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"Factors to Consider When Hiring a Nephrologist"
"Benefits of Leasing Equipment"
"Do You Really Need an Office Manager?"
"For Small Practices Looking to Stay Independent, Welcome to 'Eden'"
"Two Essential Considerations When Selling Physician Practice Assets "
"Coding for the Rest of Us: Why Everyone in Your Practice Needs a Basic Knowledge of Coding"
"An Example of How to Stretch I.T. Investments"
In the News
"Urinary Lithogenesis Risk Tests: Comparison of a Commercial Kit and a Laboratory Prototype Test"
"Circulating Urokinase Receptor as a Cause of Focal Segmental Glomerulosclerosis"
"Low Blood Pressure During Dialysis Increases Clot Risk"
"Stanford Researchers: Drugs May Starve Cancer Cells"
"Survival Better With HD Than PD in CHF Patients"
"IV Fluids Salvage Renal Function in HUS"
"Tumor Enucleation: A Safe Treatment Alternative for Renal Cell Carcinoma"
"LDL Lowering Fails to Slow Renal Disease Progression"
"Large Waistline Doubles Risk of Kidney Disease Mortality"
"Parathyroid Hormone Levels Reach Target With Paricalcitol"
"Factors Can Predict Sudden Cardiac Death in Dialysis Patients"
Factors to Consider When Hiring a Nephrologist
Renal Business Today (07/28/11) Ahern, Jack
When nephrologists look for employment opportunities, it may be worthwhile to get professional guidance to ensure that every aspect of the employment process is maximized. This includes having cultural sensitivity based on geography and demographics, because certain regions of the country and certain institutions are less formal than others in terms of dress, conduct, and location for high level decision-making meetings. Nephrologist candidates should examine how business is done at the specific institution or group practice he or she is applying for. Candidates may tend to focus more on qualifications like board certification but may neglect overall presentation and relationship building skills. It is important to note that many hiring decisions are based on what differentiates a candidate from the group. Candidates with otherwise excellent qualifications may be rejected for arriving unprepared or late, failing to send a thank you note after an interview, or because of their dress and deportment. Demographic or family issues should also be considered, such as whether a candidate and his or her spouse are both willing to relocate. Potential candidates and employers are also urged to present their situations as they are and to move forward carefully if there is a match.
Benefits of Leasing Equipment
HealthLeaders Media (07/25/11) Daugherty, Scott
Equipment leasing may be the solution to healthcare organizations' problem of complying with a federal directive for meaningful use of electronic health records, using diagnostic equipment, and exploiting technological advances in treatment options, without incurring high costs. Among leasing's benefits is the fact that medical practices can reduce their net costs by deducting the lease payments from income; 100 percent financing; immediate write-off of the dollars spent; the lessee's ability to add or upgrade equipment at any point during the lease term; the ease of upgrading or adding technology solutions; the leasing company's asset management responsibility; swift response to new opportunities with minimal documentation and bureaucratic obstacles; improved cash forecasting; flexible end of term options; easier financing than loans; tax benefits; and the bundling of "soft costs" such as training and support into the lease payment, making all costs associated with a technology acquisition easy to budget. There are a number of queries organizations should make once they have decided to lease new healthcare equipment in order to navigate the available leasing options. Those queries include determining the useful life of the equipment to the organization, how the equipment should be disposed of at the end of its useful life, who should assume tax ownership of the asset, what the accounting considerations are, and whether the cash flows can be configured to match circumstances. Seeking guidance from an experienced and reliable financing partner also is worth consideration, and when choosing this option, it should be considered whether the finance company understands the healthcare organization's needs, is quick in its credit application approval process, and is stable and able to offer expert guidance through economic highs and lows.
Do You Really Need an Office Manager?
Modern Medicine (07/25/11) Borglum, Keith
Management consultant Keith Borglum says that the need for an office manager depends on the medical practice's size and the amount of management responsibility physicians are willing to accept. In Borglum's experience, small practices of one to three physicians do not need an office manager, as they are sufficiently small and simple that the physicians should be the managers. In addition, not having an office manager in such small practices can lead to lower overhead. Borglum says that practices that add a fourth provider will likely necessitate an office manager. Among the reasons Borglum provides for installing an office manager is the need for someone to inspire staff to do what is required to satisfy both patients and providers with exceptional performance, and to seek ways to improve. An office manager is typically the go-to person for people seeking data and answers, the custodian of the office's internal and external information, and someone who may guarantee the practice's adherence to various regulations and statutes. Borglum also points out that office managers make and implement decisions so that doctors do not have to, and these decisions impact the practice's business health. Managing a small practice without an office manager can be done by having the physicians and staff convene once a week for an hour to talk about practice issues.
For Small Practices Looking to Stay Independent, Welcome to 'Eden'
Healthcare Finance News (07/12/11) Wicklund, Eric
ClearPractice has unveiled Eden, a cloud-based electronic medical record and practice management solution. The system can be accessed via Apple Macs, iPads, and iPhone devices, and is designed to provide small medical practices with the ability to oversee clinical and financial duties from any location at any time. ClearPractice CEO Joel Anderson regards Apple devices as the popular choice among small practices of two to 10 physicians, which “are the least penetrated, yet have the most options.” He notes that recent studies estimate that 27 percent of physicians own an iPad or tablet computer, a rate fivefold higher than the general population. Of those not yet owning such devices, 66 percent said they would select Mac computers. Although Eden is designed for Apple users and accessible via the Safari Web browser, it can also be used by PC-based practices through Internet Explorer, Anderson says. And because it is a cloud-based service, small practices will be able to manage office functions without having to invest in hardware, he notes. Anderson anticipates adding more functions to Eden that will be patient-focused, allowing small practices to communicate with patients more frequently outside of the office.
Two Essential Considerations When Selling Physician Practice Assets
Physicians Practice (07/08/11) Erickson III, John C.
Selling a medical practice is an important undertaking, and involves two key components--identifying valuable assets and determining a valuation approach. The identification of salable practice assets is essential because hospitals typically purchase only some parts of a practice. Practice assets should be viewed and arranged to recognize their highest and best market value. This could include examining whether ancillary services should be valued as a separate business, and which tangible and intangible assets should be included. Federal laws prevent hospitals from paying more than the “fair market value” for practice assets, so hospitals often use the services of independent appraisers to get an estimate of fair market value. This means that practices must understand the way appraisers plan to value the identified assets. A Letter of Intent between the practice and a hospital should provide the practice with the right to interview potential appraisers and take part in the selection process. Practices should check if a proposed appraiser is completely independent of the hospital, is qualified to perform the particular valuation services required, and can provide a sound valuation methodology.
Coding for the Rest of Us: Why Everyone in Your Practice Needs a Basic Knowledge of Coding
Healthcare IT News (07/07/11) Whaley, Mary Pat
Coding usually refers to two things--service codes and diagnosis codes. Service codes are used for office visits, surgery, laboratory, radiology, pathology, anesthesia, and medical procedures provided by physicians, nurse practitioners, and physician assistants. Diagnosis codes are used for identifying signs, symptoms, injuries, diseases, and conditions. It is important to note that the diagnosis will help support the medical necessity of the procedure. Service codes are called either CPT (Current Procedural Terminology) codes or HCPCS (Healthcare Common Procedure Coding System) codes based on the payer/insurer who uses them. Most commercial insurers use CPT codes, but Medicare and Medicaid use HCPCS codes that are globally grouped into Level I and Level II. Level I codes include the 5-digit numeric CPT codes developed by the American Medical Association that are updated in October and become effective as of the next calendar year. Level II codes are national codes developed by the Centers for Medicare and Medicaid Services (CMS) to describe medical services and supplies not covered in the CPT, and comprise alphabetic characters (A through V) and four digits. Practices are advised to attend webinars or seminars each year to stay up-to-date on major coding changes for their specialty or across all specialties as well as use the National Correct Coding Initiative to check which codes should be submitted individually versus bundled.
RPA Coding and Billing Seminars
RPA offers nephrology-specific coding and billing seminars each year. Check www.renalmd.org for dates and locations.
An Example of How to Stretch I.T. Investments
Health Data Management (07/11) Baldwin, Gary
Healthcare IT leaders need to maximize their IT investments, especially as costs climb and reimbursements plummet. They say that practice leaders with multiple problems should make one improvement first, then reinvest the dividends in other necessary systems. In April 2010, Canyon Park Clinic opened its new office in Seattle, providing a very different home for the multi-specialty group practice. The hallmark of the new design would be improved patient flow, says Brett Daniel, M.D., the family physician who serves as medical director for the 37-member group. The physicians wanted to free up space for revenue-generating activity, such as imaging and lab work. To accomplish these goals, Daniel says, the clinic needed a way to easily track patient, staff, and equipment location. Early in the design phase of the clinic, the group opted to add a real-time tracking system into the mix. The system, from Versus Technology, freed up the creation of the floor plan. "We have narrow hallways and we did not want the medical assistants to go get patients," he says. "We wanted the medical assistants out in the work areas so physicians knew where they are." When patients come for appointments, they are given a badge with a small radio frequency identification chip. The admissions clerk downloads demographic and other identifying information onto the chip about the patient from the group's practice management system, from GE, via an infrared scanner. The chip is activated when it receives a signal from one of multiple ceiling-mounted transmission devices as they walk around the clinic. The signal in turn feeds information about the patient location into the Versus system, which displays it graphically on workstations around the office. In addition, the system keeps tabs on patient movement from station to station, generating data about the duration of the visit. The practice is on target of meeting a five-year goal of doubling its revenue in the new clinic, Daniel says. In addition, the practice has streamlined its flow of patients, with the total door-to-door visit time now averaging about 45 minutes, compared with nearly 90 minutes in the old facility.
Financial Planning (07/01/11) Sataline, Suzanne
Physicians are becoming increasingly concerned about their retirement options as a result of upcoming healthcare law changes. Financial planners are taking such steps as placing assets in tax-free shelters and urging physicians to invest in liability and long-term-care insurance. Planners are also advising physicians in private practices to hire practice management specialists to help their workplace become more efficient and profitable. Deron Bibb at Paradigm Management says he can provide practices "with assistance on compliance issues and help them with changing their basic economic model to become more efficient." This could include establishing a process to ensure that doctors are reimbursed, such as by hiring a billing service. Michael Lewellen at OJM Group said retirement plan goals he set for a physician three years had to be revised in light of declining insurance reimbursements over that last 18 months. Certified financial planner Linda Gadkowski says it is important to become debt free, "which is contrary to the idea most of them have.' This includes paying off second homes or transferring their children's college money into 529 plans, she says.
In the News
Urinary Lithogenesis Risk Tests: Comparison of a Commercial Kit and a Laboratory Prototype Test
Renal stone formation involves several factors, but partly depends on urine composition, as well as structural or pathological features of the kidney. Routine laboratory estimation of urolithiasis risk is usually based on determination of urinary composition, a process that requires collection of at least two 24-hour urine samples. Researchers have recently completed a study to compare data obtained using a commercial kit with those of a laboratory prototype to validate the utility of these methods. The investigators compared a simple new commercial test (NefroPlus) evaluating the capacity of urine to crystallize calcium salts with a prototype test previously described by this group. The comparison used urine from 64 volunteers produced during the night. The investigators also used the commercial test to evaluate urine samples of 83 subjects in one of three hospitals. Both methods were essentially in complete agreement (98 percent) with respect to test results. Based on their findings, the researchers said that the new NefroPlus test provides fast and cheap evaluation of the overall risk of development of urinary calcium-containing calculi.
Circulating Urokinase Receptor as a Cause of Focal Segmental Glomerulosclerosis
Nature Medicine (07/11) Wei, Changli; El Hindi, Shafic; Li, Jing; et al.
Focal segmental glomerulosclerosis (FSGS) can cause proteinuric kidney disease, which compromises both native and transplanted kidneys. A complex pathogenesis, including unknown serum factors, makes treatment limited. Researchers report that a soluble form of the urokinase plasminogen activator receptor, suPAR, is often elevated in patients with primary FSGS, but not in those with other glomerular diseases. A higher concentration of suPAR before transplantation may mean a higher risk for FSGS recurrence after a kidney transplant. Researchers explored the effects of suPAR on kidney function and morphology. They found that circulating suPAR can activate podocyte beta-3 integrin in the kidneys, which can lead to foot process effacement, proteinuria, and FSGS-like glomerulopathy. This suggests that the renal disease only develops when suPAR sufficiently activates podocyte beta-3 integrin, and so the disease can be removed by lowering serum suPAR concentrations through plasmapheresis or by interfering with the suPAR–beta-3 integrin interaction. The results also indicate that serum suPAR is a circulating factor that may cause FSGS.
Low Blood Pressure During Dialysis Increases Clot Risk
Renal Business Today (07/29/11)
Low blood pressure during dialysis can increase clotting risk at the point of vascular access, new research suggests. For vascular access during dialysis, a fistula is created surgically from the patient's own blood vessels. The researchers described their results in the July 29, online edition of the Journal of the American Society of Nephrology. "Our analysis shows another adverse consequence associated with a fall in blood pressure during dialysis for patients," said lead author Dr. Tara Chang, a Stanford nephrologist. "Vascular access is their lifeline. It's required for dialysis and without dialysis, they'll die." The study was based on results from the Hemodialysis study (HEMO), a National Institutes of Health-sponsored randomized clinical trial that collected data from 1,846 patients on hemodialysis from 1995 to 2000. The new study included data from 1,426 patients. Patients who had the most frequent episodes of low blood pressure during dialysis were found to be twice as likely to have a clotted fistula compared to patients with the fewest episodes. Low blood pressure during dialysis occurs in about 25 percent of patients' sessions.
Stanford Researchers: Drugs May Starve Cancer Cells
San Francisco Chronicle (08/04/11) Allday, Erin
Stanford University scientists have found a way to target and kill certain kinds of cancer cells by starving them to death, instead of blasting them with toxic chemotherapy drugs that can harm normal, healthy cells. The therapy would work by turning off the cancer cells' ability to absorb glucose, which is often the primary source of energy in rapidly growing tumors. The researchers have found two possible drugs that could be used to starve the cancer cells, although neither has been tested in humans. If the drugs work, they may give doctors their first opportunity to kill off cells in the most common type of kidney cancer. The most common type of kidney cancer, renal cell carcinoma, is not easily treated with radiation or chemotherapy. The main treatment is usually removal of the tumor or the affected kidney, along with drug therapy to stop the cancer from spreading. Renal cell carcinomas are able to spread more quickly than normal tissues because of a specific genetic mutation that turns off the cancer cells' innate ability to suppress growth. That mutation makes the rapidly growing cancer cells especially reliant on glucose for energy. While treatment of renal cell carcinomas has improved dramatically in the past five years, it is still one of the most difficult cancers to fight, and almost no one is cured of it, says Dr. Lauren Harshman, an oncologist at Stanford.
Survival Better With HD Than PD in CHF Patients
Renal and Urology News (07/21/11) Keller, Daniel M.
A study by researchers at Lyon-Sud University Hospital indicates that for patients with congestive heart failure (CHF) who initiate maintenance dialysis, those starting on peritoneal dialysis (PD) have a much higher risk of death than those who starting on hemodialysis (HD). Approximately a third of patients begin dialysis with a pre-existing CHF, and have a median survival of less than three years. The researchers analyzed data from the French Renal Epidemiology and Information Network (REIN), a regional and national network that includes all dialysis patients. The researchers compared survival for all incident dialysis patients who started planned chronic dialysis from 2002 to 2008 with a history of CHF. During four years of follow-up and after adjusting for multiple confounders, the PD patients had a 47 percent increased risk of death compared with HD patients, reported lead researcher Florence Sens at the 48th Congress of the European Renal Association-European Dialysis and Transplant Association. Other variables that were strongly linked to death were age, NYHA stage 3/4 versus 1/2 CHF, central venous catheter use at dialysis initiation, peripheral vascular disease, liver cirrhosis, and behavioral disturbances. Karel Leunissen, a nephrology professor at Maastricht University Hospital suggested that hydration status could be a large confounder in the study because the clinical diagnosis of CHF greatly depends on the hydration status of the patient. He told Renal & Urology News that “it's very important that you fix the hydration status of these patients in such a way that you are in the [ascending part] of the Starling curve and not in the descending line.”
IV Fluids Salvage Renal Function in HUS
MedPage Today (07/24/11) Walsh, Nancy
New research suggests that early administration of intravenous (IV) fluids to children with hemolytic uremic syndrome (HUS) may prevent acute renal failure. The prospective observational study included a cohort of 50 children with bloody diarrhea and HUS. Of those who were not given IV fluid during the first four days of illness, 84 percent progressed to oligoanuric renal failure, reported Dr. Christina A. Hickey, of Washington University in St. Louis, and colleagues. Only 52 percent of those who received IV fluids stopped urinating, the researchers reported online in the Archives of Pediatric and Adolescent Medicine. These findings do not prove that IV fluid administration will prevent long-term kidney complications, the researchers did say that "intravenous volume expansion appears to be a logical strategy that can be used now to achieve this goal, because we cannot hasten renal recovery once oligoanuria is established." Potentially lethal HUS can develop in children who have been infected with Shiga toxin-producing strains of bacteria. All the children involved in the study were under age 18 and had anemia, thrombocytopenia, or renal insufficiency. Six patients experienced serious complications, including respiratory distress, but there were no cases of pulmonary edema or death.
Tumor Enucleation: A Safe Treatment Alternative for Renal Cell Carcinoma
UroToday (07/22/2011) Laryngakis NA; Van Arsdalen KN; Guzzo TJ; et al.
The treatment of renal cell carcinoma has evolved over the years, from initially removing the entire kidney along with the renal tumor, despite the size or extent of the mass. Early efforts to remove tumors with a normal surrounding parenchymal margin showed equivalent oncologic results in small renal masses. Attempts to preserve more renal parenchyma in patients with compromised renal function led to the enucleation of renal masses by blunt dissection following the natural plane between the peritumor pseudocapsule and the renal parenchyma. Patients with preoperative renal insufficiency, solitary kidneys, multiple renal lesions and hereditary renal cell carcinoma syndromes have benefited from enucleation of renal tumors for renal preservation. There has been comparable long-term progression and cancer-specific survival for tumor enucleation and standard partial nephrectomy. However, the safety of renal tumor enucleation has drawn considerable scrutiny due to histopathologic findings of pseudocapsule tumor invasion. Current data suggest that tumor enucleation is a safe alternative for small renal masses that are locally confined on preoperative imaging, easily delineated intraoperatively and do not appear to grossly invade beyond the pseudocapsule.
LDL Lowering Fails to Slow Renal Disease Progression
Renal and Urology News (07/19/11) Keller, Daniel M.
Reductions in LDL cholesterol can prevent or reverse atherosclerosis, but does not have a similar impact for the progression of chronic kidney disease (CKD), according to researchers at the 48th Congress of the European Renal Association-European Dialysis and Transplant Association. Dr. David Lewis of the Clinical Trial Service Unit at the University of Oxford, United Kingdom, presented analyses of the renal results of the SHARP (Study of Heart and Renal Protection) trial. Lewis reported that reducing LDL levels for five years with simvastatin (SIM) and ezetimibe (EZE) did not slow progression of renal disease in patients with CKD. SHARP study researchers randomly assigned CKD patients aged 40 years or older to receive SIM/EZE, SIM 20 mg, or placebo for one year. SIM-alone was used as a comparison to examine the safety of adding EZE to SIM. At one year, the patients on SIM were randomized again to either the SIM/EZE cohort (4,650 patients) or to placebo (4,620 patients). After subjects were followed for a median of 4.9 years, SIM/EZE was associated with a mean LDL reduction of 33 mg/dL at 2.5 years compared with the placebo arm. The researchers observed no significant effect from the administration of the LDL lowering therapy. “This is a robust result, as indicated by the narrow confidence interval, with over 2,000 of the 6,000-plus participants reaching end-stage renal disease during the study follow-up,” Dr. Lewis told attendees. The proportion reaching the primary endpoint--the progression to end-stage renal disease--was 33.9 percent in the SIM/EZE arm and 34.6 percent in the placebo arm. The researchers also found no difference in the annual rates of change based on patients' baseline eGFRs between the SIM/EZE and placebo groups.
Large Waistline Doubles Risk of Kidney Disease Mortality
Renal Business Today (07/15/11)
A study by researchers at the Loyola University Health System indicates that the larger a kidney patient's waist circumference, the greater the chance the patient would die during the course of the study. The study by lead researcher Dr. Holly Kramer and colleagues found that waist circumference was more strongly linked to mortality than body mass index (BMI), a height-to-weight ratio. Researchers examined data from 5,805 adults age 45 and older who had kidney disease and took part in a study called REGARDS (Reasons for Geographic and Racial Differences in Stroke). They were followed for a median of four years, and during that time 686 kidney patients, or 11.8 percent, died. The kidney patients who died were found to have a larger average waist circumference (40.1 inches) than the patients who survived (39.1 inches.) Researchers compared kidney disease patients with large waists to patients who had more normal waist sizes. After adjusting for BMI and other risk factors, women with waists equal to or greater than 42.5 inches and men with waists equal to or greater than 48 inches were 2.1 times more likely to die than those with trimmer waists--less than 31.5 inches for women and less than 37 inches for men. When looking at BMI, the average BMI of kidney disease patients who died was 29.2, which was lower than the average BMI of 30.3, of the patients who survived. A BMI between 25 and 29.9 is considered overweight, while a BMI of 30 and above is obese. The researchers concluded, "waist circumference reflects abdominal adiposity [fat] alone and may be a useful measure to determine mortality risk associated with obesity in adults with chronic kidney disease, especially when used in conjunction with BMI."
Parathyroid Hormone Levels Reach Target With Paricalcitol
Medscape (07/14/11) Keller, Daniel M.
Researchers at the 48th Congress of the European Renal Association-European Dialysis and Transplant Association reported that paricalcitol was superior to cinacalcet in achieving target parathyroid hormone (PTH) levels in patients with secondary hyperparathyroidism (SHPT), a complication of chronic kidney disease. Dr. Markus Ketteler from the division of nephrology at Klinikum Coburg, Germany, told delegates that until now, the comparative effectiveness of these two treatments had not been evaluated in patients undergoing hemodialysis. SHPT is characterized by increased serum levels of intact (i)PTH and can be treated with either a vitamin D–receptor activator such as paricalcitol, or a calcimimetic such as cinacalcet. Elevated iPTH levels can lead to skeletal and cardiovascular complications. Ketteler and colleagues conducted a phase 4 study as an open-label multinational trial where 272 patients on hemodialysis were randomly assigned to paricalcitol or to cinacalcet plus low-dose vitamin D for 28 weeks, with evaluation running from weeks 21 to 28. In the paricalcitol group, patients in the United States and Russia received intravenous (IV) paricalcitol, and those outside of the United States and Russia received oral paricalcitol; in the cinacalcet plus vitamin D group, patients in the United States received IV doxercalciferol, and those outside of the United States received oral alfacalcidol. The study revealed that IV paricalcitol was superior to cinacalcet plus IV doxercalciferol in achieving a mean serum iPTH level of 150 to 300 pg/mL, and more patients receiving IV paricalcitol than receiving cinacalcet plus IV doxercalciferol achieved the iPTH end point. However, there was no significant difference in the achievement of the iPTH end point between those receiving oral paricalcitol and those receiving cinacalcet plus oral alfacalcidol. In addition, hypocalcemia occurred in about half of the patients receiving cinacalcet plus vitamin D (either IV or oral), but in none of the patients receiving IV paricalcitol and in only 3.6 percent of the patients receiving oral paricalcitol.
Factors Can Predict Sudden Cardiac Death in Dialysis Patients
Renal and Urology News (06/30/11) Frei, Rosemary
German researchers are working to create a tool to accurately predict which dialysis patients are most likely to experience sudden cardiac death. Elements of patient history shown to be associated with sudden cardiac death in participants of the 4D study include the presence of coronary artery disease and peripheral vascular disease. Biomarkers predictive of sudden death include elevated HbA1c, hypoalbuminuria, and elevated NT-pro-BNP. Their overall discriminative ability is 0.72, which is highly statistically significant, said Dr. Christoph Wanner, a professor of nephrology at University Clinic in Wurzburg, Germany. Sudden cardiac death accounts for 26 percent of deaths among diabetic patients on dialysis, said Wanner, speaking at the 2011 World Congress of Nephrology. The 4D study was a randomized, controlled trial of atorvastatin versus placebo. In an analysis of follow-up results of 1,255 type 2 diabetes patients on dialysis who took part in the 4D study, levels of N-terminal pro b-type natriuretic peptide (NT-pro-BNP), hemoglobin A1c (HbA1c) and albumin were the only three biomarkers significantly associated with sudden cardiac death, said Wanner. "We deduced that NT-pro-BNP can be helpful in borderline cases, enabling further distinction of those patients into groups of high versus low risk of sudden cardiac death." His team is now developing a score to identify patients who are at high risk of sudden cardiac death based on easily obtainable indicators in patients' history and laboratory results. Additional indicators include severe wasting, poor glycemic control, vitamin D deficiency, and a concurrent decrease in level of parathyroid hormone and body mass index.
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