Background: People living with human immunodeficiency virus (HIV+) have greater risk for sudden arrhythmic death than HIV-uninfected (HIV–) individuals. HIV-associated abnormal cardiac repolarization may contribute to this risk. We investigated whether HIV serostatus is associated with ventricular repolarization lability by using the QT variability index (QTVI), defined as a log measure of QT-interval variance indexed to heart rate variance. Methods: We studied 1123 men (589 HIV+ and 534 HIV–) from MACS (Multicenter AIDS Cohort Study), using the ZioXT ambulatory electrocardiography patch. Beat-to-beat analysis of up to 4 full days of electrocardiographic data per participant was performed using an automated algorithm (median analyzed duration [quartile 1–quartile 3]: 78.3 [66.3–83.0] hours/person). QTVI was modeled using linear mixed-effects models adjusted for demographics, cardiac risk factors, and HIV-related and inflammatory biomarkers. Results: Mean (SD) age was 60.1 (11.9) years among HIV– and 54.2 (11.2) years among HIV+ participants ( P <0.001), 83% of whom had undetectable (<20 copies/mL) HIV-1 viral load (VL). In comparison with HIV– men, HIV+ men had higher QTVI (adjusted difference of +0.077 [95% CI, +0.032 to +0.123]). The magnitude of this association depended on the degree of viremia, such that in HIV+ men with undetectable VL, adjusted QTVI was +0.064 (95% CI, +0.017 to +0.111) higher than in HIV– men, whereas, in HIV+ men with detectable VL, adjusted QTVI was higher by +0.150 (95% CI, 0.072–0.228) than in HIV– referents. Analysis of QTVI subcomponents showed that HIV+ men had: (1) lower heart rate variability irrespective of VL status, and (2) higher QT variability if they had detectable, but not with undetectable, VL, in comparison with HIV– men. Higher levels of C-reactive protein, interleukin-6, intercellular adhesion molecule-1, soluble tumor necrosis factor receptor 2, and soluble cluster of differentiation-163 (borderline), were associated with higher QTVI and partially attenuated the association with HIV serostatus. Conclusions: HIV+ men have greater beat-to-beat variability in QT interval (QTVI) than HIV– men, especially in the setting of HIV viremia and heightened inflammation. Among HIV+ men, higher QTVI suggests ventricular repolarization lability, which can increase susceptibility to arrhythmias, whereas lower heart rate variability signals a component of autonomic dysfunction.

Despite the Affordable Care Act's push to improve the coordination of care for patients with multiple chronic conditions, most measures of coordination quality focus on a specific moment in the care process (e.g., medication errors or transfer between facilities), rather than patient outcomes. One possible supplementary way of measuring the care coordination quality of a facility would be to identify the patients needing the most coordination, and to look at outcomes for that group. This paper lays the groundwork for a new measure of care coordination quality by outlining a conceptual framework that considers the interaction between a patient's interdisciplinarity, biological susceptibility, and procedural intensity. Interdisciplinarity captures the degree of specialized medical expertise needed for a patient's care and will be an important measure to estimate the number of specialists a patient might see. We then develop a preliminary measure of interdisciplinarity and run tests linking interdisciplinarity to medical mistakes, as defined by Agency for Healthcare Research and Quality's Patient Safety Indicators. Finally, we use our preliminary measure to verify that interdisciplinarity is likely to be statistically different from existing measures of comorbidity, like the Charlson score. Future research will need to build upon our findings by developing a more statistically validated measure of interdisciplinarity.

As health studies increasingly monitor free-living heart performance via ECG patches with ac- celerometers, researchers will seek to investigate cardio-electrical responses to physical activity and sedentary behavior, increasing demand for fast, scalable methods to process accelerometer data. We provide the first published analysis of tri-axial accelerometry data from Zio XT patch and introduce an extension of posture classification algorithms for use with ECG patches worn in the free-living environment. Our novel extensions to posture classification include (1) estimation of an upright posture for each individual without the reference measurements used by existing posture classification algorithms; (2) correction for device removal and re-positioning using novel spherical change-point detection; and (3) classification of upright and recumbent periods using a clustering and voting process rather than a simple inclination threshold used in other algorithms. Methods were built using data from 14 participants from the Multicenter AIDS Cohort Study (MACS), and applied to 1, 250 MACS participants. As no posture labels exist in the free-living environment, we evaluate the algorithm against labelled data from the Towson Accelerometer Study and against data labelled by hand from the MACS study.

Objective: To use accelerometers to quantify differences in physical activity (PA) by HIV serostatus and HIV viral load (VL) in the Multicenter AIDS Cohort Study (MACS).Methods: MACS participants living with (PLWH, n ¼ 631) and without (PWOH, n ¼ 578) HIV wore an ambulatory electrocardiogram monitor containing an accelerometer for 1-14 days. PA was summarized as cumulative mean absolute deviation (MAD) during the 10 most active consecutive hours (M10), cumulative MAD during the six least active consecutive hours (L6), and daily time recumbent (DTR). PA summaries were compared by HIV serostatus and by detectability of VL (>20 vs. 20 copies/ml) using linear mixed models adjusted for sociodemographics, weight, height, substance use, physical function, and clinical factors.Results: In sociodemographic-adjusted models, PLWH with a detectable VL had higher L6 (b ¼ 0.58 mg, P ¼ 0.027) and spent more time recumbent (b ¼ 53 min/day, P ¼ 0.003) than PWOH. PLWH had lower M10 than PWOH (undetectable VL b ¼ À1.62 mg, P ¼ 0.027; detectable VL b ¼ À1.93 mg, P ¼ 0.12). A joint test indicated differences in average PA measurements by HIV serostatus and VL (P ¼ 0.001). However, differences by HIV serostatus in M10 and DTR were attenuated and no longer significant after adjustment for renal function, serum lipids, and depressive symptoms. Conclusions: Physical activity measures differed significantly by HIV serostatus and VL. Higher L6 among PLWH with detectable VL may indicate reduced amount or quality of sleep compared to PLWH without detectable VL and PWOH. Lower M10 among PLWH indicates lower amounts of physical activity compared to PWOH.

ObjectivesWe sought to estimate reliable change thresholds for the Montreal Cognitive Assessment (MoCA) for older adults with suspected Idiopathic Normal Pressure Hydrocephalus (iNPH). Furthermore, we aimed to determine the likelihood that shunted patients will demonstrate significant improvement on the MoCA, and to identify possible predictors of this improvement.MethodsPatients (N = 224) presenting with symptoms of iNPH were given a MoCA assessment at their first clinic visit, and also before and after tap test (TT) or extended lumbar drainage (ELD). Patients who were determined to be good candidates for shunts (N = 71, 31.7%) took another MoCA assessment following shunt insertion. Reliable change thresholds for MoCA were derived using baseline visit to pre-TT/ELD assessment using nine different methodologies. Baseline characteristics of patients whose post-shunt MoCA did and did not exceed the reliable change threshold were compared.ResultsAll nine of reliable change methods indicated that a 5-point increase in MoCA would be reliable for patients with a baseline MoCA from 16 to 22 (38.4% of patients). Furthermore, a majority of reliable change methods indicated that a 5-point increase in MoCA would be reliable for patients with a baseline MoCA from 14 to 25. Reliable change thresholds varied across methods from 4 to 7 points for patients outside of this range. 10.1% had at least a 5-point increase from baseline to post-TT/ELD. Compared to patients who did not receive a shunt, patients who received a shunt did not have lower average MoCA at baseline (p = 0.88) or have better improvement in MoCA scores after the tap test (p = 0.17). Among shunted patients, 23.4% improved by at least 5 points on the MoCA from baseline to post-shunt. Time since onset of memory problems and post-TT/ELD gait function were the only clinical factors significantly associated with having a reliable change in MoCA after shunt insertion (p = 0.019; p = 0.03, respectively).ConclusionsIn patients with iNPH, clinicians could consider using a threshold of 5 points for determining whether iNPH-symptomatic patients have experienced cognitive benefits from cerebrospinal fluid drainage at an individual level. However, a reliable change cannot be detected for patients with a baseline MoCA of 26 or greater, necessitating a different cognitive assessment tool for these patients.