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Table Of Contents: The Medicine Forum, Volume 25, 2023-2024

The Medicine Forum

Table of Contents: The Medicine Forum, Volume 25, 2023-2024

The Medicine Forum: Volume 25

The Medicine Forum

The Journal of Thomas Jefferson University Hospital - Department of Internal Medicine, Volume 25, 2023-2024

TABLE OF CONTENTS

• Case Reports
• Clinical Images
• Humanities & Reflections

Clinical And Genomic Profile Of Primary Cranial Neurolymphomatosis, Emily B Wolf, Robin Imperial, Liuyan Jiang, Amit K Agarwal, Han W Tun

Faculty, Staff and Student Publications

Primary cranial neurolymphomatosis (PCNL) is a rare subtype of primary CNS lymphoma (PCNSL) in which infiltrative lymphomatous involvement is confined to cranial nerves. Here, we report a case of PCNL with successful genomic profiling. A 57-year-old male had a lengthy prediagnostic phase spanning approximately 30 months, characterized by multiple episodes of cranial neuropathies managed by steroids. At the time of diagnosis, the patient had right-sided cranial neuropathies involving cranial nerves (CN) V, VI, and VII. Pathological findings of the right cavernous lesion biopsy were consistent with large B-cell lymphoma-infiltrating nerve fibers. The clinical course was aggressive and refractory, characterized by …

What Questions Do Patients Ask About Biologic Therapies For Chronic Sinusitis With Nasal Polyps?, Samuel E Razmi, Lexi Goehring, Aatin K Dhanda, Jason Shenoi, Faizaan Khan, Keyvon Rashidi, Daniel Gorelik, Kenneth R Sims, Meha G Fox, Masayoshi Takashima, Omar G Ahmed

Faculty, Staff and Students Publications

Objective: The objective of this study is to explore the questions commonly asked online about biologic therapies for use in treatment of chronic sinusitis with nasal polyps (CRSwNP) and the quality of the available content.

Methods: Most common search terms were identified via Google Trends. People Also Ask (PAA) questions were identified and extracted with their associated website using an online data-scraping program [Search Engine Optimization (SEO) Minion, Keywords Everywhere]. Sources were evaluated using Flesch Kincaid Grade Level (FKGL) and Flesch Reading Ease (FRE, higher number = better) score for readability; Journal of American Medical Association (JAMA) Benchmark …

Understanding Enterprise Data Warehouses To Support Clinical And Translational Research: Impact, Sustainability, Demand Management, And Accessibility, Thomas R Campion, Catherine K Craven, David A Dorr, Elmer V Bernstam, Boyd M Knosp

Faculty, Staff and Student Publications

OBJECTIVES: Healthcare organizations, including Clinical and Translational Science Awards (CTSA) hubs funded by the National Institutes of Health, seek to enable secondary use of electronic health record (EHR) data through an enterprise data warehouse for research (EDW4R), but optimal approaches are unknown. In this qualitative study, our goal was to understand EDW4R impact, sustainability, demand management, and accessibility.

MATERIALS AND METHODS: We engaged a convenience sample of informatics leaders from CTSA hubs (n = 21) for semi-structured interviews and completed a directed content analysis of interview transcripts.

RESULTS: EDW4R have created institutional capacity for single- and multi-center studies, democratized access …

Troponin: Think Before Testing, Shakirat Ganiyu, Fatimah Bello, Danielle Stone, Gregory Ruhnke, James Stone

School of Medicine Publications

This is a high-value care-based quality improvement project that was carried out to decrease inappropriate troponin testing in the emergency department (ED) of a tertiary health institution in the United States with the goal of promoting evidence-based practices, minimizing waste, and enhancing the quality of care.

Abdominal Aortic Aneurysm Screening And Surveillance – Can We Do Better? A Qi Project, Hassan Saeed, Hania Liaqat, Vidisha Master, Binita Neupane

Advances in Clinical Medical Research and Healthcare Delivery

Abstract

Background:

Abdominal aortic aneurysm (AAA) has a global prevalence of about 5% and its first presentation can be acute and fatal. USPSTF recommends one time screening for men aged 65 to 75 years who have ever smoked. We designed a study to evaluate the effect of resident education on AAA screening ordered in our outpatient primary care clinic.

Methods:

All men aged 65 to 75 years of age attending appointments in the resident run clinic were included in the study. Pre-intervention data was collected retrospectively for 5 weeks which included patient demographics and the rates of appropriate AAA screening …

Identification And Characterization Of Cannabichromene's Major Metabolite Following Incubation With Human Liver Microsomes, Alexandra M Ward, Touraj Shokati, Jost Klawitter, Jelena Klawitter, Vu Nguyen, Laura Kozell, Atheir I Abbas, David Jones, Uwe Christians

Faculty, Staff and Student Publications

Cannabichromene (CBC) is a minor cannabinoid within the array of over 120 cannabinoids identified in the Cannabis sativa plant. While CBC does not comprise a significant portion of whole plant material, it is available to the public in a purified and highly concentrated form. As minor cannabinoids become more popular due to their potential therapeutic properties, it becomes crucial to elucidate their metabolism in humans. Therefore, the goal of this was study to identify the major CBC phase I-oxidized metabolite generated in vitro following incubation with human liver microsomes. The novel metabolite structure was identified as 2′-hydroxycannabicitran using gas chromatography–mass …

A Rare Case Of Disseminated Extra-Nodal Natural Killer (Nk) Cell Lymphoma, Sowbharnika Arivazhagan, Guru Prasad Parthiban, Sukanthini Subbiah

School of Medicine Faculty Publications

Extranodal Natural Killer (NK)/T-cell lymphoma, nasal type, is rare and frequently found in Asia and South America. It is rarely found in the United States, mainly in the immigrant population. We present a 26-year-old male from Central America who was found to have disseminated NK/T-cell lymphoma. Through this article, we explain how we manage our patient and try to consolidate the treatment modalities for different stages of the disease.

Digital Twin Mathematical Models Suggest Individualized Hemorrhagic Shock Resuscitation Strategies, Jeremy W Cannon, Danielle S Gruen, Ruben Zamora, Noah Brostoff, Kelly Hurst, John H Harn, Fayten El-Dehaibi, Zhi Geng, Rami Namas, Jason L Sperry, John B Holcomb, Bryan A Cotton, Jason J Nam, Samantha Underwood, Martin A Schreiber, Kevin K Chung, Andriy I Batchinsky, Leopoldo C Cancio, Andrew J Benjamin, Erin E Fox, Steven C Chang, Andrew P Cap, Yoram Vodovotz

Faculty, Staff and Student Publications

BACKGROUND: Optimizing resuscitation to reduce inflammation and organ dysfunction following human trauma-associated hemorrhagic shock is a major clinical hurdle. This is limited by the short duration of pre-clinical studies and the sparsity of early data in the clinical setting.

METHODS: We sought to bridge this gap by linking preclinical data in a porcine model with clinical data from patients from the Prospective, Observational, Multicenter, Major Trauma Transfusion (PROMMTT) study via a three-compartment ordinary differential equation model of inflammation and coagulation.

RESULTS: The mathematical model accurately predicts physiologic, inflammatory, and laboratory measures in both the porcine model and patients, as well …

An Essential Gene Signature Of Breast Cancer Metastasis Reveals Targetable Pathways, Yiqun Zhang, Fengju Chen, Marija Balic, Chad J Creighton

Faculty, Staff and Students Publications

BACKGROUND: The differential gene expression profile of metastatic versus primary breast tumors represents an avenue for discovering new or underappreciated pathways underscoring processes of metastasis. However, as tumor biopsy samples are a mixture of cancer and non-cancer cells, most differentially expressed genes in metastases would represent confounders involving sample biopsy site rather than cancer cell biology.

METHODS: By paired analysis, we defined a top set of differentially expressed genes in breast cancer metastasis versus primary tumors using an RNA-sequencing dataset of 152 patients from The Breast International Group Aiming to Understand the Molecular Aberrations dataset (BIG-AURORA). To filter the genes …

Hemojuvelin-Mediated Hepcidin Induction Requires Both Bone Morphogenetic Protein Type I Receptors Alk2 And Alk3, Deniz Y Dogan, Eugen I Urzica, Isabelle Hornung, Philipp Kastl, David Oguama, Franca M Fette, Lien H Nguyen, Frank Rosenbauer, Kai Zacharowski, Ursula Klingmüller, Elise Gradhand, Andreas Von Knethen, Rüdiger Popp, Ingrid Fleming, Lisa Schrader, Andrea U Steinbicker

Faculty, Staff and Student Publications

Hemojuvelin (HJV) is a glycosylphosphatidylinositol-anchored protein of the repulsive guidance molecule family acting as a bone morphogenetic protein (BMP) coreceptor to induce the hepatic iron regulatory protein hepcidin. Hepcidin causes ubiquitination and degradation of the sole known iron exporter ferroportin, thereby limiting iron availability. The detailed signaling mechanism of HJV in vivo has yet to be investigated. In the current manuscript, we used an established model of adeno-associated virus (AAV)-mediated liver-specific overexpression of HJV in murine models of hepatocyte-specific deficiency of the BMP type I receptors Alk2 or Alk3. In control mice, HJV overexpression increased hepatic Hamp messenger RNA (mRNA) …

Driving Pressure Decoded: Precision Strategies In Adult Respiratory Distress Syndrome Management, Muhammad Adrish, Sai Doppalapudi, Dmitry Lvovsky

Faculty, Staff and Students Publications

Mechanical ventilation (MV) is an important strategy for improving the survival of patients with respiratory failure. However, MV is associated with aggravation of lung injury, with ventilator-induced lung injury (VILI) becoming a major concern. Thus, ventilation protection strategies have been developed to minimize complications from MV, with the goal of relieving excessive breathing workload, improving gas exchange, and minimizing VILI. By opting for lower tidal volumes, clinicians seek to strike a balance between providing adequate ventilation to support gas exchange and preventing overdistension of the alveoli, which can contribute to lung injury. Additionally, other factors play a role in optimizing …

Community-Acquired Pneumonia: The Importance Of The Early Detection Of Drug-Resistant Organisms, Sai Doppalapudi, Muhammad Adrish

Faculty, Staff and Students Publications

Pneumonia is a disease associated with significant healthcare burden with over 1.5 million hospitalizations annually and is the eighth leading cause of death in the United States. While community-acquired pneumonia (CAP) is generally considered an acute time-limited illness, it is associated with high long-term mortality, with nearly one-third of patients requiring hospitalization dying within one year. An increasing trend of detecting multidrug-resistant (MDR) organisms causing CAP has been observed, especially in the Western world. In this editorial, we discuss about a publication by Jatteppanavar

The Emerging Biomarkers In Chronic Obstructive Pulmonary Disease: A Narrative Review, Kaitlin M Phillips, Philip F Lavere, Nicola A Hanania, Muhammad Adrish

Faculty, Staff and Students Publications

The burden of chronic obstructive pulmonary disease (COPD) is increasing, especially for women in low-to-middle income countries. Biomarkers provide ever-increasing diagnostic precision for COPD and show promise for primary, secondary, and tertiary disease prevention. This review describes emerging applications for biomarkers in COPD, especially as they align with the Global Initiative for Chronic Obstructive Lung Disease (GOLD) emphasis on prevention, early diagnosis, and response to therapy. These biomarkers include blood eosinophils; IgE; C-reactive protein; fibrinogen; procalcitonin; interleukins 6, 8, and 33; tumor necrosis factor alpha; and soluble receptor for advanced glycated products (sRAGE). They have been used in various ways …

Social Determinants Of Health And Other Predictors In Initiation Of Treatment With Cdk4/6 Inhibitors For Hr+/Her2- Metastatic Breast Cancer, Ravi K Goyal, Sean D Candrilli, Susan Abughosh, Hua Chen, Holly M Holmes, Michael L Johnson

Faculty, Staff and Student Publications

In hormone receptor-positive/human epidermal growth factor receptor 2-negative (HR+/HER2-) metastatic breast cancer (MBC), cyclin-dependent kinase 4/6 inhibitors (CDK4/6is) have replaced endocrine therapy alone as the standard of care; however, several barriers to treatment initiation still exist. We assessed social determinants of health (SDOH) and other factors associated with the initiation of CDK4/6i for HR+/HER2- MBC in the Medicare population. Using a retrospective cohort design, patients aged ≥65 years and diagnosed during 2015-2017 were selected from the SEER-Medicare database. Time from MBC diagnosis to first CDK4/6i initiation was the study outcome. The effect of SDOH measures and other predictors on the …

Methylthioadenosine Phosphorylase Genomic Loss In Advanced Gastrointestinal Cancers, Natalie Y L Ngoi, Tin-Yun Tang, Catia F Gaspar, Dean C Pavlick, Gregory M Buchold, Emma L Scholefield, Vamsi Parimi, Richard S P Huang, Tyler Janovitz, Natalie Danziger, Mia A Levy, Shubham Pant, Anaemy Danner De Armas, David Kumpula, Jeffrey S Ross, Milind Javle, Jordi Rodon Ahnert

Faculty, Staff and Student Publications

BACKGROUND: One of the most common sporadic homozygous deletions in cancers is 9p21 loss, which includes the genes methylthioadenosine phosphorylase (MTAP), CDKN2A, and CDKN2B, and has been correlated with worsened outcomes and immunotherapy resistance. MTAP-loss is a developing drug target through synthetic lethality with MAT2A and PMRT5 inhibitors. The purpose of this study is to investigate the prevalence and genomic landscape of MTAP-loss in advanced gastrointestinal (GI) tumors and investigate its role as a prognostic biomarker.

MATERIALS AND METHODS: We performed next-generation sequencing and comparative genomic and clinical analysis on an extensive cohort of 64 860 tumors comprising 5 GI …

Prioritization Of Kidney Cell Types Highlights Myofibroblast Cells In Regulating Human Blood Pressure, Mahboube Ganji-Arjenaki, Zoha Kamali, International Consortium Of Blood Pressure; Soroush Sardari, Soroush Sardari, Martin De Borst, Harold Snieder, Ahmad Vaez

Faculty, Staff and Student Publications

INTRODUCTION: Blood pressure (BP) is a highly heritable trait with over 2000 underlying genomic loci identified to date. Although the kidney plays a key role, little is known about specific cell types involved in the genetic regulation of BP.

METHODS: Here, we applied stratified linkage disequilibrium score (LDSC) regression to connect BP genome-wide association studies (GWAS) results to specific cell types of the mature human kidney. We used the largest single-stage BP genome-wide analysis to date, including up to 1,028,980 adults of European ancestry, and single-cell transcriptomic data from 14 mature human kidneys, with mean age of 41 years.

RESULTS: …

The Internist's Post V.1 N.4, The University Of Texas Rio Grande Valley. School Of Medicine, Jian Garcia Cruz, Diana Othon Martinez, Edgar Dorsey Trevino, Eunbee Cho, Barbara Malaga-Espinoza, Roque Mifuji, Martha Solis, Cesar Gutierrez

School of Medicine Publications

No abstract provided.

Sodium-Glucose Transport Protein 2 (Sglt2) Inhibitors And The Risk Of Pancreatitis: A Case Report, Zamanali Khakhar, Soraiya Manji, Ronakkumar Patel, Sayed Karar

Internal Medicine, East Africa

Acute pancreatitis is a condition seldom encountered with the use of sodium-glucose cotransporter 2 (SGLT2) inhibitors. They are beneficial in the treatment of various conditions and offer great promise. Despite this, they are associated with several adverse effects, necessitating vigilance and further research. This case study reports a 69-year-old male with multiple comorbidities who presented with epigastric pain radiating to the back. Laboratory tests revealed elevated AST, ALT, GGT and lipase. The patient was diagnosed with acute pancreatitis secondary to the SGLT2 inhibitor therapy regimen. Cessation of dapagliflozin resulted in a complete resolution of symptoms. There is credible evidence to …

Fibroblast Subpopulations In Systemic Sclerosis: Functional Implications Of Individual Subpopulations And Correlations With Clinical Features, Honglin Zhu, Hui Luo, Brian Skaug, Tracy Tabib, Yi-Nan Li, Yongguang Tao, Alexandru-Emil Matei, Marka A Lyons, Georg Schett, Robert Lafyatis, Shervin Assassi, Jörg H W Distler

Faculty, Staff and Student Publications

Fibroblasts constitute a heterogeneous population of cells. In this study, we integrated single-cell RNA-sequencing and bulk RNA-sequencing data as well as clinical information to study the role of individual fibroblast populations in systemic sclerosis (SSc). SSc skin demonstrated an increased abundance of COMP+, COL11A1+, MYOC+, CCL19+, SFRP4/SFRP2+, and PRSS23/SFRP2+ fibroblasts signatures and decreased proportions of CXCL12+ and PI16+ fibroblast signatures in the Prospective Registry of Early Systemic Sclerosis and Genetics versus Environment in Scleroderma Outcome Study cohorts. Numerical differences were confirmed by multicolor immunofluorescence for selected fibroblast populations. COMP+, COL11A1+, SFRP4/SFRP2+, PRSS23/SFRP2+, and PI16+ fibroblasts were similarly altered between normal …

Performance Analysis Of Hybrid Deep Learning Framework Using A Vision Transformer And Convolutional Neural Network For Handwritten Digit Recognition, Vanita Agrawal, Jayant Jagtap, Shruti Patil, Ketan Kotecha

Faculty, Staff and Student Publications

Digitization created a demand for highly efficient handwritten document recognition systems. A handwritten document consists of digits, text, symbols, diagrams, etc. Digits are an essential element of handwritten documents. Accurate recognition of handwritten digits is vital for effective communication and data analysis. Various researchers have attempted to address this issue with modern convolutional neural network (CNN) techniques. Even after training, CNN filter weights remain unchanged despite the high identification accuracy. As a result, the process cannot flexibly adapt to input changes. Hence computer vision researchers have recently become interested in Vision Transformers (ViTs) and Multilayer Perceptrons (MLPs). The shortcomings of …

Development Of An Antioxidant-Rich Sugar-Free Plantain Candy And Assessment Of Its Shelf Life In A Flexible Laminate, Poulami Sarkar, Paramita Bhattacharjee, Bidhan Das

Faculty, Staff and Student Publications

RESEARCH BACKGROUND: Candy is a popular confection worldwide, and it would be beneficial to society if it were converted into a source of antioxidant molecules to eliminate its adverse health effects. The amount of antioxidants available even in fruit candies is questionable due to the high thermal processing losses they undergo and the presence of various food additives. Plantains (

EXPERIMENTAL APPROACH: To accomplish the first objective, lyophilized plantain powder, sorbitol and mannitol were used as base materials with minimal additives under minimal processing conditions to reduce processing loss. Sensory, proximate, physicochemical and phytochemical properties, including the antioxidant synergy among …

Trends In Shortages Of Lead Chelators From 2001 To 2022, James D Whitledge, Pelayia Soto, Kieran M Glowacki, Diane P Calello, Erin R Fox, Maryann Mazer-Amirshahi

Faculty, Staff and Student Publications

OBJECTIVE: The study aims to describe drug shortages affecting lead chelators in the United States from 2001 through 2022.

METHODS: Drug shortage data were retrieved from the University of Utah Drug Information Service from January 1, 2001, through December 31, 2022. Shortages of first- and second-line lead chelators were analyzed. Drug class, formulation, administration route, shortage reason, shortage duration, generic status, single-source status, and presence of temporally overlapping shortages were examined. Total shortage months, percentages of study period on shortage, and median shortage durations were calculated.

RESULTS: Thirteen lead chelator shortages were reported during the study period. Median duration was …

Pegvaliase For The Treatment Of Phenylketonuria: Final Results Of A Long-Term Phase 3 Clinical Trial Program, Cary O Harding, Nicola Longo, Hope Northrup, Stephanie Sacharow, Rani Singh, Janet A Thomas, Jerry Vockley, Roberto T Zori, Kaleigh Bulloch Whitehall, Joshua Lilienstein, Kristin Lindstrom, Drew G Levy, Shaun Jones, Barbara K Burton

Faculty, Staff and Student Publications

Phenylketonuria (PKU) is a genetic disorder caused by deficiency of the enzyme phenylalanine hydroxylase (PAH), which results in phenylalanine (Phe) accumulation in the blood and brain, and requires lifelong treatment to keep blood Phe in a safe range. Pegvaliase is an enzyme-substitution therapy approved for individuals with PKU and uncontrolled blood Phe concentrations (>600 μmol/L) despite prior management. Aggregated results from the PRISM clinical trials demonstrated substantial and sustained reductions in blood Phe with a manageable safety profile, but also noted individual variation in time to and dose needed for a first response. This analysis reports longer-term aggregate findings …

Adverse Pregnancy Outcomes And Long-Term Mortality In Women, Casey Crump, Jan Sundquist, Kristina Sundquist

Faculty, Staff and Student Publications

Importance: Women with adverse pregnancy outcomes, such as preterm delivery or preeclampsia, have higher future risks of cardiometabolic disorders; however, little is known about their long-term mortality risks. A better understanding of such risks is needed to facilitate early identification of high-risk women and preventive actions.

Objective: To determine long-term mortality risks associated with 5 major adverse pregnancy outcomes in a large population-based cohort of women.

Design, setting, and participants: This national cohort study in Sweden used the Swedish Medical Birth Register, containing prenatal and birth information for nearly all deliveries in Sweden since 1973, to identify women who had …

A Prospective Observational Study Of Disease Severity And Mortality In Hispanic American Patients With Systemic Sclerosis, Bochra Jandali, Marka Lyons, Julio Charles, Meng Zhang, Samuel Theodore, Claudia Pedroza, Maureen D Mayes, Shervin Assassi

Faculty, Staff and Student Publications

Objective: To characterize disease manifestations in Hispanic American patients with systemic sclerosis (SSc) in comparison with non-Hispanic White and Black patients.

Methods: Longitudinal clinical characteristics were collected prospectively in the Genetics versus Environment in Scleroderma Outcome Study cohort. All patients fulfilled the classification criteria for SSc and had a disease duration less than five years at enrollment.

Results: A cohort of 427 patients, consisting of 124 Hispanic, 220 non-Hispanic White, and 83 non-Hispanic Black participants were examined. At enrollment, Hispanic patients were significantly younger but had longer disease duration, higher frequency of U1-RNP positivity as well as concurrent systemic lupus …

Covid-19 Vaccine Confidence, Concerns, And Uptake In Children Aged 5 And Older In Calgary, Alberta: A Longitudinal Cohort Study, Emily J Doucette, Leah Ricketson, Tarannum Tarannum, Isabella Alatorre, Joslyn Gray, Cora Constantinescu, Susan Kuhn, Jessica K E Dunn, James D Kellner

Faculty, Staff and Student Publications

OBJECTIVES: Beginning early in the pandemic, there was a worldwide effort to develop effective vaccines against the SARS-CoV-2 virus. Before and after the approval and implementation of vaccines, there were concerns about their need as well as their safety and rapid development. We explored child demographic characteristics and parental concerns to identify factors associated with the decision to vaccinate.

METHODS: A cohort of 1035 children from Calgary was assembled in 2020 to participate in 5 visits every 6 months for survey completion and blood sampling for SARS-CoV-2 antibodies. Visits 1 to 2 occurred before approval of vaccines for children; Visits …

Incidence And Prevalence Of Hypertension In 18-40-Year-Old Patients Referred For Palpitations With Normal Cardiac Monitor Findings., Christopher Wasco, Zeryab Khan, Aimee Willett, Andrew Volio, Cody Carter, Aditya Kesari, Shaili Kothari, Andrew Scheidemantel, Katelyn Bennett, Jessalyn Schafer, Marie Lockhart, Nagesh Chopra

Ambulatory and Primary Care Articles

Sixteen percent of patients referred for cardiology evaluation are found to have no cause for palpitations. Studies show that hypertension intricately influences "heart rate" and "contractility,?" the key components of "palpitation." While the prevalence of hypertension is 22.4% in 18-39-year-olds, the relationship between palpitations and hypertension remains unknown in this age group. In our study, we assessed the incidence and prevalence of hypertension over 5 years in 18-40-year-olds referred for palpitations who had no known arrhythmic cause for palpitations between January 1, 206 and December 31, 2017. We found that over a period of 2.2 (0.7-4.1) years, an additional 56% …

Specific Gravity Improves Identification Of Clinically Significant Quantitative Proteinuria From The Dipstick Urinalysis, Meredith C Mcadams, L Parker Gregg, Pin Xu, Song Zhang, Michael Li, Ella Carroll, Vaishnavi Kannan, Duwayne L Willett, S Susan Hedayati

Faculty, Staff and Students Publications

KEY POINTS: Urine albumin-to-creatinine ratio and urine protein-to-creatinine ratio are frequently obtained and represent possible tools for screening for proteinuria and thus early CKD. Adding specific gravity to dipstick proteinuria improves the ability to screen patients with clinically significant proteinuria and can be used to identify patients with early CKD.

BACKGROUND: CKD is often underdiagnosed during early stages when GFR is preserved because of underutilization of testing for quantitative urine albumin-to-creatinine ratio (UACR) or urine protein-to-creatinine ratio (UPCR). Semiquantitative dipstick proteinuria (DSP) on urinalysis is widely obtained but not accurate for identifying clinically significant proteinuria.

METHODS: We identified all patients …