteen children underwent LTR for subglottic stenosis. D Ten patients underwent ssLTR, while five underwent dsLTR. Grade 3 subglottic stenosis was more prevalent in patients who underwent dsLTR (100%) than ssLTR (50%). The average per-patient hospital charges for ssLTR was $314,383 versus $183,638 for dsLTR. When estimated mean cost of tracheostomy supplies and nursing care until tracheostomy decannulation was included, the mean total charges associated with dsLTR patients was $269,456. Average hospital stay after initial surgery was 22 days for ssLTR versus 6 days for dsLTR. Average time to tracheostomy decannulation for dsLTR was 297 days. Average number of ancillary procedures needed was 3 versus 8 for ssLTR versus dsLTR.
For pediatric patients with subglottic stenosis, dsLTR may have a lower cost than ssLTR. Although ssLTR has the benefit of immediate decannulation, it is associated with higher patient charges, as well as longer initial hospitalization and sedation. For both patient groups, fees associated with nursing care comprised the majority of charges. Recognizing the factors that contribute to cost differences between ssLTR and dsLTR may be useful when performing cost-benefit analyses and assessing value in health care delivery.
Pediatric vocal cord paresis (VCP) has a variety of etiologies, including congenital neurologic disease. Arnold-Chiari Malformation (ACM) is one such disease with known VCP association. However, the ...natural history, need for tracheostomy, and rate of decannulation in this patient population is not well characterized.
To provide prognostic information on infants with ACM and VCP.
A retrospective chart review was conducted of patients with both ACM and VCP at a single institution. Clinical outcomes and disease progression were determined using flexible laryngoscopy, serial clinical exams, and operative reports from otolaryngology and neurosurgery services.
Eighteen patients were included in this study, four with ACM Type I and 14 with ACM Type II. These groups were analyzed separately. For ACM I, the average age at diagnosis was 25 months and two (50%) required tracheostomy. Three subjects (75%) achieved VCP resolution, with two doing so after neurosurgical decompression. For ACM II, the average age at diagnosis was eight months and 12 patients (86%) underwent tracheostomy. Four subjects with tracheostomy (33%) achieved decannulation, with three of these demonstrating VCP resolution. In total, six ACM II patients had complete and one had partial VCP resolution, all of whom underwent decompression. Two patients initially had normal endoscopic exams despite stridor and VCP was only noted on serial exams.
This study represents the largest series of pediatric patients with VCP and ACM. The majority needed decompression (80%) and tracheotomy (78%). Tracheostomy decannulation typically occurred only after decompression and resolution of VCP. No children diagnosed at age <1 month were decannulated. Early decompression was associated with successful avoidance of tracheostomy in majority of Chiari I but not Chiari II patients. Serial endoscopies were required to confirm VCP in some patients. This information could potentially aid in management and counseling parents of children with VCP and CM.
Abstract CD4+ regulatory T cells (Tregs) are key orchestrators of the immune system, fostering the establishment of protective immunity while preventing deleterious responses. Infancy and childhood ...are crucial periods of rapid immunologic development, but how Tregs mediate immune responses at these earliest timepoints of human life is poorly understood. In this study, we compare blood and tissue (tonsil) Tregs across pediatric and adult subjects to investigate age-related differences in Treg biology. We observed increased FOXP3 expression and proportions of Tregs in tonsil compared with paired blood samples in children. Within tonsil, early life Tregs accumulated in extrafollicular regions with cellular interactions biased toward CD8+ T cells. Tonsil Tregs in both children and adults expressed transcriptional profiles enriched for lineage defining signatures and canonical functionality compared with blood, suggesting tissue as the primary site of Treg activity. Early life tonsil Tregs transcriptional profiles were further defined by pathways associated with activation, proliferation, and polyfunctionality. Observed differences in pediatric tonsil Treg transcriptional signatures were associated with phenotypic differences, high proliferative capacity, and robust production of IL-10 compared with adult Tregs. These results identify tissue as a major driver of Treg identity, provide new insights into developmental differences in Treg biology across the human lifespan, and demonstrate unique functional properties of early life Tregs.
소프트웨어 정의 스토리지의 디스크 이용을 최적화하는 방법에 관한 연구 이정일; Lee Jung Il; 최윤아 ...
정보처리학회논문지. KIPS transactions on computer and communication systems 컴퓨터 및 통신 시스템,
04/2023, Letnik:
12, Številka:
4
Journal Article
Odprti dostop
최근에는 디지털 변환이 확대됨에 따라 많은 기업들이 퍼블릭 클라우드 서비스를 이용하거나 자체 데이터센터를 구축하고 있다. 소프트웨어정의 스토리지는 클라우드 플랫폼에서 데이터를 저장하기 위한 핵심적인 솔루션으로 전세계적으로 이용이 확대되고 있다. 소프트웨어 정의 스토리지는 전체 스토리지 자원을 하나의 저장장치와 같이 가상화하여 사용할 수 있고 유연한 ...Scale-out을 지원하는 장점이 있는 반면에, 가변 크기의 오브젝트 방식으로 인한 디스크의 이용에 불균형이 발생하고, 장애를 유발할 수 있다. 본 연구에서는 디스크 이용의 불균형 문제를 해결하기 위하여 스토리지의 상태정보를 바탕으로 디스크의 가중치를 최적화하여 오브젝트를 재분배하는 방법에 대하여 제안하고, 그 실험 결과를 제시하였다. 실험을 수행한 결과, 디스크의 최대 이용률이 89%에서 79%로 10%만큼 감소한 것을 확인하였다. 디스크의 이용률을 최적화함으로써 장애를 예방하고, 더 많은 데이터를 균등하게 저장할 수 있어 효율적인 스토리지 이용이 가능할 것으로 기대된다.
Recently, many companies are using public cloud services or building their own data center because digital transformation is expanding. The software-defined storage is a key solution for storing data on the cloud platform and its use is expanding worldwide. Software-defined storage has the advantage of being able to virtualize and use all storage resources as a single storage device and supporting flexible scale-out. On the other hand, since the size of an object is variable, an imbalance occurs in the use of the disk and may cause a failure. In this study, a method of redistributing objects by optimizing disk weights based on storage state information was proposed to solve the imbalance problem of disk use, and the experimental results were presented. As a result of the experiment, it was confirmed that the maximum utilization rate of the disk decreased by 10% from 89% to 79%. Failures can be prevented, and more data can be stored by optimizing the use of disk.
Background In 2020, the European Medicines Agency approved infliximab subcutaneous (SC) for the treatment of inflammatory bowel disease. This new mode of infliximab administration will reduce ...outpatient visits and costs of intravenous (IV) administration. This article describes a budget impact analysis of introducing infliximab SC to the Big-5 European (E5) market (Germany, France, Italy, Spain and UK) for 5 years, from the healthcare payer's perspective. Methods A prevalence-based budget impact model was developed to examine the financial impact of infliximab SC. "World with" versus "world without" infliximab SC scenarios were compared, including the potential administration costs of IV administration. Results Introducing infliximab SC in patients with Crohn's disease (CD) for 5 years resulted in cost savings of euro42.0 million in the UK, euro59.4 million in Germany, and euro46.4 million in France and Italy, but increased budget expenditure in Spain by euro3.8 million. For ulcerative colitis (UC), cost savings of euro42.7 million in the UK, euro44.9 million in Germany, euro44.3 million in France, and euro53.0 million in Italy occurred, but with no savings in Spain for 5 years. Cost-savings per patient was calculated by diving the net budget saving by number of treatment eligible patients. Maximum and minimum saving per patient per year ranged between euro38.25 and euro575.74 in CD, both from Germany, and euro105.06 (France) and euro647.25 (Germany) in UC. Conclusion Healthcare payers in the UK, Germany, France, and Italy, but not in Spain, will make budget savings by using infliximab SC for the treatment of inflammatory bowel disease. Keywords: Inflammatory bowel disease, Ulcerative colitis, Crohn's disease, Budget impact
Infants born with esophageal atresia and tracheoesophageal fistula, a complex congenital malformation occurring in 1/2500–4000 live births, may suffer threats to their cardiac, respiratory, and ...digestive health in addition to anomalies that may exist in the genitourinary and musculoskeletal systems. Optimal care for these patients throughout their lives is best achieved through a coordinated, multidisciplinary approach that our health care system is not always well‐equipped to provide. This review, though not exhaustive, highlights the components of care that pertain to initial surgical reconstruction and subsequent diagnosis and management of the complications that are most frequently encountered. Authors from among the many specialties involved in the care of these patients summarize the current best practice with attention to the most recent advances. Assessment and improvement of quality of life and transition to adult specialists as children grow to adulthood is also reviewed.
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