Immune thrombocytopenia (ITP) is increasingly recognized as a thrombophilic disorder. However, no further investigation of risk factors has been conducted to date. This study evaluated classic and ...disease-specific correlates of thrombosis among ITP patients. We hypothesized the disease-specific thrombosis risk profile differed between ITP and non-ITP patients.
A retrospective analysis of adult discharge data from the National Inpatient Sample between 2009 and 2014 was performed. International Disease Classification codes were used to identify ITP and non-ITP patients with or without thrombosis. Estimates of prevalence were weighted using NIS-provided discharge-level weights to reflect national estimates. Rao-Scott Chi-square test was used to analyze categoric variables; weighted simple linear regression for continuous variables; and a weighted multivariable logistic regression to determine covariates associated with thrombosis.
Thrombotic risk factors are increased in ITP patients, including postoperative state, malignancy, central venous lines, systemic lupus erythematosus, advanced age, obesity, and hypertension. Factors associated with thrombosis identified in multivariable logistic regression included antiphospholipid syndrome, systemic lupus erythematosus, central venous lines, obesity, and hypertension, which were similar to non-ITP patients.
Our results show a higher prevalence of thrombosis in ITP than in non-ITP patients, and despite their lower platelet counts, correlates of thrombosis are similar between ITP and non-ITP patients. The most significant correlates include antiphospholipid syndrome, central venous lines, surgery, hypertension, age, and obesity.
•The prevalence of thrombosis is greater in patients with ITP than without ITP, despite lower platelet counts, with a greater rate of DVT than PE.•By contrast, the rate of arterial thromboembolism in ITP was similar or lower to that in individuals without ITP.•Factors associated with thrombosis in patients with ITP, e.g. postoperative state, malignancy, central lines, are similar to non-ITP patients.•Risk factors for thrombosis in ITP include APLS, SLE, central lines, obesity, hypertension, surgery, and advancing age.•These findings suggest the need for anticoagulant trials in ITP to prevent thrombosis.
•Women diagnosed with gestational diabetes mellitus before 24 weeks are at increased risk for adverse outcomes, specifically macrosomia.•We suggest caution with use of glyburide in women with an ...early diagnosis of GDM until further studies regarding glyburide use prior to 24 weeks are available.•There is a paucity of data regarding optimal glycemic targets for high-risk women with diabetes in pregnancy, and it is possible that different glycemic targets or alternate therapeutic approaches are needed in this population.•Further studies are also needed to establish the risks and benefits of early diabetes screening and treatment.
To examine pregnancy outcomes in women with gestational diabetes mellitus (GDM) based on the timing of diagnosis.
We compared demographics, blood sugars and outcomes between women diagnosed before (n = 167) or after 24 weeks’ gestation (n = 1202) in a single hospital between 2009 and 2012. Because early screening is risk-based we used propensity score modelling and conditional logistic regression to account for systematic differences.
Women diagnosed with GDM before 24 weeks were more likely to be obese and they were less likely to have excess gestational weight gain (35 vs. 45%, p = 0.04). Early diagnosis was associated with more frequent therapy including glyburide (65 vs. 56%, p < 0.001) and insulin (19 vs 6%, p < 0.001). After propensity score modelling and accounting for covariates, early diagnosis was associated with an increased risk for macrosomia (OR 2, 95% 1–4.15, p = 0.0498). Early diagnosis was not associated with other adverse outcomes. In a subgroup analysis comparing women treated with glyburide prior to 24 weeks compared to those diagnosed after 24 weeks, early diagnosis in women treated with glyburide was associated with an increased risk for macrosomia (OR 2.3, 95% CI 1.1–5.4, P = 0.04).
Women diagnosed with GDM before 24 weeks have unique features, are at risk for adverse outcomes, and require targeted approaches to therapy.
Introduction
Among haemophilic (H) men, hepatitis C virus (HCV) is the leading cause of liver disease and mortality, but demographics and risks of hepatocellular carcinoma (HCC) in H are not well ...known.
Methods
Adult discharges in H and non‐haemophilic (NH) men, with and without HCC were identified in the National Inpatient Sample (NIS) between 1998 and 2014, using ICD‐9 codes. Analyses included NIS‐provided discharge‐level weights to reflect national estimates. Categorical variables were assessed by Rao‐Scott chi‐square and continuous variables by weighted simple linear regression. HCC predictors were determined by weighted multivariable logistic regression.
Results
Of 18 098 H, 144 (0.79%) had HCC between 1998 and 2014. Adjusted rates of HCC increased 3.0‐fold in H vs 1.7‐fold in NH (P = 0.484). Among HCV+, HCC rates adjusted for HIV, increased 2.2‐fold in H vs 1.7‐fold in NH (P = 0.740), while among HIV+, HCC increased 1.4‐fold in H vs 0.2‐fold in NH (P = 0.448). Among those with HCC, H were older than NH (P < 0.001), Caucasian (P = 0.006), platelet transfusion recipients (P < 0.001), with greater comorbidity (P < 0.001) and mortality (P < 0.006). H with HCC also had greater rates of HCV and HIV (each P < 0.001), lower rates of alcoholism and hyperlipidemia (each P < 0.001), and similar rates of HBV (P = 0.866), smoking (P = 0.507) and obesity (P = 0.502). In multivariable logistic regression, HCV was a strong predictor for HCC in haemophilia, (OR: 15.42, 95% CI: 8.75‐27.16).
Discussion
Haemophilic men have increasing rates of HCC, similar to men without haemophilia. HCV is the major predictor of HCC in haemophilia. Future trends in HCC will depend on the impact of newer HCV antiviral therapy.
Gastrointestinal tract bleeding (GIB) is a serious complication of von Willebrand Disease (VWD), but little is known regarding prevalence and risk factors. We, therefore, evaluated correlates of GIB ...among VWD using a large national database.
We conducted a retrospective analysis of adult discharges from the National Inpatient Sample (NIS) between 2009 and 2014. International Disease Classification codes were used to identify those with and without VWD with and without GIB. Prevalence estimates were weighted using NIS-provided discharge-level weights to reflect national estimates. Categorical variables were compared by Rao-Scott chi-square test, continuous variables by weighted simple linear regression, and independent factors associated with GIB in VWD were determined by weighted multivariable logistic regression.
GIB is more prevalent in VWD, 3.70%, than those without VWD, 1.49%, p < .0001, and is more common in those who are younger, male, or Black than in VWD without GIB, each p < .001. Comorbidities of GIB in VWD include surgery, hypertension, hyperlipidemia, and smoking, each more common than in VWD without GIB, p < .0001. VWD with GIB also have higher length of stay and inpatient mortality, p < .0001. In a multivariable model, variables significantly associated with GIB in VWD were angiodysplasia, diverticulitis, hepatitis C, black race, male gender, and smoking, each p < .001.
GIB is more common in VWD who are young, black, or male, and the most significant predictors of GIB include angiodysplasia, diverticulitis, hepatitis C, and smoking. After a first GIB, such individuals should consider factor prophylaxis to prevent GIB recurrence and associated morbidity.
•Gastrointestinal bleeding (GIB) in VWD is common in young, black, or male patients.•Predictors of GIB in VWD include angiodysplasia, diverticulitis, HCV, and smoking.•The most common cause of GIB recurrence in VWD is angiodysplasia.•GIB recurrence accounts for the majority of VWD hospitalizations.•Prophylactic factor should be considered to reduce VWD GIB recurrence.
Progressive disruption of renal tubular integrity in the setting of increased cellular proliferation and apoptosis is a feature of autosomal dominant polycystic kidney disease (ADPKD). Here we ...evaluated the effect of these processes on the expression of Lcn2 (NGAL) and interleukin (IL)-18, markers of tubular injury, in rodent models and in the cyst fluid and urine of patients with ADPKD. Two mouse models where Pkd2 was inactivated, which resulted in early- or adult-onset cysts, were used to evaluate NGAL levels. Further, the Han:SPRD rat model of polycystic disease was used to study IL-18 levels. In four annual serial urine samples collected from 107 patients with ADPKD in the Consortium for Radiologic Imaging for the Study of Polycystic Kidney Disease (CRISP) study, NGAL and IL-18 excretion rates were determined in conjunction with measures of total kidney volume and estimated glomerular filtration rate (eGFR) by the Modification of Diet in Renal Disease equation. Kidneys from affected mice and rats showed prominent expression of NGAL and IL-18/IL-18R, respectively, in epithelial cells lining kidney cysts. In human ADPKD cyst fluid, both NGAL and IL-18 were elevated. In CRISP patients, the mean percentage increase in total kidney volume was 5.4/year and the mean decline in eGFR 2.4ml/min/year. The trend of increased mean urine NGAL and IL-18 over 3 years was statistically significant; however, there was no association between tertiles of IL-18 or quartiles of NGAL and change in total kidney volume or eGFR over this period. Thus, urinary NGAL and IL-18 excretion is mildly and stably elevated in ADPKD, but does not correlate with changes in total kidney volume or kidney function. This may be due, in part, to the lack of communication between individual cysts and the urinary collecting system in this disorder.
No clinical consensus regarding the optimal diagnostic approach for gestational diabetes mellitus (GDM) exists. Participants were randomized to two GDM testing criteria following a blinded ...non-fasting 50g glucose challenge test (GCT): Carpenter Coustan (CC) or IADPSG. GDM was diagnosed in the CC arm if the 50g GCT was > 135 mg/dL and the fasting 100g OGTT had 2 or more abnormal values. GDM was diagnosed in the IADPSG arm if the fasting 75g OGTT had one or more abnormal values; the 50g GCT was ignored for diagnosis. Participants and providers were informed whether GDM was present but blinded to all test results and which criteria were used for diagnosis. Treatment for GDM occurred per routine clinical care. We hypothesized lower rates of LGA favoring the IADPSG arm, both overall and after restricting to women without GDM. From 2015-2019, 921 women were enrolled and randomized (CC=460; IADPSG-461); however, delivery records were available for only 878 women. Baseline characteristics were similar between groups. While GDM diagnosis (14.4% vs. 4.5%, p<0.001) and diabetes medication use (9.3 v 2.4%; p<0.001) were more common in the IADPSG arm, there were no differences in LGA, either overall (OR=0.90, 95% CI 0.51-1.58) or restricting to women without GDM (OR=0.86, 95% CI 0.47-1.57).
Disclosure
C.M. Scifres: None. K. Abebe: None. H. Simhan: None. P. Catalano: None. T. Costacou: None. D.M. Comer: None. S.R. Orris: None. K. Ly: None. A. Decker: None. D. Mendez: None. E. Davis: None.
Funding
National Institutes of Health (1R01HD079647)
Allosensitization is associated with inferior waitlist outcomes in pediatric heart transplant candidates, presumably because of the requirement for a negative prospective crossmatch. However, there ...are no reports of heart transplant candidate outcomes according to prospective crossmatch requirements.
We analyzed data on all children listed for isolated heart transplantation from 1995 to 2009 in the USA according to prospective crossmatch requirement (PXMR). Primary objectives were to describe the prevalence of PXMR at and during listing and to compare waitlist and post-transplant survival for patients based on PXMR. Patients with a PXMR during listing include those with a PXMR at the time of listing as well as those who were designated by the listing center as needing a prospective crossmatch at some point after being placed onto the waitlist.
Among 6,343 listed children, 7.7% had a requirement for a prospective crossmatch at the time of listing and 11.8% had a requirement for a prospective crossmatch during listing. After controlling for risk factors associated with inferior survival, PXMR at listing was associated with increased waitlist mortality (HR 1.32, 95% CI 1.10 to 1.56; p = 0.003). Recipients with a PXMR during listing more commonly had a positive DSXM (22.1% vs 10.3%, p < 0.0001), as did recipients who carried a PXMR throughout listing (21.7% vs 11.3%, p = 0.004). However, there was no significant difference in post-transplant survival on the basis of a PXMR during listing (HR 1.04, 95% CI 0.87 to 1.25; p = 0.67). Nearly 30% of recipients with a PXMR during listing had a peak pre-transplant PRA ≤ 10%.
PXMR increases the likelihood of death while awaiting, but not after, pediatric heart transplantation. Further study is necessary to understand how PXMR is applied, and changes, after listing for pediatric heart transplantation.
Introduction:
Improved life expectancy of persons with hemophilia (PWHs) has led to a greater interest in the role of age-related chronic diseases, such as hypertension, in this cohort. Several ...observational studies have reported an increased prevalence of hypertension in PWHs; however, this has not been assessed using a large, national database in the United States.
Aims:
We hypothesized the prevalence of hypertension is increased in PWHs and compared the prevalence of hypertension and associated risk factors among patients with and without hemophilia.
Methods:
A cross-sectional analysis was performed using discharge data among adult males from the National Inpatient Sample over the 3-year period, 2009 to 2011. Hypertension was compared across groups using Rao-Scott χ2 test. Multivariable logistic regression was used to estimate the odds of hypertension in patients with hemophilia after adjustment for hypertension-associated risk factors.
Results:
The prevalence of hypertension in patients with hemophilia was less than the prevalence of hypertension in patients without hemophilia (39.5% vs 56.3%, P < .001). Hemophilia was associated with a decreased odds of hypertension after adjusting for associated risk factors (odds ratio: 0.87; 95% confidence interval: 0.81-0.94).
Conclusion:
In contrast to the findings of several other recent studies, we report a decreased prevalence of hypertension in PWHs. The discrepancy among the reported prevalence of hypertension in our study and several others highlights the potential biases inherent to retrospective and cross-sectional studies and underscores the need for well-designed prospective studies to determine the true incidence of hypertension in PWHs, which may lie somewhere in between our findings and the findings of others.
Abstract
Introduction
Thrombosis is more common in inflammatory bowel disease (IBD) patients than the general population, but disease-specific correlates of thrombosis remain unclear.
Methods
We ...performed a retrospective analysis of discharge data from the National Inpatient Sample between 2009 and 2014, using International Disease Classification codes to identify IBD and non-IBD patients with or without thrombosis. We used NIS-provided discharge-level weights to reflect prevalence estimates. Categoric variables were analyzed by Rao-Scott Chi-square test, continuous variables by weighted simple linear regression, and covariates associated with thrombosis by weighted multivariable logistic regression.
Results
Thrombosis prevalence in IBD was significantly greater than in non-IBD, 7.52 versus 4.54%,
p
< 0.0001. IBD patients with thrombosis were older and more likely to be Caucasian than IBD without thrombosis, each
p
< 0.001. Thrombosis occurred most commonly in the mesenteric vein. Thrombotic risk factors in IBD include surgery, ports, malignancy, dehydration, malnutrition, and steroids at 53.7, 13.2, 13.1, 12.4, 8.9, and 8.2%, respectively. Those with thrombosis had greater severity of illness, 1.42 versus 0.96; length of stay, 7.7 versus 5.5 days; and mortality, 3.8 versus 1.5%; all
p
< 0.0001. Adjusting for age and comorbidity, odds ratios for predictors of thrombosis included ports, steroids, malnutrition, and malignancy at 1.73, 1.61, 1.34, and 1.13, respectively, while Asian race, 0.61, was protective, each
p
< 0.001.
Conclusion
Thrombosis prevalence is 1.7-fold greater in IBD than non-IBD patients. Adjusting for age and comorbidity, the odds ratio for thrombosis in IBD was 73% higher with ports, 61% higher with steroids, 34% with malnutrition, and 13% with malignancy. Whether long-term anticoagulation would benefit the latter is unknown.
To test the feasibility of conducting a pragmatic randomized controlled trial (RCT) comparing the International Association of Diabetes in Pregnancy Study Groups (IADPSG) versus Carpenter–Coustan ...diagnostic criteria for gestational diabetes (GDM), and to examine patient and provider views on GDM screening. A single-blinded pragmatic pilot RCT. Participants with a singleton pregnancy between 24 and 28 weeks gestation received a 50 g oral glucose challenge test and if the value was <200 mg/dL were randomized to either the 2 h 75 g OGTT using the IADPSG criteria or the 3 h 100 g OGTT using the Carpenter–Coustan criteria. Primary outcome was the feasibility of randomization and screening. Secondary outcomes included patient and provider views (or preferences) on GDM testing. Sixty-eight women were recruited, 48 (71 %) enrolled and 47 (69 %) were randomized. Participants in both study arms identified the main challenges to GDM testing to be: drinking the glucola, fasting prior to testing, waiting to have blood drawn, and multiple venipuntures. Women in both study arms would prefer the 2 h 75 g OGTT or whichever test is recommended by their doctor in a future pregnancy. Physicians and nurse midwives endorsed screening and were comfortable with being blinded to the GDM testing strategy and results values. Both pregnant women and providers value GDM screening, and pregnant women can be recruited to a blinded, randomized GDM screening trial with minimal attrition and missing data.
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