Discharge Codes Research Articles

Association of Midlife to Late-Life Blood Pressure Patterns With Incident Dementia

The association between late-life blood pressure (BP) and cognition may depend on the presence and chronicity of past hypertension. Late-life declines in blood pressure following prolonged hypertension may be associated with poor cognitive outcomes. To examine the association of midlife to late-life BP patterns with subsequent dementia, mild cognitive impairment, and cognitive decline. The Atherosclerosis Risk in Communities prospective population-based cohort study enrolled 4761 participants during midlife (visit 1, 1987-1989) and followed-up over 6 visits through 2016-2017 (visit 6). BP was examined over 24 years at 5 in-person visits between visits 1 and 5 (2011-2013). During visits 5 and 6, participants underwent detailed neurocognitive evaluation. The setting was 4 US communities: Washington County, Maryland; Forsyth County, North Carolina; Jackson, Mississippi; and Minneapolis, Minnesota. Follow-up ended on December 31, 2017. Five groups based on longitudinal patterns of normotension, hypertension (>140/90 mm Hg), and hypotension (<90/60 mm Hg) at visits 1 to 5. Primary outcome was dementia onset after visit 5, based on Ascertain Dementia-8 informant questionnaires, Six-Item Screener telephone assessments, hospital discharge and death certificate codes, and the visit 6 neurocognitive evaluation. Secondary outcome was mild cognitive impairment at visit 6, based on the neurocognitive evaluation. Among 4761 participants (2821 [59%] women; 979 [21%] black race; visit 5 mean [SD] age, 75 [5] years; visit 1 mean age range, 44-66 years; visit 5 mean age range, 66-90 years), there were 516 (11%) incident dementia cases between visits 5 and 6. The dementia incidence rate for participants with normotension in midlife (n = 833) and late life was 1.31 (95% CI, 1.00-1.72 per 100 person-years); for midlife normotension and late-life hypertension (n = 1559), 1.99 (95% CI, 1.69-2.32 per 100 person-years); for midlife and late-life hypertension (n = 1030), 2.83 (95% CI, 2.40-3.35 per 100 person-years); for midlife normotension and late-life hypotension (n = 927), 2.07 (95% CI, 1.68-2.54 per 100 person-years); and for midlife hypertension and late-life hypotension (n = 389), 4.26 (95% CI, 3.40-5.32 per 100 person-years). Participants in the midlife and late-life hypertension group (hazard ratio [HR], 1.49 [95% CI, 1.06-2.08]) and in the midlife hypertension and late-life hypotension group (HR, 1.62 [95% CI, 1.11-2.37]) had significantly increased risk of subsequent dementia compared with those who remained normotensive. Irrespective of late-life BP, sustained hypertension in midlife was associated with dementia risk (HR, 1.41 [95% CI, 1.17-1.71]). Compared with those who were normotensive in midlife and late life, only participants with midlife hypertension and late-life hypotension had higher risk of mild cognitive impairment (37 affected individuals (odds ratio, 1.65 [95% CI, 1.01-2.69]). There was no significant association of BP patterns with late-life cognitive change. In this community-based cohort with long-term follow-up, sustained hypertension in midlife to late life and a pattern of midlife hypertension and late-life hypotension, compared with midlife and late-life normal BP, were associated with increased risk for subsequent dementia.

Validity of hospital ICD-10-GM codes to identify acute liver injury in Germany.

Acute liver injury (ALI) is an important adverse drug reaction. We estimated the positive predictive values (PPVs) of ICD-10-GM codes of ALI used in an international postauthorisation safety study (PASS). Analyses used routine data (2007 to 2016, adults) from a German academic hospital in a cross-sectional design. Two algorithms from the PASS were applied to extract potential cases from the hospital information system: specific end point (A) (discharge diagnosis of liver disease-specific codes) and less specific end point (B) (discharge and outpatient-specific and nonspecific codes suggestive of liver injury). ALI cases were confirmed on the basis of plasma liver enzyme activity elevation. Secondary analysis was performed following exclusion of cases with known cancer, chronic liver, biliary and pancreatic disease, heart failure, and alcohol-related disorders, as applied in the PASS. On the basis of ICD codes: outcome A, 154 cases (143 with case notes and lab data for case verification); outcome B, 485 cases (357 with case notes and lab data). ALI was confirmed in 71 outcome A cases, PPV of 49.7% (95% confidence interval [CI], 41.2%-58.1%), and 100 outcome B cases, PPV of 28.0% (95% CI, 23.4%-33.0%). Applying exclusion criteria increased PPV (95% CI) to 62.7% (50.0%-74.2%) for outcome A and 45.7% (37.2%-54.3%) for outcome B. In safety studies on hepatotoxicity based on routine data using ICD-10-GM discharge codes and when validation of potential cases is not feasible, only the more specific codes should be used to describe ALI, and competing diagnoses for liver injury should be excluded to avoid substantial misclassification.

Community-acquired invasive Staphylococcus aureus: Uncovering disparities and the burden of disease in Auckland children.

Staphylococcus aureus (SA) causes serious invasive disease in children. Large studies have measured the incidence of SA bacteraemia, but there is less information on the total burden of community-acquired invasive SA (iSA) in children. A retrospective, cross-sectional analysis of Auckland resident children aged 0-14 years who were hospitalised with iSA between 2011 and 2015 was performed. Laboratory databases and SA-related international classification of diseases 10 discharge codes were searched to identify community-onset cases with SA isolated from a normally sterile site. Clinical records and coroner's reports were reviewed to determine clinical syndromes and exclude nosocomial infections. A total of 295 children with iSA were identified. The average annual incidence of iSA was 18.6 per 100 000 - for Pacific populations 44.3 per 100 000, Māori 24.3 per 100 000 and New Zealand European and other 8.8 per 100 000; 68% had bacteraemia. The incidence of iSA for Pacific infants was 10 times greater than non-Māori/non-Pacific (113.4/100 000 population vs. 11.8/100 000). Multivariate analysis found a higher risk of admission in Pacific children, males and those living in areas of high deprivation. Thirty-two patients (10.8%) were admitted to the intensive care unit; risk was higher in infants, Pacific children and those with respiratory infection (Relative Risk (RR) 12.2, 95% confidence interval (CI) 5.7-26.4) and multifocal (RR 6.9, 95% CI 3.4-13.8) and endovascular disease (RR 8.9, 95% CI 3.9-20.6). All deaths (n = 7) had respiratory infections, and four were patients <1 year of age. Studies investigating SA bacteraemia alone significantly underestimate the total burden of iSA disease. There are marked ethnic and socio-economic disparities in iSA disease among Auckland children. Pacific infants are at the highest risk.

Chronic kidney disease in preeclamptic patients: not found unless searched for-Is a nephrology evaluation useful after an episode of preeclampsia?

Preeclampsia (PE) and chronic kidney disease (CKD) are linked by an only partially known cause-effect relationship. Knowledge on prevalence of CKD in PE patients is needed for evaluating the diagnostic yield of nephrology work-up after PE. The study was undertaken in the Centre Hospitalier Le Mans (CHM), setting of tertiary level obstetric service (about 3500 deliveries/year). PE was identified on hospital's discharge codes; after review, the study included 99 patients, 36 of which were also evaluated in Nephrology. A descriptive analysis was performed as appropriate. Logistic multiple regression tested the outcome "CKD diagnosis"; covariates that emerged as significant were selected; only singletons were included. Analysis was performed in SPSS. The ethics committee of the CHM approved the study. Prevalence of CKD was 14%; CKD was in stage 1 in 8/14 (57%); 5 patients were in stage 2 (36%), 1 in stage 3 (7%). CKD was known or acknowledged in 1 case only. Diagnoses included reflux nephropathy-other malformations (5 cases), kidney stones-chronic pyelonephritis (3), PKD (1), interstitial nephropathy (2), diabetic nephropathy (1), albuminuria in metabolic syndrome (2). At the logistic regression analysis, preterm delivery [OR 7.849 (1.667-36.968)] and a baby normal for gestational age [> 10th centile; OR 6.193 (1.400-27.394)] were significantly correlated with the diagnosis of CKD. Within the limits of a single-center study, our data quantify CKD as common in PE women and suggest the presence of a "CKD phenotype" characterised by preterm delivery and adequate growth, implying that CKD is compatible with good placental function up to the last phase of pregnancy.

The prevalence of atrial fibrillation on 48-hour ambulatory electrocardiography in African Americans compared to Whites: The Atherosclerosis Risk in Communities (ARIC) study

BackgroundA lower prevalence of atrial fibrillation (AF), but paradoxically higher burden of cardiovascular disease risk factors, has been observed among African Americans compared to Whites in studies of AF identified by mostly 12-lead electrocardiograms (ECGs) and clinically. MethodsWe performed 48-hour ambulatory electrocardiography (aECG) in a biracial sample of 1,193 participants in the Atherosclerosis Risk in Communities (ARIC) (mean age = 78 years, 62% African Americans, 64% female). Atrial fibrillation was identified from aECG, study visit ECGs, and discharge codes from cohort hospitalizations. We used covariate-adjusted logistic regression to estimate prevalence odds ratios (ORs) for AF in African Americans versus Whites, with adjustment for sampling and nonresponse. ResultsAfrican Americans were more likely than Whites to have hypertension and diabetes but less likely to have coronary heart disease. The prevalence of AF detected by aECG or ARIC study ECG (adjusted for age and coronary heart disease) was lower in African Americans than Whites (2.7% vs 5.0%). White men had a higher (although not significant) AF prevalence of 7.8% compared to the other race and gender groups at 2.3%-2.8%. The adjusted OR for AF was 0.49 (0.24-0.99) comparing African Americans to Whites. Findings were similar when AF was defined to include prior AF hospitalizations (OR = 0.42, 0.25-0.72). There were no significant differences by race for asymptomatic or paroxysmal AF. ConclusionsAtrial fibrillation was less prevalent in African American than white older adults, regardless of detection method. Although overall detection of new AF cases with aECG was low, future studies should consider longer-term monitoring to characterize AF by race.

Detecting Undiagnosed Diabetes: Proof-of-Concept Based on the Health-Information Exchange System of the Veneto Region (North-East Italy).

Diabetes is a chronic illness characterised by elevated blood glucose levels, driving excess mortality. Its prompt detection and accurate management are critical for delaying complications. Nevertheless, diabetes can remain undiagnosed for years from the onset. The identification of undiagnosed diabetes is a public health priority: in Italy, it is estimated that up to 30% of diabetes cases remain undetected, i.e., that ~1.8 million citizens may be unaware they need medical help. Sometimes, this happens even though these subjects undergo routine or emergency check-ups. Veneto, a region in North-East Italy with 4.9 million residents, implements a regional Health Information Exchange system (rHIE) to collect healthcare data, including laboratory reports, and integrate them with administrative claims. Their combination may be instrumental in finding otherwise undetected cases of diabetes. On the one hand, known diabetic patients should have disease management-generated claims; on the other, laboratory test results can be independently evaluated against diagnostic criteria. In the present work, we examined the anonymised claims and laboratory data, extracted from the rHIE, of 23,376 citizens of the Veneto region. We compared their exemptions, diabetes-related hospitalisation discharge codes, and antidiabetic drugs between 2012 and 2018 to the results of their fasting glucose, glycated haemoglobin, and oral glucose tolerance tests in 2017-2018. We identified 1,407 (6.02%) subjects who, according to administrative claims, appear to be free from diabetes, but met at least one laboratory diagnostic criterion. Such a discrepancy suggests that these people may be undiagnosed diabetic patients. To the best of our knowledge, this is the first proof of concept of an automatic system for the detection of undiagnosed diabetes in Italy. Its full integration in the rHIE and its consequent capillary application could potentially reveal thousands of hidden cases throughout Veneto.

Validity of ICD-9 and ICD-10 codes used to identify acute liver injury: A study in three European data sources.

PurposeValidating cases of acute liver injury (ALI) in health care data sources is challenging. Previous validation studies reported low positive predictive values (PPVs).MethodsCase validation was undertaken in a study conducted from 2009 to 2014 assessing the risk of ALI in antidepressants users in databases in Spain (EpiChron and SIDIAP) and the Danish National Health Registers. Three ALI definitions were evaluated: primary (specific hospital discharge codes), secondary (specific and nonspecific hospital discharge codes), and tertiary (specific and nonspecific hospital and outpatient codes). The validation included review of patient profiles (EpiChron and SIDIAP) and of clinical data from medical records (EpiChron and Denmark). ALI cases were confirmed when liver enzyme values met a definition by an international working group.ResultsOverall PPVs (95% CIs) for the study ALI definitions were, for the primary ALI definition, 84% (60%‐97%) (EpiChron), 60% (26%‐88%) (SIDIAP), and 74% (60%‐85%) (Denmark); for the secondary ALI definition, 65% (45%‐81%) (EpiChron), 40% (19%‐64%) (SIDIAP), and 70% (64%‐77%) (Denmark); and for the tertiary ALI definition, 25% (18%‐34%) (EpiChron), 8% (7%‐9%) (SIDIAP), and 47% (42%‐52%) (Denmark). The overall PPVs were higher for specific than for nonspecific codes and for hospital discharge than for outpatient codes. The nonspecific code “unspecified jaundice” had high PPVs in Denmark.ConclusionsPPVs obtained apply to patients using antidepressants without preexisting liver disease or ALI risk factors. To maximize validity, studies on ALI should prioritize hospital specific discharge codes and should include hospital codes for unspecified jaundice. Case validation is required when ALI outpatient cases are considered.

Analysis of Emergency Department Visits for Motor Vehicle Injuries in Utah, 2016

ObjectiveTo describe the characteristics of emergency department (ED) visits for motor vehicle injuries in Utah using 2016 syndromic surveillance data.IntroductionMotor vehicle injury is the leading cause of death in injury category in the United States. In 2016, motor vehicle crashes were one of the main causes of death resulting from injury (8.8 per 100,000 population) in Utah. Motor vehicle crashes can lead to physical and economic consequences that impact the lives of individuals and their families. In addition, the treatment of injuries places an enormous burden on hospital Emergency Departments (EDs). Currently; there are no data sources other than syndromic data in the Utah Department of Health to monitor ED visits due to motor vehicle injuries in real time.MethodsUtah participates in the National Syndromic Surveillance Program (NSSP) to which all hospitals in the state submit ED visit data via the Electronic Surveillance System for the Early Notification of Community-based Epidemics (ESSENCE). ESSENCE was used to analyze 2016 ED visit data. Total population data were obtained from Utah population estimates. Data from 2017 was not included due to major system changes at a major healthcare system that interrupted data feeds resulting in lower than expected data volume.Motor vehicle injury is defined by existing subsyndrome definition in the Centers for Disease Control and Prevention ESSENCE system. All ED visit data were analyzed by querying key terms in the chief complaint field including any mention of: vehicle, wheeler, motorcycle, motor scooter, motor cycle, motor cross, truck, motorbike etc. Exclusion terms included any mention of: car dealership, hit head and car door. Ages were divided into seven groups for data distribution and comparison: 0–17, 18–24, 25–34, 35–44, 45–54, 55–64 and ≥ 65 years.ResultsIn 2016, a total of 28,472 ED visits (2% of total visits) were identified using the motor vehicle injury query. The ED visit rate for motor vehicle injuries was highest among persons aged 18–24 years (1,682 per 100,000 population). Rates continued to decline with increasing age after 18–24 years. The rate of females visiting the ED was higher than males (1,040 versus 826 per 100,000 population respectively; p &lt; 0.01) (Figure 1). The majority of injuries (11722(52%)) were reported between 10:00 a.m. and 5:59 p.m. Injuries were highest August-September (5913(22%)).ConclusionsSyndromic data is a robust source of data for analyzing ED visits due to motor vehicle injuries in real time, and providing information to injury prevention programs for targeting interventions. Our data suggest an increased risk of visiting an ED due to motor vehicle injuries by age group (18-24 year olds), sex (females), month (August-September), and time (10:00 a.m. to 5:59 p.m.). These results do not include visits with incomplete or incorrectly coded chief complaints or discharge codes, patients of motor vehicle injuries who do not present to the ED, or not classified as ‘emergency’ patient class.

Association of Brain Magnetic Resonance Imaging Signs With Cognitive Outcomes in Persons With Nonimpaired Cognition and Mild Cognitive Impairment

Brain atrophy and vascular lesions contribute to dementia and mild cognitive impairment (MCI) in clinical referral populations. Prospective evidence in older general populations is limited. To evaluate which magnetic resonance imaging (MRI) signs are independent risk factors for dementia and MCI. This population-based cohort study included 1553 participants sampled from the Atherosclerosis Risk in Communities Study who had brain MRI scans and were dementia free during visit 5 (June 2011 to September 2013). Participants' cognitive status was evaluated through visit 6 (June 2016 to December 2017). Brain regional volumes, microhemorrhages, white matter hyperintensity (WMH) volumes, and infarcts measured on 3-T MRI. Cognitive status (dementia, MCI, or nonimpaired cognition) was determined from in-person evaluations. Dementia among participants who missed visit 6 was identified via dementia surveillance and hospital discharge or death certificate codes. Cox proportional hazards models were used to evaluate the risk of dementia in 3 populations: dementia-free participants (N = 1553), participants with nonimpaired cognition (n = 1014), and participants with MCI (n = 539). Complementary log-log models were used for risk of MCI among participants with nonimpaired cognition who also attended visit 6 (n = 767). Models were adjusted for demographic variables, apolipoprotein E ε4 alleles, vascular risk factors, depressive symptoms, and heart failure. Overall, 212 incident dementia cases were identified among 1553 participants (mean [SD] age at visit 5, 76 [5.2] years; 946 [60.9%] women; 436 [28.1%] African American) with a median (interquartile range) follow-up period of 4.9 (4.3-5.2) years. Significant risk factors of dementia included lower volumes in the Alzheimer disease (AD) signature region, including hippocampus, entorhinal cortex, and surrounding structures (hazard ratio [HR] per 1-SD decrease, 2.40; 95% CI, 1.89-3.04), lobar microhemorrhages (HR, 1.90; 95% CI, 1.30-2.77), higher volumes of WMH (HR per 1-SD increase, 1.44; 95% CI, 1.23-1.69), and lacunar infarcts (HR, 1.66; 95% CI, 1.20-2.31). The AD signature region volume was also consistently associated with both MCI and progression from MCI to dementia, while subcortical microhemorrhages and infarcts contributed less to the progression from MCI to dementia. In this study, lower AD signature region volumes, brain microhemorrhages, higher WMH volumes, and infarcts were risk factors associated with dementia in older community-based residents. Vascular changes were more important in the development of MCI than in its progression to dementia, while AD-related signs were important in both stages.

The association between admission glucose levels and outcomes in adults admitted to a tertiary care hospital

ABSTRACTBackground: Hyperglycemia at the time of hospital admission has been associated with poor outcomes in several patient groups, but there is little information about this association in hospitalized patients with diverse diagnoses.Methods: We identified all adult patients admitted between 10/1/2015 and 9/30/2016 who had glucose levels measured during the first 24 h after admission to the hospital. Clinical information included age, gender, glucose levels, diagnoses based on ICD 10 discharge coding, length of stay (LOS), and mortality. Patients were classified into quartiles based on glucose levels and into clinically relevant glucose categories.Results: This study included 18,478 adult patients admitted to a tertiary care hospital. The median age was 53 years, the median LOS was 4 days, and the overall in-hospital mortality was 3.8%. The median admission glucose level was 117 mg/dL. Mortality increased in each glucose quartile; it was also highest in patients admitted with a glucose <55 mg/dL or with a glucose >200 mg/dL. The LOS was significantly shorter in patients in glucose quartiles 1 and 2.Conclusions: Admission glucose levels were associated with in-hospital mortality and LOS in this cohort of hospitalized patients. Attention to glucose levels can help identify patients at risk for poor outcomes.

PGI14 HOSPITAL LENGTH OF STAY FOR PATIENTS DIAGNOSED WITH C. DIFFICILE INFECTION LINKED TO DIAGNOSTIC TEST METHOD – – REAL WORLD EVIDENCE FROM U.S.

Yearly, Clostridioides difficile (C. diff) leads to almost half a million infections among patients in the U.S. Inpatient C. diff infections (CDI) are attributed to greater institutional costs and worse patient outcomes, which include increased: (1) total length of stay (LOS); (2) rates of intensive care unit (ICU) admission; and (3) inpatient mortality. Reducing risk factors for C. diff transmission and incorporating effective infection control measures lead to demonstrated improvements in overall outcomes and quality measures. Among these strategies, LOS-focused interventions, whereby the potential C. diff exposure time is reduced, have shown to decrease overall transmission rates and positively impact patient outcomes. The diagnosis of CDI is based on a combination of both observed clinical symptoms and diagnostic tests that either detect the presence of the toxin antigen via enzyme immunoassays (EIAs) or the organism directly using nucelic acid amplification tests (NAATs). Here, we assess the impact to inpatient LOS relative to the CDI diagnostic test method used based on discharges captured in the Premier Healthcare Database, a patient-level data warehouse containing de-identified inpatient and outpatient records from over 700 U.S.-based hospitals. The retrospective observational cohort study included patients with a discharge code of CDI between January 1, 2011 and December 31, 2016. Matched patients tested by either NAAT or EIA were included in the analysis, with a total of 11,180 patients per group. The mean LOS for CDIs diagnosed with NAATs and EIAs were 9.51 (95% CI: 9.34-9.68) and 10.27 (95% CI: 10.08-10.46) days, respectively (P < 0.0001). The use of a NAAT assay for the diagnosis of CDI demonstrated an overall, and significant, reduced LOS. Due to the correlation between LOS and CDI transmission rates, any measure aimed at reducing LOS should be considered as part of a larger CDI-prevention strategy.

Circulating ceruloplasmin, ceruloplasmin‐associated genes and the incidence of venous thromboembolism in the Atherosclerosis Risk in Communities study

Essentials Ceruloplasmin (CP) is an acute-phase reactant and a potential biomarker of atherothrombotic risk. We assessed associations between CP and venous thromboembolism (VTE) risk in 9933 individuals. Higher circulating CP but not CP-related genes were associated with greater incident VTE rates. Circulating CP could be considered a non-causal biomarker of VTE risk in the community. SUMMARY: Background Ceruloplasmin (CP) is an acute-phase reactant and a potential biomarker of atherothrombotic risk. We assessed the associations between CP, CP-associated genetic variants and incident venous thomboembolism (VTE) in the Atherosclerosis Risk in Communities study. Methods and results In an observational study, 9933 men and women aged 53-75years without prevalent VTE were included in 1996-1998 and followed through 2011. Circulating CP was measured in stored blood samples obtained in 1996-1998. Polymorphisms rs11708215 and rs13072552, which have been previously associated with CP concentrations, were measured in 8439 participants. VTEs were identified from hospital discharge codes and validated by physician review of medical records and imaging reports. Over a mean of 10.5years of follow-up, 376 cases of VTE were identified. The association between circulating CP, CP-associated polymorphisms and the incidence of VTE was estimated. After adjustment for traditional risk factors and biomarkers, higher concentrations of circulating CP were associated with greater incident VTE rates (hazard ratio 1.82, 95% confidence interval 1.12-2.95, comparing the 87.5-100th percentile with the bottom quartile). Both rs11708215 and rs13072552 were associated with CP concentrations but not with VTE risk. Conclusions Even though high CP concentrations were associated with an increased VTE risk, CP-associated genetic variants were not associated with a higher risk of VTE. Our results suggest that circulating CP concentrations may not be causally related to the risk of incident VTE.

Low-Carbohydrate Diets and Risk of Incident Atrial Fibrillation: AProspective Cohort Study.

BackgroundThe influences of low‐carbohydrate diets in cardiovascular disease are controversial. Few studies have examined the relationship of carbohydrate intake and risk of incident atrial fibrillation (AF). We aimed to evaluate the association between carbohydrate intake and the risk of incident AF in the ARIC (Atherosclerosis Risk in Communities) Study.Methods and ResultsWe included 13 385 participants (age, 54.2±5.8 years; 45.1% men and 74.7% white) who completed a dietary questionnaire at baseline (1987–1989) in the ARIC Study. The primary outcome was incident AF, which was identified by ECG performed during study examinations, hospital discharge codes, and death certificates. We used multivariable Cox hazard regression models to assess the association between carbohydrate intake and incident AF. We further explored the effects of specific food source (animal versus plant based) used to replace carbohydrate intake in the low‐carbohydrate intake setting. During a median follow‐up of 22.4 years, 1808 cases (13.5%) of AF occurred. The hazard ratio for incident AF associated with a 1‐SD (9.4%) increase in carbohydrate intake as a percentage of energy intake was 0.82 (95% CI, 0.72–0.94), after adjustment for traditional AF risk factors and other diets factors. Results were similar when individuals were categorized by carbohydrate intake quartiles (hazard ratio, 0.64; 95% CI, 0.49–0.84; comparing extreme quartiles). No association was found between the type of protein or fat used to replace the carbohydrate and risk of incident AF.ConclusionsLow‐carbohydrate diets were associated with increased risk of incident AF, regardless of the type of protein or fat used to replace the carbohydrate.

Validation of hospital discharge coding for neonatal abstinence syndrome

To validate the diagnostic discharge coding of neonatal abstinence syndrome (NAS) (International Classification of Diseases [ICD]-10-AM, P96.1). Retrospective record review of infants diagnosed with NAS (P96.1) in a non-tertiary Australian hospital between 2000 and 2016. NAS criteria were predetermined to include the following: (i) maternal opioid use; (ii) infant requiring NAS medication and (iii) at least one score of ≥8 on the Finnegan Neonatal Abstinence Scoring Tool (FNAST). Of the 253 infants coded with P96.1, 82/146 (56%) opioid-exposed infants and 9/107(18%) infants exposed to non-opioid drugs only received withdrawal medication: sensitivity 56.2 (95% confidence interval: 47.7-64.3), specificity 91.6 (84.2-95.8%), positive predictive value (PPV) 90.1 (81.6-95.1%) and negative predictive value (NPV) 60.5 (52.5-68.0%) for all three criteria. Using the criterion of ≥1 FNAST score ≥8 resulted in 58.0 (51.3-64.4%) sensitivity, 63.6 (40.8-82.0%) specificity, 94.4 (88.8-97.4%) PPV and 12.6 (7.3-20.6%) NPV for identifying need for NAS medications. A diagnosis of P96.1 is highly specific and predictive but poorly sensitive for identifying opioid-exposed infants requiring medications for withdrawal.

Risk of Cardiovascular Disease and Mortality in Young Adults With End-stage Renal Disease

Cardiovascular disease (CVD) is a leading cause of death among patients with end-stage renal disease (ESRD). Young adult (ages 22-29 years) have risks for ESRD-associated CVD that may vary from other ages. To test the hypothesis that young adult-onset ESRD is associated with higher cardiovascular (CV) hospitalizations and mortality with different characteristics than childhood-onset disease. This population-based cohort study used the US Renal Data System to categorize patients who initiated ESRD care between 2003 and 2013 by age at ESRD onset (1-11, 12-21, and 22-29 years). Cardiovascular hospitalizations were identified via International Classification of Diseases, Ninth Revision discharge codes and CV mortality from the Centers for Medicare & Medicaid ESRD Death Notification Form. Patients were censored at death from non-CVD events, loss to follow-up, recovery, or survival to December 31, 2014. Adjusted proportional hazard models (95% CI) were fit to determine risk of CV hospitalization and mortality by age group. Data analysis occurred from May 2016 and December 2017. Onset of ESRD. Cardiovascular mortality and hospitalization. A total of 33 156 patients aged 1 to 29 years were included in the study population. Young adults (aged 22-29 years) had a 1-year CV hospitalization rate of 138 (95% CI, 121-159) per 1000 patient-years. Young adults had a higher risk for CV hospitalization than children (aged 1-11 years; hazard ratio [HR], 0.41 [95% CI, 0.26-0.64]) and adolescents (aged 12-21 years; HR, 0.86 [95% CI, 0.77-0.97]). Of 4038 deaths in young adults, 1577 (39.1%) were owing to CVD. Five-year cumulative incidence of mortality in this group (7.3%) was higher than in younger patients (adolescents, 4.0%; children, 1.7%). Adjusted HRs for CV mortality were higher for young adults with all causes of ESRD than children (cystic, hereditary, and congenital conditions: HR, 0.22 [95% CI, 0.11-0.46]; P < .001; glomerulonephritis: HR, 0.21 [95% CI, 0.10-0.44]; P < .001; other conditions: HR, 0.33 [95% CI, 0.23-0.49]; P < .001). Adolescents had a lower risk for CV mortality than young adults for all causes of ESRD except glomerulonephritis (cystic, hereditary, and congenital conditions: HR, 0.45 [95% CI, 0.27-0.74]; glomerulonephritis: HR, 0.99 [95% CI, 0.76-1.11]; other: HR, 0.47 [95% CI, 0.40-0.57]). Higher risks for CV hospitalization and mortality were associated with lack of preemptive transplant compared with hemodialysis (hospital: HR, 14.24 [95% CI, 5.92-34.28]; mortality: HR, 13.64 [95% CI, 8.79-21.14]) and peritoneal dialysis [hospital: HR, 8.47 [95% CI, 3.50-20.53]; mortality: HR, 7.86 [95% CI, 4.96-12.45]). Nephrology care before ESRD was associated with lower risk for CV mortality (HR, 0.77 [95% CI, 0.70-0.85]). Cardiovascular disease accounted for nearly 40% of deaths in young adults with incident ESRD in this cohort. Identified risk factors may inform development of age-appropriate ESRD strategies to improve the CV health of this population.

Body mass index and body fat distribution and new-onset atrial fibrillation: Substudy of the European Prospective Investigation into Cancer and Nutrition in Norfolk (EPIC-Norfolk) study

Background and aimObesity is a recognized risk factor for new-onset atrial fibrillation (AF). The association between body fat distribution, which is measured by body mass index (BMI) and waist–hip ratio (WHR), its changes, and new-onset AF is conflicting. Methods and resultsParticipants of the European Prospective Investigation into Cancer and Nutrition in Norfolk cohort study were included, with exclusion criteria of prevalent AF, rheumatic heart disease, and cancer. AF was confirmed by the International Classification of Diseases-10 hospital discharge code I48. Adjusted sex-specific Cox proportional hazards models were used to quantify the AF risk per 1 standard deviation increase and for quintiles of adiposity indices. A total of 10,885 men and 12,857 women were followed up for a median of 19 years, yielding 451,098 person-years. New-onset AF was diagnosed in 1408 (12.9%) men and 1102 (8.6%) women. Multivariable analyses showed that BMI predicted new-onset AF in all, while WHR predicted only in men. New-onset AF risk gradually increased across the range of adiposity indices: for men in the highest BMI quintile, HR: 1.59 (CI 1.32–1.91, p for trend<0.001), whereas for women in the highest BMI quintile, HR: 1.52 (CI 1.23–1.88, p for trend<0.001). Further, for men in the highest WHR quintile, HR: 1.31 (CI 1.09–1.57, p for trend: 0.01), whereas for women in the highest WHR quintile, HR: 1.12 (CI 0.90–1.41, p for trend: 0.17). The change in BMI and WHR was similar in participants with or without new-onset AF. ConclusionsAn increased body mass, as measured by BMI, is associated with an increased risk of developing new-onset AF. More abdominal fat distribution, as measured by WHR, is associated with an increased risk of developing new-onset AF in men but not in women.

Abstract MP21: Heart Failure Risk Associated With Optimal Levels of Modifiable HF Risk Factors: The Atherosclerosis Risk in Communities Study (ARIC)

Background: Several heart failure (HF) risk factors, including hypertension, diabetes mellitus, obesity, and physical activity, are well described. However, the degree to which optimization of these modifiable risk factors might impact the incidence of HF is not yet fully defined. Hypothesis: We hypothesized more optimal control of major modifiable HF risk factors is associated with progressively lower HF risk. Methods: We performed a prospective analysis of 13,534 ARIC participants (mean age 57, 55% female), examining HF risk associations of different cutpoints of glycemia (HbA1c), systolic blood pressure (SBP), body mass index (BMI) and physical activity (assessed at Visit 2 [1990-92], except for physical activity assessed at Visit 1 (1987-89]). Optimal risk factor control was defined as HbA1c &lt; 7%, SBP &lt; 120 mmHg, BMI 18.5-25 kg/m 2 , and AHA-recommended activity levels. Severely uncontrolled risk factors were defined as HbA1c &gt; 8%, SBP &gt; 160 mmHg, BMI &gt; 35 kg/m 2 and no exercise physical activity. Intermediate values were considered mild to moderately uncontrolled. Cox models simultaneously including all risk factors were constructed to assess associations of risk factor levels with incident HF (by discharge codes) after Visit 2 through 2016. Results: There were 2,827 HF events over a median 24 years of follow-up. Risk gradations were seen across categorizations of each risk factor (Table). In the full model, relative to optimal control, HRs were 2.06 for BMI ≥ 35 kg/m 2 , 1.16 for poor physical activity, 2.31 for HbA1c &gt; 8% and 1.80 for SBP ≥ 160 mmHg. No risk gradient was seen from SBP &lt; 120 to 140 mmHg among hypertensives. Incidence rates (per 1000 PYs) were 7.9 for all optimally controlled risk factors, 14.5 for 3-4 mild to moderately uncontrolled risk factors and 39.5 for 3-4 severely uncontrolled risk factors. Conclusion: Optimal control of modifiable risk factors is strongly linked to lower HF risk. Our findings suggest prioritizing optimization of existing risk factors may be central to successful strategies to prevent HF onset.

Abstract P147: Longer Duration on a Chronic Disease Management Plan is Associated with Fewer CVD-Related Readmissions by 3 Years Among Australian Survivors of Stroke

Background: Chronic Disease Management (CDM) plans are usually administered by general practitioners (GPs) to assist those with a chronic medical condition, such as stroke, and provide better management of risk factors. Despite the prevalent use of CDM plans, its comprehensiveness and the fact that there is a government commitment to fund it, there is limited evidence of its effectiveness in Australian survivors of stroke. We aimed to assess the effectiveness of CDM plans on preventing the recurrence of CVD-related serious adverse events. Methods: Patients comprised survivors of stroke/TIA who participated in the Shared Team Approach between Nurses and Doctors For Improved Risk factor Management (STAND FIRM) trial (n = 563). We used standardised anthropometric, biochemical and blood pressure data, collected at baseline, to evaluate risk factors for stroke/TIA. Poisson regression models were used to determine the incidence rate ratio (IRRs) of increasing exposure to being on a CDM plan over 3 years, while adjusting for confounding factors. We used the total count of CVD-related events and deaths within 3 years after stroke/TIA, based on either hospital discharge codes or adjudication by two independent stroke specialists. Results: Five hundred and sixty-three patients were included (median age 70; 36% female). There were 305 CVD-related events over the three years (mean 0.54), in which a third (104) were adjudicated and two-thirds (201) were derived from hospital discharge codes alone. Nearly a quarter (27%) did not take up a CDM plan over the three years, a third (33%) were on plans for less than 1.5 years and 40% were on plans from 1.5 years to 3 years. The factors most strongly associated with decreased incidence of CVD-related events were duration on a CDM plan (Adjusted IRR (aIRR) 0.85, 95% confidence interval (95%CI) 0.77-0.93; p&lt;0.001), higher level of education (aIRR 0.55, 95%CI 0.42-0.71; p&lt;0.001), more physically active occupation (aIRR 0.54, 95%CI 0.41-0.70; p&lt;0.001) and greater Assessment of Quality of Life (AQoL) score (aIRR 0.24, 95%CI 0.15-0.41; p&lt;0.001). Conclusion: Being on a CDM plan for a longer duration appeared to reduce the occurrence of CVD-related events within 3 years after stroke, potentially via more closely controlled risk factors. Patients should be encouraged to return for regular reviews of their CDM plans to enhance secondary prevention strategies, and maintain a better quality of life.

Abstract P013: Serum Uric Acid is Not Associated With Incident Dementia in the ARIC-NCS Cohort

Background: Recent studies have investigated the involvement of serum uric acid (SUA) in the progression of cognitive decline and dementia with conflicting results. SUA is known to be associated with hypertension, inflammation, and other cardiovascular risk factors, which often contribute to dementia and dementia-like morbidity, yet several cross-sectional studies have suggested that its antioxidant properties may be protective against cognitive decline. Hypothesis: We hypothesized lower levels of serum uric acid at baseline would be associated with an increased risk of incident dementia. Methods: The ARIC study is an ongoing, biracial, community-based cohort study in the US with longitudinal data first collected in 1987. Participants were examined during follow-up throughout 6 visits (last one 2016-17). Serum uric acid measurements were collected through fasting blood samples in 1990-92 (age range 47-70 years), baseline for this analysis. Incident dementia was determined based on examiner assessments at visits 5 (2011-13) and 6 (2016-17), dementia surveillance based on dementia screeners conducted over telephone interviews starting from visit 5, hospitalization discharge codes, and death certificates prior to visit 6. We estimated the association of SUA, categorized into quartiles, with incidence of dementia by calculating hazard ratios (HR) using Cox regression models adjusting for potential confounders. Results: Our analysis included 11,452 participants free of dementia, prevalent coronary heart disease, or stroke, and with available SUA followed for a median of 24.1 years. Baseline SUA in the highest quartile was associated with incident dementia [HR (95% CI): 1.22 (1.07, 1.38)] when adjusted for age, race, gender, and education level. However, after full adjustment including cardiovascular risk factors, this relationship disappeared (Table). Conclusion: Within a large community-based cohort, we found no evidence of SUA’s influence on incident dementia independent of cardiovascular risk factors.

Risk of Acute Liver Injury in Agomelatine and Other Antidepressant Users in Four European Countries: A Cohort and Nested Case-Control Study Using Automated Health Data Sources.

BackgroundAgomelatine is a melatonin receptor agonist and serotonin 5-HT2C receptor antagonist indicated for depression in adults. Hepatotoxic reactions like acute liver injury (ALI) are an identified risk in the European risk management plan for agomelatine. Hepatotoxic reactions have been reported for other antidepressants, but population studies quantifying these risks are scarce. Antidepressants are widely prescribed, and users often have risk factors for ALI (e.g. metabolic syndrome).ObjectiveThe goal was to estimate the risk of ALI associated with agomelatine and other antidepressants (fluoxetine, paroxetine, sertraline, escitalopram, mirtazapine, venlafaxine, duloxetine, and amitriptyline) when compared with citalopram in routine clinical practice.MethodA nested case–control study was conducted using data sources in Denmark, Germany, Spain, and Sweden (study period 2009–2014). Three ALI endpoints were defined using International Classification of Diseases (ICD) codes: primary (specific codes) and secondary (all codes) endpoints used only hospital discharge codes; the tertiary endpoint included both inpatient and outpatient settings (all codes). Validation of endpoints was implemented. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for current use were estimated for each data source and combined.ResultsWe evaluated 3,238,495 new antidepressant and 74,440 agomelatine users. For the primary endpoint, the OR for agomelatine versus citalopram was 0.48 (CI 0.13–1.71). Results were also < 1 when no exclusion criteria were applied (OR 0.37; CI 0.19–0.74), when all exclusion criteria except alcohol and drug abuse were applied (OR 0.47; CI 0.20–1.07), and for the secondary (OR 0.40; CI 0.05–3.11) and tertiary (OR 0.79; CI 0.50–1.25) endpoints. Regarding other antidepressants versus citalopram, most OR point estimates were also below one, although with varying widths of the 95% CIs. The result of the tertiary endpoint and the sensitivity analyses of the primary endpoint were the most precise.ConclusionIn this study, using citalopram as a comparator, agomelatine was not associated with an increased risk of ALI hospitalisation. The results for agomelatine should be interpreted in the context of the European risk minimisation measures in place. Those measures may have induced selective prescribing and could explain the lower risk of ALI for agomelatine when compared with citalopram. Most other antidepressants evaluated had ORs suggesting a lower risk than citalopram, but additional studies are required to confirm or refute these results.Electronic supplementary materialThe online version of this article (10.1007/s40263-019-00611-9) contains supplementary material, which is available to authorized users.