Publications

Background

Women with congenital heart disease (CHD) may be at increased risk for adverse events during pregnancy and delivery.

Objective

To compare delivery outcomes between women with and without CHD.

Design, Setting, and Participants

This retrospective study of inpatient delivery admissions in the Healthcare Cost and Utilization Project's California State Inpatient Database compared maternal and fetal outcomes between women with and without CHD by using multivariate logistic regression. Female patients with codes for delivery from the International Classification of Diseases, Ninth Revision, from January 1, 2005, through December 31, 2011, were included. The association of CHD with readmission was assessed to 7 years after delivery. Cardiovascular morbidity and mortality were hypothesized to be higher among women with CHD. Data were analyzed from April 4, 2014, through January 23, 2017.

Exposures

Noncomplex and complex CHD.

Main Outcomes and Measures

Maternal outcomes included in-hospital arrhythmias, eclampsia or preeclampsia, congestive heart failure (CHF), length of stay, preterm labor, anemia complicating pregnancy, placental abnormalities, infection during labor, maternal readmission at 1 year, and in-hospital mortality. Fetal outcomes included growth restriction, distress, and death.

Results

Among 3 642 041 identified delivery admissions, 3189 women had noncomplex CHD (mean [SD] age, 28.6 [7.6] years) and 262 had complex CHD (mean [SD] age, 26.5 [6.8] years). Women with CHD were more likely to undergo cesarean delivery (1357 [39.3%] vs 1 164 509 women without CHD [32.0%]; P < .001). Incident CHF, atrial arrhythmias, ventricular arrhythmias, and maternal mortality were uncommon during hospitalization, with each occurring in fewer than 10 women with noncomplex or complex CHD (<0.5% each). After multivariate adjustment, noncomplex CHD (odds ratio [OR], 9.7; 95% CI, 4.7-20.0) and complex CHD (OR, 56.6; 95% CI, 17.6-182.5) were associated with greater odds of incident CHF. Similar odds were found for atrial arrhythmias in noncomplex (OR, 8.2; 95% CI, 3.0-22.7) and complex (OR, 31.8; 95% CI, 4.3-236.3) CHD, for fetal growth restriction in noncomplex (OR, 1.6; 95% CI, 1.3-2.0) and complex (OR, 3.5; 95% CI, 2.1-6.1) CHD, and for hospital readmission in both CHD groups combined (OR, 3.6; 95% CI, 3.3-4.0). Complex CHD was associated with greater adjusted odds of serious ventricular arrhythmias (OR, 31.8; 95% CI, 4.3-236.3) and maternal in-hospital mortality (OR, 79.1; 95% CI, 23.9-261.8).

Conclusions and Relevance

In this study of hospital admissions for delivery in California, CHD was associated with incident CHF, atrial arrhythmias, and fetal growth restriction and complex CHD was associated with ventricular arrhythmias and maternal in-hospital mortality, although these outcomes were rare, even in women with complex CHD. These findings may guide monitoring decisions and risk assessment for pregnant women with CHD at the time of delivery.

Clear cell renal cell carcinoma (ccRCC) represents the most common type of kidney cancer with high mortality in its advanced stages. Our study aim was to explore the correlation between tumor epithelial-to-mesenchymal transition (EMT) and patient survival. Renal biopsies of tumorous and adjacent nontumorous tissue were taken with a 16 g needle from our patients ( = 26) undergoing partial or radical nephrectomy due to ccRCC RNA sequencing libraries were generated using Illumina TruSeq Access library preparation protocol and TruSeq Small RNA library preparation kit. Next generation sequencing (NGS) was performed on Illumina HiSeq2500. Comparative analysis of matched sample pairs was done using the Bioconductor Limma/voom R-package. Liquid chromatography-tandem mass spectrometry and immunohistochemistry were applied to measure and visualize protein abundance. We detected an increased generic EMT transcript score in ccRCC Gene expression analysis showed augmented abundance of and , as well as down-regulated expression of (klotho). Moreover, microRNA analyses demonstrated a positive expression correlation of miR-34a and its targets and Survival analysis based on a subset of genes from our list EMT-related genes in a publicly available dataset showed that the EMT genes correlated with ccRCC patient survival. Several of these genes also play a known role in fibrosis. Accordingly, recently published classifiers of solid organ fibrosis correctly identified EMT-affected tumor samples and were correlated with patient survival. EMT in ccRCC linked to fibrosis is associated with worse survival and may represent a target for novel therapeutic interventions.

OBJECTIVE

Among African Americans, the apolipoprotein L1 () risk variants have been associated with various types of kidney disease and chronic kidney disease progression. We aimed to determine whether these same risk variants also confer an increased risk for cardiovascular disease.

APPROACH AND RESULTS

In a cohort of African Americans with hypertension-attributed chronic kidney disease followed for up to 12 years, we used Cox proportional hazards models to estimate the relative hazard of a composite cardiovascular disease outcome (cardiovascular death or hospitalization for myocardial infarction, cardiac revascularization procedure, heart failure, or stroke) for the high- (2 risk variants) versus low-risk (0-1 risk variant) genotypes. We adjusted for age, sex, ancestry, smoking, heart disease history, body mass index, cholesterol, randomized treatment groups, and baseline and longitudinal estimated glomerular filtration rate, systolic blood pressure, and proteinuria. Among 693 participants with genotyping available (23% high risk), the high-risk group had lower mean estimated glomerular filtration rate (44.7 versus 50.1 mL/min per 1.73 m) and greater proteinuria (median 0.19 versus 0.06) compared with the low-risk group at baseline. There was no significant association between genotypes and the composite cardiovascular disease outcome in both unadjusted (hazard ratio=1.23; 95% confidence interval: 0.83-1.81) and fully adjusted (hazard ratio=1.16; 95% confidence interval: 0.77-1.76) models; however, in using an additive model, high-risk variants were associated with increased cardiovascular mortality.

CONCLUSIONS

Among African Americans with hypertension-attributed chronic kidney disease, risk variants were not associated with an overall risk for cardiovascular disease although some signals for cardiovascular mortality were noted.

OBJECTIVE

Obstructive sleep apnea (OSA) remains a prevalent condition, but its occupational burden is unclear. We carried out a systematic review to characterize the consistency and magnitude of occupational associations with OSA.

METHODS

We studied OSA within three occupational categories: commercial drivers, organic solvent-exposed workers, other selected occupations. We performed a meta-analysis on the prevalence of OSA among drivers and the risk of OSA associated with solvent exposure.

RESULTS

The pooled OSA prevalence in drivers was 41% (95% confidence interval [CI] 26% to 56%) for apnea hypopnea-index (AHI) is greater than 5, and 15% (95% CI 12% to 19%) for AHI is greater than 15. Exposure to solvents was associated with increased but non-statistically significant risk of OSA: summary relative risk, 2.38 (95% CI 0.89 to 6.32). Evidence of occupational association was inconsistent for other factors.

CONCLUSIONS

OSA is common among commercial drivers and potentially associated with occupations involving likely solvent exposure.

Little is known about associations between viral suppression, adherence, and duration of prior viral suppression in sub-Saharan Africa. Study participants were from the UARTO study in Mbarara, Uganda. We fit regression models to characterize relationships between average adherence, treatment interruptions, and rebound viremia (>400 copies/mL) following a previously undetectable result. Our goal was to understand the impact of prior viral suppression on these relationships. 396 participants contributed 2864 quarterly visits. Restricted to periods with average adherence <50 %, each 10 % increase in adherence reduced the odds of rebound viremia by 74 % [adjusted odds ratio (AOR) = 0.26, P = 0.002] and 29 % (AOR = 0.71, P = 0.057) during the first 12 months of suppression and beyond 12 months respectively, interaction term P = 0.018. Among periods with adherence ≥50 %, the risk of rebound viremia decreased with increasing adherence during the first 12 months of viral suppression (AOR = 0.73 for each 10 % increase, P = 0.001), but not thereafter (AOR = 1.09, P = 0.67), interaction term P = 0.027. In contrast, 72-h interruptions, were associated with increased rebound viremia during the first 12 months (AOR = 1.30, P = 0.009) and after (AOR = 1.39, P = 0.005), interaction term P = 0.69. Completing 12 months of viral suppression decreases the impact of average adherence, but not prolonged treatment interruptions, on risk of rebound viremia.