Saint Louis Veterans Affairs Medical Center

Saint Louis, MI, United States

Saint Louis Veterans Affairs Medical Center

Saint Louis, MI, United States

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Al-Aly Z.,Saint Louis Veterans Affairs Medical Center | Al-Aly Z.,Saint Louis Veterans Affairs Clinical Research and Epidemiology Center | Zeringue A.,Saint Louis Veterans Affairs Clinical Research and Epidemiology Center | Fu J.,Saint Louis Veterans Affairs Clinical Research and Epidemiology Center | And 10 more authors.
Journal of the American Society of Nephrology | Year: 2010

The effect of rate of decline of kidney function on risk for death is not well understood. Using the Department of Veterans Affairs national databases, we retrospectively studied a cohort of 4171 patients who had rheumatoid arthritis and early stage 3 chronic kidney disease (CKD; estimated GFR 45 to 60 ml/min) and followed them longitudinally to characterize predictors of disease progression and the effect of rate of kidney function decline on mortality. After a median of 2.6 years, 1604 (38%) maintained stable kidney function; 426 (10%), 1147 (28%), and 994 (24%) experienced mild, moderate, and severe progression of CKD, respectively (defined as estimated GFR decline of 0 to 1, 1 to 4, and >4 ml/min per yr). Peripheral artery disease predicted moderate progression of CKD progression. Black race, hypertension, diabetes, cardiovascular disease, and peripheral artery disease predicted severe progression of CKD. After a median of 5.7 years, patients with severe progression had a significantly increased risk for mortality (hazard ratio 1.54; 95% confidence interval 1.30 to 1.82) compared with those with mild progression; patients with moderate progression exhibited a similar trend (hazard ratio 1.10; 95% confidence interval 0.98 to 1.30). Our results demonstrate an independent and graded association between the rate of kidney function decline and mortality. Incorporating the rate of decline into the definition of CKD may transform a static definition into a dynamic one that more accurately describes the potential consequences of the disease for an individual. Copyright © 2010 by the American Society of Nephrology.


Lawson E.H.,University of California at Los Angeles | Lawson E.H.,VA Greater Los Angeles Healthcare System | Zingmond D.S.,University of California at Los Angeles | Stey A.M.,Mount Sinai School of Medicine | And 4 more authors.
Annals of Surgery | Year: 2014

Methods: Records (2005-2008) for all patients undergoing colectomy procedures in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) were linked to Medicare inpatient claims. Cost was derived from hospital payments by Medicare. Quality was derived from the occurrence of 30-day postoperative major complications and/or death as recorded in ACS-NSQIP. Risk-adjusted cost and quality metrics were developed using hierarchical multivariable modeling, consistent with a National Quality Forum-endorsed colectomy measure.Objective: To evaluate the relationship between risk-adjusted cost and quality for colectomy procedures and to identify characteristics of "high value" hospitals (high quality, low cost). CopyrightBackground: Policymakers are currently focused on rewarding high-value health care. Hospitals will increasingly be held accountable for both quality and cost.Results: The study population included 14,745 colectomy patients in 169 hospitals. Average hospitalization cost was $21,350 (SD $20,773, median $16,092, interquartile range $14,341-$24,598). Thirty-four percent of patients had a postoperative complication and/or death. Higher hospital quality was significantly correlated with lower cost (correlation coefficient 0.38, P 0.001). Among hospitals classified as high quality, 52% were found to be low cost (representing highest value hospitals) whereas 14% were high cost (P = 0.001). Forty-one percent of low-quality hospitals were high cost. Highest "value" hospitals represented a mix of teaching/nonteaching affiliation, small/large bed sizes, and regional locations.Conclusions: Using national ACS-NSQIP and Medicare data, this study reports an association between higher quality and lower cost surgical care. These results suggest that high-value surgical care is being delivered in a wide spectrum of hospitals and hospital types. © 2014 by Lippincott Williams & Wilkins.


Al-Aly Z.,Saint Louis Veterans Affairs Medical Center | Al-Aly Z.,Saint Louis Veterans Affairs Clinical Research and Epidemiology Center | Balasubramanian S.,Saint Louis Veterans Affairs Clinical Research and Epidemiology Center | McDonald J.R.,Saint Louis Veterans Affairs Clinical Research and Epidemiology Center | And 3 more authors.
Kidney International | Year: 2012

Intra-individual variability in kidney function is a common phenomenon; however, predictors of kidney function variability and its prognostic significance are not known. To examine this question, we assembled a cohort of 51,304 US veterans with an estimated glomerular filtration rate (eGFR) <60 ml/min at the end of the study period and who had at least two eGFR measurements during the previous 3 years. Variability in kidney function was defined for each patient as the coefficient of variation of the regression line fitted to all outpatient measures of eGFR during this time frame. In adjusted analyses, blacks, women, and those with Current Procedural Terminology and ICD-9-CM diagnostic codes for hypertension, diabetes, cardiovascular disease, peripheral artery disease, chronic lung disease, hepatitis C, dementia, acute kidney injury, and those with a greater number of hospitalizations had greater variability in eGFR. After a median follow-up of 4.9 years, there were 23.66%, 25.68%, and 31.23% deaths among patients in the lowest, intermediate, and highest tertiles of eGFR variability, respectively. Compared with the referent (those in the lowest tertile), patients in the highest tertile had a significantly increased risk of death with a hazard ratio of 1.34 (1.28-1.40), an association consistently present in all sensitivity analyses. Thus, our results demonstrate that greater variability in kidney function is independently associated with increased risk of death. © 2012 International Society of Nephrology.


Al-Aly Z.,Saint Louis Veterans Affairs Medical Center | Al-Aly Z.,Saint Louis Veterans Affairs Clinical Research
Kidney International | Year: 2011

Phosphate-induced vascular calcification, characterized by induction of osteogenic programs, mineral vesicle release, and apoptosis, is prevalent in patients with kidney disease. Zhao et al. provide a mechanistic link between phosphate-induced calcification and increased mitochondrial membrane potential, increased mitochondrial reactive oxygen species, activation of the nuclear factor-B pathway, and subsequent expression of osteogenic genes and vascular mineralization. This link clarifies the intracellular mechanism of vascular calcification and may allow exploration of antioxidants as therapeutic agents for vascular calcification. © 2011 International Society of Nephrology.


Al-Aly Z.,Saint Louis Veterans Affairs Medical Center | Al-Aly Z.,Saint Louis Veterans Affairs Clinical Research
Nephron - Clinical Practice | Year: 2011

Chronic kidney disease (CKD) is associated with increased risk of death. A wave of recent studies used longitudinal data to examine the effect of the rate of decline of kidney function on the risk of death. The results from these studies show that there is an independent and graded association between the rate of kidney function decline and the risk of death. There is a need to incorporate the rate of decline in the definition of CKD. This redefinition of CKD will transform a static definition into a dynamic one that more accurately describes the disease state in an individual patient. Copyright © 2011 S. Karger AG, Basel.


Asaad B.O.,State University of New York at Stony Brook | Helwani M.,Saint Louis Veterans Affairs Medical Center | Wheeler D.M.,Cleveland Clinic | O'Connor M.S.,Cleveland Clinic
Respiratory Care | Year: 2011

We present a case of severe postoperative hypercarbia in a patient with severe COPD. Hypercarbia and respiratory acidosis continued to increase despite maximal ventilation, bronchodilator therapy, sedation, and paralysis. Mistaken use of non-partitioned ventilator circuit was the cause of the hypercarbia. The ventilator's self-test function failed to detect the error. We changed to a partitioned-lumen circuit, with much less ventilation dead space, and the hypercarbia resolved immediately. © 2011 Daedalus Enterprises.


Balasubramanian G.,Saint Louis Veterans Affairs Medical Center | Balasubramanian G.,Saint Louis University | Al-Aly Z.,Saint Louis Veterans Affairs Medical Center | Al-Aly Z.,Clinical Research and Epidemiology Center | And 10 more authors.
American Journal of Kidney Diseases | Year: 2011

Background The optimal timing of nephrology consultation in patients with hospital-acquired acute kidney injury (AKI) is unknown. Study Design Prospective controlled nonrandomized intervention study. Setting & Participants We screened daily serum creatinine (SCr) levels of 4,296 patients admitted to the St. Louis Veterans Affairs Medical Center between September and November 2008 (control group) and January to May 2009 (intervention group). 354 patients (8.2%) met the definition of in-hospital AKI (SCr level increase of 0.3 mg/dL over 48 hours); 176 of whom met all inclusion criteria; 85 and 91 patients were enrolled in the control (standard care) and intervention groups, respectively. Intervention Early renal service involvement (EARLI), defined as a 1-time nephrology consultation within 18 hours of the onset of AKI. Outcome Primary outcome defined as 2.5-fold increase in SCr level from admission. Measurement Daily SCr until discharge. Results The 2 groups had similar characteristics at baseline and at the time of AKI. The intervention was completed at a mean of 13.1 ± 0.8 hours from the onset of AKI. Nephrology recommendations in the EARLI group included specific diagnostic, therapeutic, and preventative components. The primary outcome occurred in 12.9% of patients in the control group compared with 3.3% of patients in the EARLI group (P = 0.02). Patients in the EARLI group had a lower peak SCr level of 1.8 ± 0.1 versus 2.1 ± 0.2 mg/dL in controls (P = 0.01). Limitations Single-center nonrandomized study of mostly US male veterans. Conclusions Early nephrologist involvement in patients with AKI may reduce the risk of a further decrease in kidney function. A larger randomized trial is needed to confirm the findings.


El-Achkar T.M.,Saint Louis University | El-Achkar T.M.,Saint Louis Veterans Affairs Medical Center | Mccracken R.,Saint Louis University | Mccracken R.,Saint Louis Veterans Affairs Medical Center | And 6 more authors.
American Journal of Physiology - Renal Physiology | Year: 2011

Tamm-Horsfall protein (THP) is a glycoprotein expressed exclusively in thick ascending limbs (TAL) of the kidney. We recently described a novel protective role of THP against acute kidney injury (AKI) via downregulation of inflammation in the outer medulla. Our current study investigates the mechanistic relationships among the status of THP, inflammation, and tubular injury. Using an ischemia-reperfusion model in wild-type and THP-/- mice, we demonstrate that it is the S3 proximal segments but not the THP-deficient TAL that are the main targets of tubular injury during AKI. The injured S3 segments that are surrounded by neutrophils in THP-/- mice have marked overexpression of neutrophil chemoattractant MIP-2 compared with wild-type counterparts. Neutralizing macrophage inflammatory protein-2 (MIP-2) antibody rescues S3 segments from injury, decreases neutrophil infiltration, and improves kidney function in THP-/- mice. Furthermore, using immunofluorescence volumetric imaging of wild-type mouse kidneys, we show that ischemia alters the intracellular translocation of THP in the TAL cells by partially shifting it from its default apical surface domain to the basolateral domain, the latter being contiguous to the basolateral surface of S3 segments. Concomitant with this is the upregulation, in the basolateral surface of S3 segments, of the scavenger receptor SRB-1, a putative receptor for THP. We conclude that TAL affects the susceptibility of S3 segments to injury at least in part by regulating MIP-2 expression in a THP-dependent manner. Our findings raise the interesting possibility of a direct role of basolaterally released THP on regulating inflammation in S3 segments. © 2011 by the American Physiological Society.


Strasberg S.M.,Washington University in St. Louis | Hall B.L.,Washington University in St. Louis | Hall B.L.,Saint Louis Veterans Affairs Medical Center
Journal of the American College of Surgeons | Year: 2011

Background: Postoperative complications are key outcomes of surgical procedures, but currently there is no uniform quantitative measure of complication severity. The purpose of this study was to evaluate and establish feasibility of quantitative morbidity scores for several common abdominal surgical procedures. Study Design: Using American College of Surgeons' National Surgical Quality Improvement Program data, complications were identified in 5 common abdominal procedures for one institution in 2005-2008, including inguinal hernia, appendectomy, laparoscopic colectomy, hepatectomy, and pancreaticoduodenectomy. Complications were graded by the 6-level "expanded" Accordion Severity Grading System. Quantification was performed using severity scores described previously. Results: Six hundred and seventy-six procedures were identified, including 88 patients (13.84%) who had complications and 5 patients (0.79%) who died. After severity weighting, the postoperative morbidity index (PMI) for each procedure was derived. An index of 0 would indicate no complication in any patient and an index of 1.000 would indicate that all operated patients died. PMIs were hernia repair 0.005; appendectomy 0.031; laparoscopic colectomy 0.082; hepatectomy 0.145; and pancreaticoduodenectomy 0.150. PMI of hepatectomy was greatly affected by the presence of a second procedure, ie, 0.070 without a second procedure and 0.427 with a second procedure. Weighted severity spectragrams were developed, portraying the impact of each grade of complication on overall morbidity. Conclusions: Quantification of severity of postoperative complications is possible using American College of Surgeons' National Surgical Quality Improvement Program methods and the Accordion Severity Grading System. Procedural PMI can be useful in assessing surgical outcomes. Certain limitations, particularly the need for risk adjustment, still need to be addressed. © 2011 American College of Surgeons.


PubMed | Saint Louis Veterans Affairs Medical Center
Type: Journal Article | Journal: Translational behavioral medicine | Year: 2013

High rates of posttraumatic stress disorder (PTSD) among post-deployment veterans and the associated long-term consequences highlight the importance of early identification and treatment. The Veterans Health Administration (VHA)s Primary Care Mental Health Integration (PCMHI) program aims to increase identification and access to care for veterans with mental illness, decrease stigma, improve continuity of care, and the efficiency of healthcare utilization. This project examines PCMHIs progress towards these goals within the Operation Iraqi Freedom/Operation Enduring Freedom (OEF/OIF) population. We examined data from consults to the OEF/OIF PTSD clinic for 18months. PCMHI placed 129 consults and 91 (70.5%) were completed. Veterans referred by PCMHI tended to have increased consult completion in specialty care, higher rates of confirmed PTSD, however, no significant differences in reported PTSD symptoms, or follow-up visits in the OEF/OIF PTSD clinic compared to Veterans referred from the hospital at large. PCMHI potentially preserve resources, increases continuity of care, and increases treatment access for OEF/OIF/OND veterans.

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