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Spokane, WA, United States

Raabe R.D.,Providence Sacred Heart Medical Center And Childrens Hospital | Burr R.B.,Providence Sacred Heart Medical Center And Childrens Hospital | Short R.,Providence Medical Research Center
Journal of Vascular and Interventional Radiology | Year: 2010

Purpose: To assess relatively long-term (ie, 1 year) neurocognitive outcomes of patients undergoing carotid artery stent (CAS) placement with cerebral protection. Materials and Methods: Sixty-two patients (19 symptomatic; mean age, 73 years) with significant carotid stenosis (≥ 70% for symptomatic patients, ≥ 80% for asymptomatic patients) underwent CAS placement with embolic protection. Cognitive function was assessed prospectively with use of a battery of standardized tests administered at baseline (1-5 days before CAS endovascular therapy) and at 3, 6, and 12 months after CAS placement. Diffusion-weighted imaging (DWI) was performed before the procedure and within 24 hours after CAS placement. Results: Results of statistical modeling across occasions of measurement indicated significant main effects of occasion for the Dementia Rating Scale (DRS)-2 concept formation (P < .001), memory (P = .029), and total scores (P = .001); the DRS-2 total age- and education-corrected Mayo Older Americans Normative Studies score (P < .001); and the North American Adult Reading Test IQ score (P = .003). The vast majority of patients showed improvement or no change relative to baseline DRS-2 total scores at all time points. No significant relationship between DWI outcomes and cognition scores over time was found. Age influenced improvement on cognitive tests, whereas baseline symptom status did not. Conclusions: Revascularization with a carotid stent and neuroprotection, at a minimum, left cognitive function unchanged in patients receiving a CAS, and in many instances improved it. The preliminary findings of this prospective pilot study should be confirmed with a larger, controlled trial. © 2010 SIR.


Afkarian M.,University of Washington | Sachs M.C.,University of Washington | Kestenbaum B.,University of Washington | Hirsch I.B.,University of Washington | And 4 more authors.
Journal of the American Society of Nephrology | Year: 2013

Type 2 diabetes associates with increased risk of mortality, but how kidney disease contributes to this mortality risk among individuals with type 2 diabetes is not completely understood.Here, we examined 10-year cumulative mortality by diabetes and kidney disease status for 15,046 participants in the Third National Health and Nutrition Examination Survey (NHANES III) by linking baseline data from NHANES III with the National Death Index. Kidney disease, defined as urinary albumin/creatinine ratio ≥30 mg/g and/or estimated GFR ≤60 ml/min per 1.73 m2, was present in 9.4% and 42.3% of individuals without and with type 2 diabetes, respectively. Among people without diabetes or kidney disease (reference group), 10-year cumulative all-causemortality was 7.7% (95%confidence interval [95%CI], 7.0%-8.3%), standardized to population age, sex, and race. Among individuals with diabetes but without kidney disease, standardized mortality was 11.5% (95% CI, 7.9%-15.2%), representing an absolute risk difference with the reference group of 3.9% (95% CI, 0.1%-7.7%), adjusted for demographics, and 3.4% (95% CI, 20.3% to 7.0%) when further adjusted for smoking, BP, and cholesterol. Among individuals with both diabetes and kidney disease, standardized mortality was 31.1% (95% CI, 24.7%-37.5%), representing an absolute risk difference with the reference group of 23.4% (95% CI, 17.0%-29.9%), adjusted for demographics, and 23.4% (95% CI, 17.2%-29.6%) when further adjusted. We observed similar patterns for cardiovascular and noncardiovascular mortality. In conclusion, those with kidney disease predominantly account for the increased mortality observed in type 2 diabetes. Copyright © 2013 by the American Society of Nephrology.


Tuttle K.R.,Providence Medical Research Center | Tuttle K.R.,University of Washington | Tuot D.S.,University of California at San Francisco | Corbett C.L.,Providence Medical Research Center | And 4 more authors.
Clinical Journal of the American Society of Nephrology | Year: 2013

Strategies to effectively treat people with CKD have been identified by conventional clinical research. Despite this evidence, awareness, screening, detection, diagnosis, risk factor control, treatment, and outcomes remain substandard. Translating clinical evidence into actionable measures that reduce the burden of CKD is a pressing need. Expansion from a "bench-to-bedside" paradigm (conventional type 1 translation) to research that encompasses "clinic and community" is the core concept of type 2 translation. Specifically, this is the discipline of identifying factors and using strategies that lead to adoption, maintenance, and sustainability of science-based interventions in practice. This review identifies key elements of type 2 translational research and highlights the current scope of this type of research for CKD. For type 2 translation to achieve the goals of providing high-quality care and better health outcomes, key facilitators (e.g., theory-based frameworks, adaptable interventions, and inclusion of sustainability and evaluation metrics) and essential elements (e.g., multidisciplinary team care, health information technology, and stakeholder engagement) must be integrated. The National Institute of Diabetes and Digestive and Kidney Diseases recently funded five proposals that aim to improve outcomes for people with CKD, focusing on diverse components of the healthcare continuum: patient safety and transitions; delivery of highquality, evidence-based CKD care; and elimination of disparities. The need for type 2 translational research in CKD is urgent because of preventable human suffering and unsustainable costs of providing care. Focus on the theory, framework, and approaches we have suggested may help us meet that challenge. © 2013 by the American Society of Nephrology.


Tuttle K.R.,Providence Medical Research Center | Tuttle K.R.,University of Washington | Milton J.E.,Providence Medical Research Center | Packard D.P.,Providence Medical Research Center | And 3 more authors.
American Journal of Kidney Diseases | Year: 2012

Background: Dietary protein has been variably reported to either lower or raise blood pressure. The purpose of this study was to determine whether intakes of specific amino acids differentially associate with blood pressure. Study Design: Observational cohort study by secondary analysis of clinical trial data. Setting & Participants: Study of low-fat versus Mediterranean-style diets in patients with prevalent cardiovascular disease. Predictor: Dietary amino acids. Outcomes: Systolic and diastolic blood pressure. Measurements: Dietary nutrients and cardiovascular risk factors were assessed at baseline, 3 and 6 months, and then every 6 months for 2 years. Results: Baseline blood pressure was 119 ± 16 (SD)/72 ± 10 (SD) mm Hg (n = 92) and dietary protein intake was 80 ± 31 g/d. Independent amino acid variables (quartiles of intake) were analyzed by generalized estimating equation models with prespecified covariates for time-varying systolic and diastolic blood pressure. The odds of each 1-SD higher systolic or diastolic blood pressure (ie, 16 and 10 mm Hg, respectively) were increased per quartile of intake for methionine (ORs of 1.29 [95% CI, 1.14-1.46] and 1.21 [95% CI, 1.05-1.39], respectively) and alanine (ORs of 1.17 [95% CI, 1.05-1.30] and 1.22 [95% CI, 1.07-1.38], respectively). Quartiles of intake for threonine (ORs of 0.84 [95% CI, 0.74-0.96] and 0.87 [95% CI, 0.75-1.01], respectively) and histidine (ORs of 0.92 [95% CI, 0.86-1.00] and 0.89 [95% CI, 0.82-0.97], respectively) had inverse associations with the same degree of difference in blood pressure. Limitations: Modest sample-size biases toward the chance of false-negative results; potential for residual confounding; colinearity between amino acids may obscure relevant relationships to blood pressure; associational findings do not establish causality. Conclusions: Intakes of methionine and alanine were associated positively with higher blood pressure, whereas intakes of threonine and histidine had inverse associations. These amino acids merit further study for advancing dietary approaches to blood pressure reduction. © 2012 National Kidney Foundation, Inc.


Salvatierra G.,Seattle University | Bindler R.C.,Washington State University | Corbett C.,Washington State University | Roll J.,Washington State University | And 3 more authors.
Critical Care Medicine | Year: 2014

OBJECTIVE:: To determine the relationship between implementation of rapid response teams and improved mortality rate using a large, uniform dataset from one state in the United States. DESIGN:: This observational cohort study included 471,062 adult patients hospitalized between 2001 and 2009. SETTING:: Ten acute tertiary care hospitals in Washington State. PATIENTS OR OTHER PARTICIPANTS:: Hospital abstract records on adult patients (18 years old or older) were examined (n = 471,062). Patients most likely to benefit from rapid response team interventions were included and other prognostic factors of severity of illness and comorbidities were controlled. Each participating hospital provided the implementation date of their rapid response team intervention. Mortality rates in 31 months before rapid response team implementation (pre-rapid response team time period) were compared with mortality rates in 31 months following rapid response team implementation (post-rapid response team time period). INTERVENTION(S):: Implementation of a rapid response team within each acute tertiary care hospital. MEASUREMENTS AND MAIN RESULTS:: In-hospital mortality. Relative risk for in-hospital mortality improved in the post-rapid response team time period compared with the pre-rapid response team time period (relative risk = 0.76; 95% CI = 0.72-0.80; p < 0.001). CONCLUSIONS:: In-hospital mortality improved in six of 10 acute tertiary care hospitals in the post-rapid response team time period when compared with the pre-rapid response team time period. Because of a long-term trend of decline in hospital mortality, these decreases could not be unambiguously attributed to rapid response team implementation. Further research should examine additional objective outcomes and optimal configuration of rapid response teams to maximize intervention effectiveness. © 2014 by the Society of Critical Care Medicine and Lippincott Williams and Wilkins.

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